£-Cigarette Use Among Youth and 


Young Adults 


A Report ofthe Surgeon General 


U.S. Department of Health and Human Services 

E-Cigarette Use Among Youth

and Young Adults: A Report of

the Surgeon General

2016 

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Public Health Service 

Office of the Surgeon General 

Rockville, MD 
National Library of Medicine Cataloging-in-Publication Data 

Names: United States. Public Health Service. Office of the Surgeon General, issuing body. | National 

Center for Chronic Disease Prevention and Health Promotion (U.S.). Office on Smoking and 

Health, issuing body. 

Title: E-cigarette use among youth and young adults : a report of the Surgeon General. 

Description: Atlanta, GA : U.S. Department of Health and Human Services, Centers for Disease Control 

and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on 

Smoking and Health, 2016. | Includes bibliographical references. 

Subjects: MESH: Electronic Cigarettes – utilization. | Smoking – adverse effects. | Electronic Cigarettes – 

adverse effects. | Tobacco Industry. | Young Adult. | Adolescent. | United States. 

Classification: NLM QV 137 

U.S. Department of Health and Human Services 

Centers for Disease Control and Prevention 

National Center for Chronic Disease Prevention and 	Health Promotion 

Office on Smoking and Health 

For more information 

For more information about the Surgeon General’s report, visit www.surgeongeneral.gov. 

To download copies of this document, go to www.cdc.gov/tobacco. 

To order copies of this document, go to www.cdc.gov/tobacco and click on Publications 

Catalog or call 1-800-CDC-INFO (1-800-232-4636); TTY: 1-888-232-6348. 

Suggested Citation 

U.S. Department of Health and Human Services. E-Cigarette Use Among Youth and Young 

Adults. A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and 

Human Services, Centers for Disease Control and Prevention, National Center for Chronic 

Disease Prevention and Health Promotion, Office on Smoking and Health, 2016. 

Use of trade names is for identification only and does not constitute endorsement by the 

U.S. Department of Health and Human Services. 
Message from Sylvia Burwell 

Secretary, U.S. Department of Health and Human Services 

The mission of the Department of Health and Human Services is to enhance and protect the 

health and well-being of all Americans. This report confirms that the use of electronic cigarettes (or 

e-cigarettes) is growing rapidly among American youth and young adults. While these products are 

novel, we know they contain harmful ingredients that are dangerous to youth. Important strides have 

been made over the past several decades in reducing conventional cigarette smoking among youth and 

young adults. We must make sure this progress is not compromised by the initiation and use of new 

tobacco products, such as e-cigarettes. That work is already underway. 

To protect young people from initiating or continuing the use of e-cigarettes, actions must be 

taken at the federal, state, and local levels. At the federal level, the U.S. Food and Drug Administration 

(FDA)—under authority granted to it by Congress under the Family Smoking Prevention and Tobacco 

Control Act of 2009—took a historic step to protect America’s youth from the harmful effects of using 

e-cigarettes by extending its regulatory authority over the manufacturing, distribution, and marketing 

of e-cigarettes. Through such action, FDA now requires minimum age restrictions to prevent sales 

to minors and prohibits sales through vending machines (in any facility that admits youth), and will 

require products to carry a nicotine warning. 

We have more to do to help protect Americans from the dangers of tobacco and nicotine, especially our youth. As cigarette smoking among those under 18 has fallen, the use of other nicotine 

products, including e-cigarettes, has taken a drastic leap. All of this is creating a new generation of 

Americans who are at risk of nicotine addiction. 

The findings from this report reinforce the need to support evidence-based programs to prevent 

youth and young adults from using tobacco in any form, including e-cigarettes. The health and wellbeing of our nation’s young people depend on it. 

iii 

Foreword 

Tobacco use among youth and young adults in any form, including e-cigarettes, is not safe. In 

recent years, e-cigarette use by youth and young adults has increased at an alarming rate. E-cigarettes 

are now the most commonly used tobacco product among youth in the United States. This timely report 

highlights the rapidly changing patterns of e-cigarette use among youth and young adults, assesses 

what we know about the health effects of using these products, and describes strategies that tobacco 

companies use to recruit our nation’s youth and young adults to try and continue using e-cigarettes. 

The report also outlines interventions that can be adopted to minimize the harm these products cause 

to our nation’s youth. 

E-cigarettes are tobacco products that deliver nicotine. Nicotine is a highly addictive substance, 

and many of today’s youth who are using e-cigarettes could become tomorrow’s cigarette smokers. 

Nicotine exposure can also harm brain development in ways that may affect the health and mental 

health of our kids. 

E-cigarette use among youth and young adults is associated with the use of other tobacco products, including conventional cigarettes. Because most tobacco use is established during adolescence, 

actions to prevent our nation’s young people from the potential of a lifetime of nicotine addiction are 

critical. 

E-cigarette companies appear to be using many of the advertising tactics the tobacco industry 

used to persuade a new generation of young people to use their products. Companies are promoting 

their products through television and radio advertisements that use celebrities, sexual content, and 

claims of independence to glamorize these addictive products and make them appealing to young 

people. 

Comprehensive tobacco control and prevention strategies for youth and young adults should 

address all tobacco products, including e-cigarettes. Further reductions in tobacco use and initiation 

among youth and young adults are achievable by regulating the manufacturing, distribution, marketing, and sales of all tobacco products—including e-cigarettes, and particularly to children—and 

combining those approaches with other proven strategies. These strategies include funding tobacco 

control programs at levels recommended by the Centers for Disease Control and Prevention (CDC); 

increasing prices of tobacco products; implementing and enforcing comprehensive smokefree laws; and 

sustaining hard-hitting media campaigns, such as CDC’s Tips from Former Smokers that encourages 

smokers to quit for good, and FDA’s Real Cost that is aimed at preventing youth from trying tobacco and 

reducing the number of youth who move from experimenting to regular use. We can implement these 

cost-effective, evidence-based, life-saving strategies now. Together with additional effort and support, 

we can protect the health of our nation’s young people. 

Thomas R. Frieden, M.D., M.P.H. 

Director 

Centers for Disease Control and Prevention 

v 

Preface 

from the Surgeon General 

E-cigarette use among U.S. youth and young adults is now a major public health concern. 

E-cigarette use has increased considerably in recent years, growing an astounding 900% among high 

school students from 2011 to 2015. These products are now the most commonly used form of tobacco 

among youth in the United States, surpassing conventional tobacco products, including cigarettes, 

cigars, chewing tobacco, and hookahs. Most e-cigarettes contain nicotine, which can cause addiction 

and can harm the developing adolescent brain. 

Compared with older adults, the brain of youth and young adults is more vulnerable to the negative consequences of nicotine exposure. The effects include addiction, priming for use of other addictive substances, reduced impulse control, deficits in attention and cognition, and mood disorders. 

Furthermore, fetal exposure to nicotine during pregnancy can result in multiple adverse consequences, 

including sudden infant death syndrome, altered corpus callosum, auditory processing deficits, effects 

on behaviors and obesity, and deficits in attention and cognition. Ingestion of e-cigarette liquids containing nicotine can also cause acute toxicity and possibly death if the contents of refill cartridges or 

bottles containing nicotine are consumed. 

This report highlights what we know and do not know about e-cigarettes. Gaps in scientific evidence do exist, and this report is being issued while these products and their patterns of use continue to 

change quickly. For example, the health effects and potentially harmful doses of heated and aerosolized 

constituents of e-cigarette liquids—including solvents, flavorants, and toxicants—are not completely 

understood. However, although e-cigarettes generally emit fewer toxicants than combustible tobacco 

products, we know that aerosol from e-cigarettes is not harmless. 

Although we continue to learn more about e-cigarettes with each passing day, we currently know 

enough to take action to protect our nation’s young people from being harmed by these products. 

Previous reports of the Surgeon General have established that nearly all habitual tobacco use begins 

during youth and young adulthood. To prevent and reduce the use of e-cigarettes by youth and young 

adults, we must work together as a society. We must implement proven prevention and education strat

egies. Health care providers, parents, teachers, and other caregivers should advise youth about the 

dangers of nicotine and discourage tobacco use in any form, including e-cigarettes. They can set a posi

tive example by being tobacco-free and encouraging those who already use these products to quit. Free 

help is available at 1-800-QUIT-NOW or 

­

­

http://www.smokefree.gov. Preventing tobacco use in any form 

among youth and young adults is critical to ending the tobacco epidemic in the United States. 

Vivek H. Murthy, M.D., M.B.A. 

U.S. Surgeon General 

vii 

ix 

E-Cigarette Use Among Youth and Young Adults

Acknowledgments 

This report was prepared by the U.S. Department of Health 

and Human Services under the general direction of the 

Centers for Disease Control and Prevention, National 

Center for Chronic Disease Prevention and Health 

Promotion, Office on Smoking and Health. 

Vice Admiral (VADM) Vivek H. Murthy, M.D., M.B.A., 

Surgeon General, Office of the Surgeon General, Office 

of the Secretary, U.S. Department of Health and Human 

Services, Washington, D.C. 

Thomas R. Frieden, M.D., M.P.H., Director, Centers for 

Disease Control and Prevention, Atlanta, Georgia. 

Ursula E. Bauer, Ph.D., M.P.H., Director, National Center 

for Chronic Disease Prevention and Health Promotion, 

Centers for Disease Control and Prevention, Atlanta, 

Georgia. 

Dana Shelton, M.P.H., Deputy Director, National Center 

for Chronic Disease Prevention and Health Promotion, 

Centers for Disease Control and Prevention, Atlanta, 

Georgia. 

Peter A. Briss, M.D., M.P.H., Medical Director, National 

Center for Chronic Disease Prevention and Health 

Promotion, Centers for Disease Control and Prevention, 

Atlanta, Georgia. 

Rachel Kaufmann, Ph.D., M.P.H., Associate Director for 

Science, National Center for Chronic Disease Prevention 

and Health Promotion, Centers for Disease Control and 

Prevention, Atlanta, Georgia. 

Corinne Graffunder, Dr.P.H., M.P.H., Director, Office on 

Smoking and Health, National Center for Chronic Disease 

Prevention and Health Promotion, Centers for Disease 

Control and Prevention, Atlanta, Georgia. 

Editors of the report were 

Cheryl L. Perry, Ph.D., Senior Scientific Editor, Professor 

and Regional Dean, The Rockwell Distinguished Chair 

in Society and Health, The University of Texas Health 

Science Center at Houston (UTHealth) School of Public 

Health, Austin, Texas. 

Melissa Harrell, Ph.D., M.P.H., Senior Scientific Editor, 

Associate Professor, Department of Health Promotion and 

Behavioral Sciences and the Michael & Susan Dell Center 

for Healthy Living, The University of Texas Health Science 

Center at Houston (UTHealth) School of Public Health, 

Austin, Texas. 

MeLisa R. Creamer, Ph.D., M.P.H., Senior Scientific Editor, 

Faculty Associate, Department of Health Promotion and 

Behavioral Sciences and the Michael & Susan Dell Center 

for Healthy Living, The University of Texas Health Science 

Center at Houston (UTHealth) School of Public Health, 

Austin, Texas. 

Steven Kelder, Ph.D., Senior Scientific Editor, Beth Toby 

Grossman Distinguished Professor of Spirituality and 

Healing; Associate Regional Dean; Co-Director, Michael & 

Susan Dell Center for Healthy Living; Professor, Division 

of Epidemiology, Human Genetics, and Environmental 

Sciences, The University of Texas Health Science Center 

at Houston (UTHealth) School of Public Health, Austin, 

Texas. 

Brian King, Ph.D., Senior Associate Editor, Deputy 

Director for Research Translation, Office on Smoking and 

Health, National Center for Chronic Disease Prevention 

and Health Promotion, Centers for Disease Control and 

Prevention, Atlanta, Georgia. 

Leslie A. Norman, M.B.A., Managing Editor, Office on 

Smoking and Health, National Center for Chronic Disease 

Prevention and Health Promotion, Centers for Disease 

Control and Prevention, Atlanta, Georgia. 

Peter L. Taylor, M.B.A., Technical Editor, Fairfax, Virginia. 

Contributing editors were 

Thomas Eissenberg, Ph.D., Director, Center for the 

Study of Tobacco Products; Professor of Psychology 

(Health Program), College of Humanities and Sciences 

and Member Scientist, Massey Cancer Center, Virginia 

Commonwealth University, Richmond, Virginia. 

Rachel A. Grana, Ph.D., M.P.H., Program Director, Tobacco 

Control Research Branch, Behavioral Research Program, 

Division of Cancer Control and Population Sciences, 

National Cancer Institute, National Institutes of Health, 

Rockville, Maryland. 
A Report of the Surgeon General

x

Pamela Ling, M.D., M.P.H., Professor, Division of General 

Internal Medicine, Department of Medicine, Center for 

Tobacco Control Research and Education, University of 

California, San Francisco, California.

Mark Parascandola, Ph.D., M.P.H., Epidemiologist, 

Tobacco Control Research Branch, Behavioral Research 

Program, Division of Cancer Control and Population 

Sciences, National Cancer Institute, National Institutes of 

Health, Rockville, Maryland.

Jennifer L. Pearson, Ph.D., M.P.H., Research Investigator, 

The Schroeder Institute for Tobacco Research and Policy 

Studies at Truth Initiative, Washington, D.C.; Adjunct 

Assistant Professor, Department of Health, Behavior, 

and Society, Bloomberg School of Public Health, Johns 

Hopkins University, Baltimore, Maryland.

Jonathan M. Samet, M.D., M.S., Distinguished Professor 

and Flora L. Thornton Chair, Department of Preventive 

Medicine, Keck School of Medicine; Director, Institute 

for Global Health, University of Southern California, Los 

Angeles, California.

Andrea C. Villanti, Ph.D., M.P.H., Director for 

Regulatory Science and Policy, The Schroeder Institute 

for Tobacco Research and Policy Studies at Truth 

Initiative, Washington, D.C.; Adjunct Assistant Professor, 

Department of Health, Behavior, and Society, Bloomberg 

School of Public Health, Johns Hopkins University, 

Baltimore, Maryland.

Contributing authors were

Melissa D. Blank, Ph.D., Assistant Professor, Department 

of Psychology, West Virginia University, Morgantown, 

West Virginia.

Frank J. Chaloupka, Ph.D., Director, Health Policy Center, 

Institute for Health Research and Policy, and Distinguished 

Professor, Department of Economics, University of Illinois 

at Chicago, Chicago, Illinois.

Shari P. Feirman, Ph.D., M.S., Project Director for 

Regulatory Science and Policy, The Schroeder Institute for 

Tobacco Research and Policy Studies at Truth Initiative, 

Washington, D.C.

Jonathan Foulds, Ph.D., Professor, Departments of Public 

Health Sciences and Psychiatry, College of Medicine, Penn 

State University, Hershey, Pennsylvania.

Allison M. Glasser, M.P.H., Senior Project Manager, The 

Schroeder Institute for Tobacco Research and Policy 

Studies at Truth Initiative, Washington, D.C. 

Maciej L. Goniewicz, Ph.D., Pharm.D., Assistant Professor 

of Oncology, Department of Health Behavior, Roswell Park 

Cancer Institute, Buffalo, New York.

Rachel A. Grana, Ph.D., M.P.H., Program Director, Tobacco 

Control Research Branch, Behavioral Research Program, 

Division of Cancer Control and Population Sciences, 

National Cancer Institute, National Institutes of Health, 

Rockville, Maryland.

Lisa Henriksen, Ph.D., Senior Research Scientist, 

Stanford Prevention Research Center, Department of 

Medicine, School of Medicine, Stanford University, Palo 

Alto, California.

Jidong Huang, Ph.D., Senior Research Scientist, Institute 

for Health Research and Policy, University of Illinois at 

Chicago, Chicago, Illinois.

Lauren K. Katz, M.P.H., Research Associate I, The 

Schroeder Institute for Tobacco Research and Policy 

Studies at Truth Initiative, Washington, D.C.

Frances Leslie, Ph.D., Vice Provost for Graduate Education; 

Dean of the Graduate Division; Professor of Pharmacology 

and Anatomy and Neurobiology, University of California, 

Irvine, California.

M. Jane Lewis, Dr.Ph., Associate Professor, Health 

Education and Behavioral Science and Center for Tobacco 

Studies, School of Public Health, Rutgers University, New 

Brunswick, New Jersey. 

Kristy Marynak, M.P.P., Public Health Analyst, Office on 

Smoking and Health, National Center for Chronic Disease 

Prevention and Health Promotion, Centers for Disease 

Control and Prevention, Atlanta, Georgia.

Mark Parascandola, Ph.D., M.P.H., Epidemiologist, 

Tobacco Control Research Branch, Behavioral Research 

Program, Division of Cancer Control and Population 

Sciences, National Cancer Institute, National Institutes of 

Health, Rockville, Maryland.

Terry F. Pechacek, Ph.D., Professor and Interim Division 

Director of Health Management and Policy, School of 

Public Health, Georgia State University, Atlanta, Georgia. 
xi 

E-Cigarette Use Among Youth and Young Adults

Gabbi Promoff, M.A., Associate Director for Policy, Office 

on Smoking and Health, National Center for Chronic 

Disease Prevention and Health Promotion, Centers for 

Disease Control and Prevention, Atlanta, Georgia. 

Kurt M. Ribisl, Ph.D., Professor, Department of Health 

Behavior, University of North Carolina Gillings School 

of Global Public Health; Program Leader in Cancer 

Prevention and Control, University of North Carolina 

Lineberger Comprehensive Cancer Center, Chapel Hill, 

North Carolina. 

April Roeseler, B.S.N., M.S.P.H., Chief, California Tobacco 

Control Program, California Department of Public Health, 

Sacramento, California. 

Jonathan M. Samet, M.D., M.S., Distinguished Professor 

and Flora L. Thornton Chair, Department of Preventive 

Medicine, Keck School of Medicine; Director, Institute 

for Global Health, University of Southern California, Los 

Angeles, California. 

Laura R. Stroud, Ph.D., Senior Research Scientist, 

Centers for Behavioral and Preventive Medicine, The 

Miriam Hospital; Associate Professor, Department of 

Psychiatry and Human Behavior, Alpert Medical School, 

and Department of Behavioral and Social Sciences, School 

of Public Health, Brown University, Providence, Rhode 

Island. 

Prue Talbot, Ph.D., Director, University of California, 

Riverside Stem Cell Center and Core; Professor of Cell 

Biology, Department of Cell Biology and Neuroscience, 

University of California, Riverside, California. 

Mark Travers, Ph.D., M.S., Assistant Professor of Oncology, 

Department of Health Behavior and Air Pollution Exposure 

Research Laboratory, Roswell Park Cancer Institute, 

Buffalo, New York. 

Scott Weaver, Ph.D., M.A., Assistant Professor, Division of 

Epidemiology and Biostatistics, School of Public Health, 

Georgia State University, Atlanta, Georgia. 

Reviewers were 

David B. Abrams Ph.D., Executive Director, The Schroeder 

Institute for Tobacco Research and Policy Studies at Truth 

Initiative, Washington, D.C.; Professor, Department of 

Health, Behavior, and Society, Bloomberg School of 

Public Health, Johns Hopkins University, Baltimore, 

Maryland; Professor of Oncology, Georgetown University 

Medical Center, Lombardi Comprehensive Cancer Center 

(adjunct), Washington, D.C. 

Heather Rubino Althouse, Senior Regulatory Counsel, 

Office of Compliance and Enforcement, Center for 

Tobacco Products, U.S. Food and Drug Administration, 

Silver Spring, Maryland. 

René A. Arrazola, M.P.H., Epidemiologist, Epidemiology 

Branch, Office on Smoking and Health, National Center 

for Chronic Disease Prevention and Health Promotion, 

Centers for Disease Control and Prevention, Atlanta, 

Georgia. 

David L. Ashley, Ph.D., Director, Office of Science, Center 

for Tobacco Products, U.S. Food and Drug Administration, 

Silver Spring, Maryland. 

Cathy L. Backinger, Ph.D., M.P.H., Deputy Director for 

Research, Office of Science, Center for Tobacco Products, 

U.S. Food and Drug Administration, Silver Spring, 

Maryland. 

Tracey E. Barnett, Ph.D., Associate Professor, Department 

of Epidemiology, College of Public Health and Health 

Professions and College of Medicine, University of Florida, 

Gainesville, Florida. 

Neal L. Benowitz, M.D., Professor of Medicine, 

Bioengineering, and Therapeutic Sciences, Chief, Division 

of Clinical Pharmacology, University of California, San 

Francisco, California. 

Jay M. Bernhardt, Ph.D., M.P.H., Interim Dean and 

Professor, Moody College of Communication; Founding 

Director, Center for Health Communication, The 

University of Texas, Austin, Texas. 

Nazleen Bharmal, M.D., Ph.D., M.P.P., Director of Science 

and Policy, Office of the Surgeon General, U.S. Department 

of Health and Human Services, Washington, D.C. 

Allan M. Brandt, Ph.D., Amalie Moses Kass Professor of 

the History of Medicine, Department of Global Health 

and Social Medicine, Harvard University Medical School, 

Boston, Massachusetts. 

April Brubach, M.A., Director, Division of Public Health 

Education, Office of Health Communication and 

Education, Center for Tobacco Products, U.S. Food and 

Drug Administration, Silver Spring, Maryland. 

Priscilla Callahan-Lyon, M.D., Medical Branch Chief, 

Division of Individual Health Science, Office of Science, 

Center for Tobacco Products, U.S. Food and Drug 

Administration, Silver Spring, Maryland. 
A Report of the Surgeon General

xii

Frank J. Chaloupka, Ph.D., Director, Health Policy Center, 

Institute for Health Research and Policy; Distinguished 

Professor, Department of Economics, University of Illinois 

at Chicago, Chicago, Illinois.

Ii-Lun Chen, M.D., Director, Division of Individual Health 

Science, Office of Science, Center for Tobacco Products, U.S. 

Food and Drug Administration, Silver Spring, Maryland.

Beverly Chernaik, J.D., Director, Office of Regulations, 

Center for Tobacco Products, U.S. Food and Drug 

Administration, Silver Spring, Maryland. 

Joanna E. Cohen, Ph.D., Director, Institute for Global 

Tobacco Control; Bloomberg Professor of Disease 

Prevention, Department of Health, Behavior, and Society, 

Bloomberg School of Public Health, Johns Hopkins 

University, Baltimore, Maryland.

Catherine G. Corey, M.S.P.H., Epidemiologist, Office of 

Science, Center for Tobacco Products, U.S. Food and Drug 

Administration, Silver Spring, Maryland.

Kathleen Crosby, Director, Office of Health Communication 

and Education, Center for Tobacco Products, U.S. Food 

and Drug Administration, Silver Spring, Maryland.

Cristine D. Delnevo, Ph.D., M.P.H., Professor and Director, 

Center for Tobacco Studies, Rutgers School of Public 

Health, New Brunswick, New Jersey.

Lauren M. Dutra, Sc.D., M.A., Postdoctoral Fellow, Center 

for Tobacco Control Research and Education, University of 

California, San Francisco, California.

Lucinda J. England, M.D., M.S.P.H., Medical Officer, Office 

on Smoking and Health, National Center for Chronic 

Disease Prevention and Health Promotion, Centers for 

Disease Control and Prevention, Atlanta, Georgia. 

Michael P. Eriksen, Sc.D., Sc.M., Dean and Regents’ Professor, 

Division of Health Management and Policy, School of Public 

Health, Georgia State University, Atlanta, Georgia.

Michael C. Fiore, M.D., M.P.H., M.B.A., University of Wisconsin 

Hilldale Professor of Medicine; Director, Center for Tobacco 

Research and Intervention, University of Wisconsin School of 

Medicine and Public Health, Madison, Wisconsin.

Neal D. Freedman, Ph.D., M.P.H., Senior Investigator, 

Metabolic Epidemiology Branch, Division of Cancer 

Epidemiology and Genetics, National Cancer Institute, 

National Institutes of Health, Rockville, Maryland.

Elizabeth M. Ginexi, Ph.D., Program Director, Tobacco 

Control Research Branch, Division of Cancer Control and 

Population Sciences, National Cancer Institute, National 

Institutes of Health, Rockville, Maryland.

Gary A. Giovino, Ph.D., M.S., Professor and Chair, 

Department of Community Health and Health Behavior, 

School of Public Health and Health Professions, University 

at Buffalo, The State University of New York, Buffalo, New 

York.

Stanton A. Glantz, Ph.D., Professor of Medicine and 

American Legacy Foundation Distinguished Professor in 

Tobacco Control; Director, Center for Tobacco Control 

Research and Education, University of California, San 

Francisco, California.

Maciej L. Goniewicz, Ph.D., Pharm.D., Assistant Professor 

of Oncology, Department of Health Behavior, Roswell Park 

Cancer Institute, Buffalo, New York.

Rachel A. Grana, Ph.D., M.P.H., Program Director, Tobacco 

Control Research Branch, Behavioral Research Program, 

Division of Cancer Control and Population Sciences, 

National Cancer Institute, National Institutes of Health, 

Rockville, Maryland.

Bonnie Halpern-Felsher, Ph.D., FSAHM, Director of 

Research, Professor, Division of Adolescent Medicine, 

Stanford University, Palo Alto, California.

Dorothy K. Hatsukami, Ph.D., Forster Family Professor in 

Cancer Prevention, Masonic Cancer Center, University of 

Minnesota, Minneapolis, Minnesota.

Corinne Husten, M.D., M.P.H., Senior Medical Advisor, 

Center for Tobacco Products, U.S. Food and Drug 

Administration, Silver Spring, Maryland.

Frances Jensen, M.D., F.A.C.P., Professor and Chair, 

Neurology Department, Perelman School of Medicine, 

University of Pennsylvania, Philadelphia, Pennsylvania.

Ronald L. Johnson, Ph.D., Program Director, DNA and 

Chromosome Aberrations Branch, Division of Cancer 

Biology, National Cancer Institute, National Institutes of 

Health, Bethesda, Maryland.

Sarah E. Johnson, Ph.D., Social Scientist, Office of 

Science, Center for Tobacco Products, U.S. Food and Drug 

Administration, Silver Spring, Maryland.
xiii 

E-Cigarette Use Among Youth and Young Adults

Annette R. Kaufman, Ph.D., M.P.H., Health Scientist and 

Program Director, Tobacco Control Research Branch, 

Behavioral Research Program, Division of Cancer Control 

and Population Sciences, National Cancer Institute, 

National Institutes of Health, Rockville, Maryland. 

Ryan David Kennedy, Ph.D., Assistant Professor, Institute 

for Global Tobacco Control, Department of Health, 

Behavior, and Society, Bloomberg School of Public Health, 

Johns Hopkins University, Baltimore, Maryland. 

Jonathan D. Klein, M.D., M.P.H., F.A.A.P., Associate 

Executive Director; Director, Julius B. Richmond Center, 

American Academy of Pediatrics, Elk Grove Village, 

Illinois. 

Suchitra Krishnan-Sarin, Ph.D., Professor, Department 

of Psychiatry, School of Medicine, Yale University, New 

Haven, Connecticut. 

Lauren K. Lempert, J.D., M.P.H., Associate Specialist, 

Center for Tobacco Control Research and Education, 

University of California, San Francisco, California. 

Maggie Mahoney, J.D., Executive Director, Tobacco 

Control Legal Consortium at the Public Health Law 

Center, St. Paul, Minnesota. 

Tim McAfee, M.D., Medical Officer, Office on Smoking and 

Health, National Center for Chronic Disease Prevention 

and Health Promotion, Centers for Disease Control and 

Prevention, Atlanta, Georgia. 

Daniel McGoldrick, M.A., Vice President, Global Health 

Advocacy Incubator, Campaign for Tobacco-Free Kids, 

Washington, D.C. 

Cindy Miner, Ph.D., Associate Director for Scientific 

Communication, Office of Science, Center for Tobacco 

Products, U.S. Food and Drug Administration, Silver 

Spring, Maryland. 

Matthew L. Myers, J.D., President, Campaign for TobaccoFree Kids, Washington, D.C. 

Linda J. Neff, Ph.D., Senior Epidemiologist, Epidemiology 

Branch, Office on Smoking and Health, National Center 

for Chronic Disease Prevention and Health Promotion, 

Centers for Disease Control and Prevention, Atlanta, 

Georgia. 

Richard J. O’Connor, Ph.D., Member and Professor of 

Oncology, Department of Health Behavior, Division of 

Cancer Prevention and Population Sciences, Roswell Park 

Cancer Institute, Buffalo, New York. 

Mark Parascandola, Ph.D., M.P.H., Epidemiologist, 

Tobacco Control Research Branch, Behavioral Research 

Program, Division of Cancer Control and Population 

Sciences, National Cancer Institute, National Institutes of 

Health, Rockville, Maryland. 

Terry F. Pechacek, Ph.D., Professor and Interim Division 

Director of Health Management and Policy, School of 

Public Health, Georgia State University, Atlanta, Georgia. 

Alexander Persoskie, Ph.D., Social Scientist, Center for 

Tobacco Products, U.S. Food and Drug Administration, 

Silver Spring, Maryland. 

John P. Pierce, Ph.D., Professor Emeritus, Department of 

Family Medicine and Public Health and the Moores Cancer 

Center, University of California, San Diego, La  Jolla, 

California. 

David W. Racine, M.S., Senior Program Management 

Officer, Office of Compliance and Enforcement, Center for 

Tobacco Products, U.S. Food and Drug Administration, 

Silver Spring, Maryland. 

Chad J. Reissig, Ph.D., Addiction Branch Chief, Office of 

Science, Center for Tobacco Products, U.S. Food and Drug 

Administration, Silver Spring, Maryland. 

Joelle Robinson, M.P.H., Social Scientist, Office of 

Science, Center for Tobacco Products, U.S. Food and Drug 

Administration, Silver Spring, Maryland. 

Jonathan M. Samet, M.D., M.S., Distinguished Professor 

and Flora L. Thornton Chair, Department of Preventive 

Medicine, Keck School of Medicine; Director, Institute 

for Global Health, University of Southern California, Los 

Angeles, California. 

Peter G. Shields, M.D., Deputy Director, Comprehensive 

Cancer Center, James Cancer Hospital; Professor, College 

of Medicine, The Ohio State University, Columbus, Ohio. 

Ann Simoneau, J.D., M.B.A., Director, Office of Compliance 

and Enforcement, Center for Tobacco Products, U.S. Food 

and Drug Administration, Silver Spring, Maryland. 
A Report of the Surgeon General

Theodore A. Slotkin, Ph.D., Professor, Department of 

Pharmacology and Cancer Biology, Duke University 

Medical Center, Durham, North Carolina. 

Anne Sowell, Ph.D., Health Scientist, National Center 

for Chronic Disease Prevention and Health Promotion, 

Centers for Disease Control and Prevention, Atlanta, 

Georgia. 

Erin L. Sutfin, Ph.D., Associate Professor and Vice Chair, 

Department of Social Sciences and Health Policy, Division 

of Public Health Sciences, Wake Forest School of Medicine, 

Wake Forest University, Winston-Salem, North Carolina. 

Robert E. Vollinger, Jr., M.S.P.H., (Dr.P.H. Candidate), 

Program Director and Public Health Advisor, Tobacco 

Control Research Branch, Behavioral Research Program, 

Division of Cancer Control and Population Sciences, 

National Cancer Institute, National Institutes of Health, 

Rockville, Maryland. 

Kenneth E. Warner, Ph.D., Avedis Donabedian 

Distinguished University Professor of Public Health, 

Department of Health Management and Policy, University 

of Michigan School of Public Health, Ann Arbor, 

Michigan. 

Geoffrey Ferris Wayne, M.A., Research Consultant, 

Sebastopol, California. 

Deborah M. Winn, Ph.D., Deputy Director, Division 

of Cancer Control and Population Sciences, National 

Cancer Institute, National Institutes of Health, Rockville, 

Maryland. 

Mitchell Zeller, J.D., Director, Center for Tobacco 

Products, U.S. Food and Drug Administration, Silver 

Spring, Maryland. 

Other contributors were 

Katherine J. Asman, M.S.P.H., Statistician, Biostatistics 

and Epidemiology Division, RTI International, Atlanta, 

Georgia. 

Adam J. Burke, M.A., Research Associate Lead, The 

Monitoring the Future Study, University of Michigan, Ann 

Arbor, Michigan. 

Dayana Chanson, M.P.H., Research Associate to Jonathan 

M. Samet, M.D., M.S., Department of Preventive Medicine, 

Keck School of Medicine, University of Southern 

California, Los Angeles, California. 

Tara Christine Chu, M.P.H., Research Associate to 

Jonathan M. Samet, M.D., M.S., Department of Preventive 

Medicine, Keck School of Medicine, University of Southern 

California, Los Angeles, California. 

Stephanie L. Clendennen, M.P.H., Predoctoral Fellow, 

Tobacco Center of Regulatory Science on Youth and 

Young Adults, The University of Texas Health Science 

Center at Houston (UTHealth) School of Public Health, 

Austin, Texas. 

Sarah J. Cross, Graduate Student Researcher, Department 

of Anatomy and Neurobiology, University of California, 

Irvine, California. 

Nicholas J. Felicione, Graduate Research Assistant, 

Department of Psychology, West Virginia University, 

Morgantown, West Virginia. 

Kyle R. Gregory, J.D., M.S.H.A., Postdoctoral Research 

Associate, Tobacco Center of Regulatory Science, School of 

Public Health, Georgia State University, Atlanta, Georgia. 

Emily T. Hébert, M.P.H., Doctoral Student, Michael & 

Susan Dell Center for Healthy Living, The University 

of Texas Health Science Center at Houston (UTHealth) 

School of Public Health, Austin, Texas. 

Erin O’Connor Landau, M.S., Data Analyst, DB Consulting 

Group (Contractor), Office on Smoking and Health, 

National Center for Chronic Disease Prevention and 

Health Promotion, Centers for Disease Control and 

Prevention, Atlanta, Georgia. 

Pamela Lemos, M.S., Public Health Analyst, Office on 

Smoking and Health, National Center for Chronic Disease 

Prevention and Health Promotion, Centers for Disease 

Control and Prevention, Atlanta, Georgia. 

Gerald V. [Simon] McNabb, Lead Public Health Analyst, 

Office on Smoking and Health, National Center for Chronic 

Disease Prevention and Health Promotion, Centers for 

Disease Control and Prevention, Washington, D.C. 

Ronald L. Johnson, Ph.D., Program Director, DNA and 

Chromosome Aberrations Branch, Division of Cancer 

Biology, National Cancer Institute, National Institutes of 

Health, Bethesda, Maryland. 

Hoda S. Magid, M.H.S., Center for Tobacco Control 

Research and Education, University of California, 

San Francisco, California. 

xiv 
xv 

E-Cigarette Use Among Youth and Young Adults

Dale Mantey, M.P.A., Predoctoral Fellow, Tobacco Center 

of Regulatory Science on Youth and Young Adults, The 

University of Texas Health Science Center at Houston 

(UTHealth) School of Public Health, Austin, Texas. 

Mandie Mills, Photographer, Office of the Associate 

Director for Communication, Centers for Disease Control 

and Prevention, Atlanta, Georgia. 

Richard Miech, Ph.D., Professor, Institute for Social 

Research, University of Michigan, Ann Arbor, Michigan. 

Luz M. Moncayo, Executive Assistant to Jonathan M. 

Samet, M.D., M.S., Department of Preventive Medicine, 

Keck School of Medicine, Institute for Global Health, 

University of Southern California, Los Angeles, California. 

Maureen O’Brien, J.D., Staff Attorney, Tobacco Control 

Legal Consortium at the Public Health Law Center, 

St. Paul, Minnesota. 

Patrick M. O’Malley, Ph.D., Research Professor, Survey 

Research Center, Institute for Social Research, University 

of Michigan, Ann Arbor, Michigan. 

Gabriela V. Portillo, Masters Student, Michael & Susan 

Dell Center for Healthy Living, The University of Texas 

Health Science Center at Houston (UTHealth) School of 

Public Health, Austin, Texas. 

Anna Teplinskaya, M.D., M.P.H., Public Health Analyst, 

Epidemiology Branch, Office on Smoking and Health, 

National Center for Chronic Disease Prevention and 

Health Promotion, Centers for Disease Control and 

Prevention, Atlanta, Georgia. 

Tenecia Smith, M.P.H., Data Analyst, DB Consulting Group 

(Contractor), Office on Smoking and Health, National 

Center for Chronic Disease Prevention and Health 

Promotion, Centers for Disease Control and Prevention, 

Atlanta, Georgia. 

Kathryn E. Szynal, Editorial Assistant, McNeal 

Professional Services (Contractor), Office on Smoking and 

Health, National Center for Chronic Disease Prevention 

and Health Promotion, Centers for Disease Control and 

Prevention, Atlanta, Georgia. 

Teresa Wang, Ph.D., M.S., Epidemic Intelligence Service 

Officer, Lieutenant, U.S. Public Health Service, Office on 

Smoking and Health, National Center for Chronic Disease 

Prevention and Health Promotion, Centers for Disease 

Control and Prevention, Atlanta, Georgia. 

Jennifer Whitmill, M.P.H., Data Analyst, DB Consulting 

Group (Contractor), Office on Smoking and Health, 

National Center for Chronic Disease Prevention and 

Health Promotion, Centers for Disease Control and 

Prevention, Atlanta, Georgia 

 

 

 

 

 

E-Cigarette Use Among Youth and Young Adults 

Chapter 1 Introduction, Conclusions, and Historical Background Relative to E-Cigarettes 1

Introduction 3
 

Major Conclusions 5
 

Chapter Conclusions 6
 

Historical Background 8
 

The E-Cigarette 10
 

E-Cigarette Companies 14
 

Federal Regulation of E-Cigarettes 15
 

Summary 18
 

References 19
 

Chapter 2 Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 25
 

Introduction 27
 

Key Findings 28
 

Evidence Summary 86
 

Conclusions 88
 

References 89
 

Chapter 3 Health Effects of E-Cigarette Use Among U.S. Youth and Young Adults 95
 

Introduction 97
 

Conclusions from Previous Surgeon General’s Reports 97
 

Health Effects of E-Cigarette Use 100
 

Evidence Summary 124
 

Conclusions 125
 

References 126
 

Chapter 4 Activities of the E-Cigarette Companies 147
 

Introduction 149
 

Manufacturing and Price 149
 

Marketing and Promotion of E-Cigarettes 157
 

Evidence Summary 172
 

Conclusions 172
 

References 173
 

Chapter 5 E-Cigarette Policy and Practice Implications 181
 

Introduction 183
 

Critical Issues Related to Policies on E-Cigarettes in 2016 184
 

Potential Public Policy Approaches 187
 

Case Studies 224
 

Summary and Recommendations 225
 

Conclusions 226
 

References 227
 

xvii 
 

The Call to Action 235
 

The Call to Action on E-Cigarette Use Among Youth and Young Adults 237
 

Goal 2. Provide Information About the Dangers of E-Cigarette Use Among Youth 


Goal 5. Curb Advertising and Marketing that Encourages Youth and Young Adults 


Goal 1. First, Do No Harm 237
 

and Young Adults 239
 

Goal 3. Continue to Regulate E-Cigarettes at the Federal Level to Protect Public Health 241
 

Goal 4. Programs and Policies to Prevent E-Cigarette Use Among Youth and Young Adults 243
 

to Use E-Cigarettes 246
 

Goal 6. Expand Surveillance, Research, and Evaluation Related to E-Cigarettes 247
 

Conclusions 249
 

References 250
 

List of Abbreviations 253
 

List of Tables and Figures 257
 

Index 261
 

xviii 
1

Introduction 3

Organization of the Report 4

Preparation of this Report 4

Scientific Basis of the Report 5

Major Conclusions 5

Chapter Conclusions 6

Chapter 1. Introduction, Conclusions, and Historical Background Relative to E-Cigarettes 6

Chapter 2. Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 6

Chapter 3. Health Effects of E-Cigarette Use Among U.S. Youth and Young Adults 6

Chapter 4. Activities of the E-Cigarette Companies 7

Chapter 5. E-Cigarette Policy and Practice Implications 7

Historical Background 8

Early Efforts to Modify Cigarettes 8

Filters, Tar Reduction, and Light and Low-Tar Cigarettes 8

The Role of Nicotine and Nicotine Delivery 9

FDA and Nicotine Regulation 9

The E-Cigarette 10

Invention of the E-Cigarette 10

E-Cigarette Products 11

Components and Devices 11

Flavors and E-Cigarettes 11

E-Cigarette Devices 11

E-Cigarette Product Components and Risks 13

E-Cigarette Companies 14

Federal Regulation of E-Cigarettes 15

A “Two-Pronged” Approach to Comprehensive Tobacco Control 15

Legal Basis for Regulating E-Cigarettes as Tobacco Products 16

Deeming Rule 17

Future Regulatory Options 17

Summary 18

References 19

Chapter 1 

Introduction, Conclusions, and Historical Background 

Relative to E-Cigarettes

Introduction, Conclusions, and Historical Background Relative to E-Cigarettes 3

E-Cigarette Use Among Youth and Young Adults

Introduction

Although conventional cigarette smoking has 

declined markedly over the past several decades among 

youth and young adults in the United States (U.S. 

Department of Health and Human Services [USDHHS] 

2012), there have been substantial increases in the use of 

emerging tobacco products among these populations in 

recent years (Centers for Disease Control and Prevention 

[CDC] 2015c). Among these increases has been a dramatic 

rise in electronic cigarette (e-cigarette) use among youth 

and young adults. It is crucial that the progress made 

in reducing cigarette smoking among youth and young 

adults not be compromised by the initiation and use of 

e-cigarettes. This Surgeon General’s report focuses on the 

history, epidemiology, and health effects of e-cigarette use 

among youth and young adults; the companies involved 

with marketing and promoting these products; and 

existing and proposed public health policies regarding the 

use of these products by youth and young adults.

E-cigarettes include a diverse group of devices that 

allow users to inhale an aerosol, which typically contains 

nicotine, flavorings, and other additives. E-cigarettes vary 

widely in design and appearance, but generally operate in 

a similar manner and are composed of similar components 

(Figure 1.1). A key challenge for surveillance of the products and understanding their patterns of use is the diverse 

and nonstandard nomenclature for the devices (Alexander 

et al. 2016). These devices are referred to, by the companies 

themselves, and by consumers, as “e-cigarettes,” “e-cigs,” 

“cigalikes,” “e-hookahs,” “mods,” “vape pens,” “vapes,” 

and “tank systems.” In this report, the term “e-cigarette” 

is used to represent all of the various products in this rapidly diversifying product category. The terms may differ 

by geographic region or simply by the prevailing preferences among young users. For example, some refer to all 

cigarette-shaped products as “e-cigarettes” or as “cigalikes,” 

and some may refer to the pen-style e-cigarettes as “hookah 

pens” or “vape pens” (Richtel 2014; Lempert et al. 2016).

Figure 1.1 Diversity of e-cigarette products

Source: Photo by Mandie Mills, CDC.
A Report of the Surgeon General

4 Chapter 1

This report focuses on research conducted among 

youth and young adults because of the implications of 

e-cigarette use in this population, particularly the potential for future public health problems. Understanding 

e-cigarette use among young persons is critical because 

previous research suggests that about 9 in 10 adult 

smokers first try conventional cigarettes during adolescence (USDHHS 2012). Similarly, youth e-cigarette experimentation and use could also extend into adulthood; 

however, e-cigarette use in this population has not been 

examined in previous reports of the Surgeon General. 

The first Surgeon General’s report on the health consequences of smoking was published in 1964; of the subsequent reports, those published in 1994 and 2012 focused 

solely on youth and young adults (USDHHS 1994, 2012). 

More recently, the 2012 report documented the evidence 

regarding tobacco use among youth and young adults, 

concluding that declines in cigarette smoking had slowed 

and that decreases in the use of smokeless tobacco had 

stalled. That report also found that the tobacco industry’s 

advertising and promotional activities are causal to the 

onset of smoking in youth and young adults and the continuation of such use as adults (USDHHS 2012). However, 

the 2012 report was prepared before e-cigarettes were as 

widely promoted and used in the United States as they are 

now. Therefore, this 2016 report documents the scientific 

literature on these new products and their marketing, 

within the context of youth and young adults. This report 

also looks to the future by examining the potential impact 

of e-cigarette use among youth and young adults, while 

also summarizing the research on current use, health 

consequences, and marketing as it applies to youth and 

young adults.

Evidence for this report was gathered from studies 

that included one or more of three age groups. We defined 

these age groups to be young adolescents (11–13 years of 

age), adolescents (14–17 years of age), and young adults 

(18–24 years of age). Some studies refer to the younger 

groups more generally as youth. Despite important issues 

related to e-cigarette use in adult populations, clinical and 

otherwise (e.g., their potential for use in conventional 

smoking cessation), that literature will generally not be 

included in this report unless it also discusses youth and 

young adults (Farsalinos and Polosa 2014; Franck et al. 

2014; Grana et al. 2014).

Given the recency of the research that pertains to 

e-cigarettes, compared with the decades of research on 

cigarette smoking, the “precautionary principle” is used 

to guide actions to address e-cigarette use among youth 

and young adults. This principle supports intervention 

to avoid possible health risks when the potential risks 

remain uncertain and have been as yet partially undefined 

(Bialous and Sarma 2014; Saitta et al. 2014; Hagopian et al. 

2015). Still, the report underscores and draws its conclusions from the known health risks of e-cigarette use in 

this age group.

Organization of the Report

This chapter presents a brief introduction to this 

report and includes its major conclusions followed by the 

conclusions of the chapters, the historical background of 

e-cigarettes, descriptions of the products, a review of the 

marketing and promotional activities of e-cigarette companies, and the current status of regulations from the U.S. 

Food and Drug Administration (FDA). Chapter 2 (“Patterns 

of E-Cigarette Use Among U.S. Youth and Young Adults”) 

describes the epidemiology of e-cigarette use, including current use (i.e., past 30 day); ever use; co-occurrence of using 

e-cigarettes with other tobacco products, like cigarettes; 

and psychosocial factors associated with using e-cigarettes, 

relying on data from the most recent nationally representative studies available at the time this report was prepared. 

Chapter 3 (“Health Effects of E-Cigarette Use Among U.S. 

Youth and Young Adults”) documents the evidence related 

to the health effects of e-cigarette use, including those that 

are associated with direct aerosol inhalation by users, the 

indirect health effects of e-cigarette use, other non-aerosol 

health effects of e-cigarette use, and secondhand exposure 

to constituents of the aerosol. Chapter 4 (“Activities of the 

E-Cigarette Companies”) describes e-cigarette companies’ 

influences on e-cigarette use and considers manufacturing 

and price; the impact of price on sales and use; the rapid 

changes in the industry, particularly the e-cigarette companies; and the marketing and promotion of e-cigarettes. 

Chapter 5 (“E-Cigarette Policy and Practice Implications”) 

discusses the implications for policy and practice at the 

national, state, and local levels. The report ends with a Call 

to Action to stakeholders—including policymakers, public 

health practitioners and clinicians, researchers, and the 

public—to work to prevent harms from e-cigarette use 

and secondhand aerosol exposure among youth and young 

adults.

Preparation of this Report

This Surgeon General’s report was prepared by 

the Office on Smoking and Health, National Center for 

Chronic Disease Prevention and Health Promotion, CDC, 

which is part of USDHHS. The initial drafts of the chapters were written by 27 experts who were selected for their 

knowledge of the topics addressed. These contributions 

are summarized in five chapters that were evaluated by 
Introduction, Conclusions, and Historical Background Relative to E-Cigarettes 5

E-Cigarette Use Among Youth and Young Adults

approximately 30  peer reviewers. After peer review, the 

entire manuscript was sent to more than 20 scientists 

and other experts, who examined it for its scientific integrity. After each review cycle, the drafts were revised by the 

report’s scientific editors on the basis of reviewers’ comments. Subsequently, the report was reviewed by various 

institutes and agencies within USDHHS. 

Scientific Basis of the Report

The statements and conclusions throughout this 

report are documented by the citation of studies published 

in the scientific literature. Publication lags have prevented an up-to-the-minute inclusion of all recently published articles and data. This overall report primarily cites 

peer-reviewed journal articles, including reviews that integrate findings from numerous studies and books that were 

published through December 2015. However, selected 

studies from 2016 have been added during the review process that provide further support for the conclusions in 

this report. When a cited study has been accepted for publication, but the publication has not yet occurred because 

of the delay between acceptance and final publication, the 

study is referred to as “in press.” This report also refers, on 

occasion, to unpublished research, such as presentations 

at a professional meeting, personal communications from 

a researcher, or information available in various media. 

These references are employed when acknowledged by 

the editors and reviewers as being from reliable sources, 

which add to the emerging literature on a topic.

Major Conclusions

1. E-cigarettes are a rapidly emerging and diversified 

product class. These devices typically deliver nicotine, flavorings, and other additives to users via an 

inhaled aerosol. These devices are referred to by a 

variety of names, including “e-cigs,” “e-hookahs,” 

“mods,” “vape pens,” “vapes,” and “tank systems.”

2. E-cigarette use among youth and young adults has 

become a public health concern. In 2014, current 

use of e-cigarettes by young adults 18–24 years of 

age surpassed that of adults 25 years of age and older.

3. E-cigarettes are now the most commonly used 

tobacco product among youth, surpassing conventional cigarettes in 2014. E-cigarette use is strongly 

associated with the use of other tobacco products 

among youth and young adults, including combustible tobacco products.

4. The use of products containing nicotine poses dangers to youth, pregnant women, and fetuses. The use 

of products containing nicotine in any form among 

youth, including in e-cigarettes, is unsafe.

5. E-cigarette aerosol is not harmless. It can contain harmful and potentially harmful constituents, 

including nicotine. Nicotine exposure during adolescence can cause addiction and can harm the 

developing adolescent brain.

6. E-cigarettes are marketed by promoting flavors 

and using a wide variety of media channels and 

approaches that have been used in the past for marketing conventional tobacco products to youth and 

young adults.

7. Action can be taken at the national, state, local, tribal, 

and territorial levels to address e-cigarette use among 

youth and young adults. Actions could include 

incorporating e-cigarettes into smokefree policies, 

preventing access to e-cigarettes by youth, price and 

tax policies, retail licensure, regulation of e-cigarette 

marketing likely to attract youth, and educational initiatives targeting youth and young adults.
A Report of the Surgeon General

6 Chapter 1

Chapter Conclusions

Chapter 1. Introduction, 

Conclusions, and Historical 

Background Relative to 

E-Cigarettes 

1. E-cigarettes are devices that typically deliver nicotine, flavorings, and other additives to users via an 

inhaled aerosol. These devices are referred to by a 

variety of names, including “e-cigs,” “e-hookahs,” 

“mods,” “vape pens,” “vapes,” and “tank systems.”

2. E-cigarettes represent an evolution in a long history 

of tobacco products in the United States, including 

conventional cigarettes.

3. In May 2016, the Food and Drug Administration 

issued the deeming rule, exercising its regulatory 

authority over e-cigarettes as a tobacco product.

Chapter 2. Patterns of E-Cigarette 

Use Among U.S. Youth and Young 

Adults

1. Among middle and high school students, both ever 

and past-30-day e-cigarette use have more than tripled since 2011. Among young adults 18–24 years 

of age, ever e-cigarette use more than doubled from 

2013 to 2014 following a period of relative stability 

from 2011 to 2013.

2. The most recent data available show that the prevalence of past-30-day use of e-cigarettes is similar 

among high school students (16% in 2015, 13.4% in 

2014) and young adults 18–24 years of age (13.6% 

in 2013–2014) compared to middle school students 

(5.3% in 2015, 3.9% in 2014) and adults 25 years of 

age and older (5.7% in 2013–2014).

3. Exclusive, past-30-day use of e-cigarettes among 

8th-, 10th-, and 12th-grade students (6.8%, 10.4%, 

and 10.4%, respectively) exceeded exclusive, 

past-30-day use of conventional cigarettes in 2015 

(1.4%, 2.2%, and 5.3%, respectively). In contrast—

in 2013–2014 among young adults 18–24 years of 

age—exclusive, past-30-day use of conventional cigarettes (9.6%) exceeded exclusive, past-30-day use of 

e-cigarettes (6.1%). For both age groups, dual use of 

these products is common.

4. E-cigarette use is strongly associated with the use 

of other tobacco products among youth and young 

adults, particularly the use of combustible tobacco 

products. For example, in 2015, 58.8% of high 

school students who were current users of combustible tobacco products were also current users of 

e-cigarettes.

5. Among youth—older students, Hispanics, and 

Whites are more likely to use e-cigarettes than 

younger students and Blacks. Among young 

adults—males, Hispanics, Whites, and those with 

lower levels of education are more likely to use 

e-cigarettes than females, Blacks, and those with 

higher levels of education.

6. The most commonly cited reasons for using 

e-cigarettes among both youth and young adults are 

curiosity, flavoring/taste, and low perceived harm 

compared to other tobacco products. The use of 

e-cigarettes as an aid to quit conventional cigarettes 

is not reported as a primary reason for use among 

youth and young adults.

7. Flavored e-cigarette use among young adult current 

users (18–24 years of age) exceeds that of older adult 

current users (25 years of age and older). Moreover, 

among youth who have ever tried an e-cigarette, a 

majority used a flavored product the first time they 

tried an e-cigarette.

8. E-cigarette products can be used as a delivery 

system for cannabinoids and potentially for other 

illicit drugs. More specific surveillance measures are 

needed to assess the use of drugs other than nicotine 

in e-cigarettes.

Chapter 3. Health Effects of 

E-Cigarette Use Among U.S. Youth 

and Young Adults

1. Nicotine exposure during adolescence can cause addiction and can harm the developing adolescent brain.
Introduction, Conclusions, and Historical Background Relative to E-Cigarettes 7

E-Cigarette Use Among Youth and Young Adults

2. Nicotine can cross the placenta and has known effects 

on fetal and postnatal development. Therefore, nicotine delivered by e-cigarettes during pregnancy can 

result in multiple adverse consequences, including 

sudden infant death syndrome, and could result in 

altered corpus callosum, deficits in auditory processing, and obesity.

3. E-cigarettes can expose users to several chemicals, 

including nicotine, carbonyl compounds, and volatile organic compounds, known to have adverse 

health effects. The health effects and potentially 

harmful doses of heated and aerosolized constituents 

of e-cigarette liquids, including solvents, flavorants, 

and toxicants, are not completely understood.

4. E-cigarette aerosol is not harmless “water vapor,” 

although it generally contains fewer toxicants than 

combustible tobacco products.

5. Ingestion of e-cigarette liquids containing nicotine 

can cause acute toxicity and possibly death if the 

contents of refill cartridges or bottles containing 

nicotine are consumed.

Chapter 4. Activities of the 

E-Cigarette Companies

1. The e-cigarette market has grown and changed 

rapidly, with notable increases in total sales of 

e-cigarette products, types of products, consolidation of companies, marketing expenses, and sales 

channels.

2. Prices of e-cigarette products are inversely related 

to sales volume: as prices have declined, sales have 

sharply increased.

3. E-cigarette products are marketed in a wide variety 

of channels that have broad reach among youth and 

young adults, including television, point-of-sale, 

magazines, promotional activities, radio, and the 

Internet.

4. Themes in e-cigarette marketing, including sexual 

content and customer satisfaction, are parallel to 

themes and techniques that have been found to be 

appealing to youth and young adults in conventional 

cigarette advertising and promotion.

Chapter 5. E-Cigarette Policy and 

Practice Implications

1. The dynamic nature of the e-cigarette landscape 

calls for expansion and enhancement of tobaccorelated surveillance to include (a) tracking patterns 

of use in priority populations; (b) monitoring the 

characteristics of the retail market; (c) examining 

policies at the national, state, local, tribal, and territorial levels; (d) examining the channels and messaging for marketing e-cigarettes in order to more 

fully understand the impact future regulations 

could have; and (e) searching for sentinel health 

events in youth and young adult e-cigarette users, 

while longer-term health consequences are tracked.

2. Strategic, comprehensive research is critical to 

identify and characterize the potential health risks 

from e-cigarette use, particularly among youth and 

young adults.

3. The adoption of public health strategies that are precautionary to protect youth and young adults from 

adverse effects related to e-cigarettes is justified.

4. A broad program of behavioral, communications, 

and educational research is crucial to assess how 

youth perceive e-cigarettes and associated marketing messages, and to determine what kinds of 

tobacco control communication strategies and 

channels are most effective.

5. Health professionals represent an important 

channel for education about e-cigarettes, particularly for youth and young adults.

6. Diverse actions, modeled after evidence-based 

tobacco control strategies, can be taken at the 

state, local, tribal, and territorial levels to address 

e-cigarette use among youth and young adults, 

including incorporating e-cigarettes into smokefree policies; preventing the access of youth to 

e-cigarettes; price and tax policies; retail licensure; 

regulation of e-cigarette marketing that is likely to 

attract youth and young adults, to the extent feasible 

under the law; and educational initiatives targeting 

youth and young adults. Among others, research 

focused on policy, economics, and the e-cigarette 

industry will aid in the development and implementation of evidence-based strategies and best 

practices.
A Report of the Surgeon General

8 Chapter 1

Historical Background

Understanding the role of e-cigarettes requires 

understanding the long history of tobacco use in the United 

States, including the role of nicotine delivery, the multiple examples of “reduced-harm” products and associated 

health claims, and the impact of using tobacco products on 

the public’s health. Since the late nineteenth century, when 

the “modern” cigarette came into use, scientists and public 

health officials have linked cigarette smoking to a remarkable number of adverse effects, and it is now recognized as 

the primary cause of premature death in the United States 

(USDHHS 2014). Correspondingly, for a century, manufacturers, scientists, entrepreneurs, and public health leaders 

have promoted or recommended product changes that 

might remove some of the harmful elements in cigarette 

smoke. E-cigarettes are among the latest products.

E-cigarettes are designed for users to inhale nicotine, flavorings, and other additives through an aerosol. 

The claims and marketing strategies employed by the 

e-cigarette companies, and the efforts made by others to 

develop scientific and regulatory tools to deal with these 

new products, both contribute to the current discourse 

on e-cigarettes. Many lessons for assessing the potential (and future) consequences of these products can be 

learned from examining the relevant experiences of the 

past century, especially the introduction of novel products (including e-cigarettes as well as other tobacco and 

nicotine products) and the claims of reduced exposure to 

toxins made by the industry and elsewhere.

Early Efforts to Modify Cigarettes

In the 1880s and 1890s, entrepreneurs promoted 

novel products that allegedly blocked nicotine and other 

constituents of conventional cigarettes believed to be 

poisonous. Dr. Scott’s Electric Cigarettes, advertised 

in Harper’s Weekly, claimed not only to light without 

matches but also to contain a cotton filter that “strains 

and eliminates the injurious qualities from the smoke,” 

including nicotine (Harper’s Weekly 1887). Nicotine 

delivery was essential to the development of the modern 

cigarette in the twentieth century; early on, this substance 

was thought to be addicting and thus vital to retaining 

customers. In 1913, the Camel brand was a new kind of 

cigarette that introduced high-nicotine content by using 

burley tobacco, which was generally too harsh to inhale 

into the lungs, but was made more inhalable through the 

addition of casings (e.g., sugars, licorice) (Tindall 1992; 

Proctor 2011). In 1916, American Tobacco introduced 

its Lucky Strike blended cigarette, and in 1918 Liggett & 

Myers (L&M) reformulated its Chesterfield brand to make 

it more palatable to users. As the market grew, advertisements for major brands routinely included health-related 

statements and testimonials from physicians. During 

the 1930s and 1940s, prominent advertising campaigns 

included claims like “Not a cough in a carload” (Old Gold) 

(Federal Trade Commission [FTC] 1964, p. LBA-5); “We 

removed from the tobacco harmful corrosive ACRIDS 

(pungent irritants) present in cigarettes manufactured 

in the old-fashioned way” (Lucky Strike) (FTC 1964, 

p. LBA-2); and “Smoking Camels stimulates the natural 

flow of digestive fluids ... increases alkalinity” (Camel) 

(FTC 1964, p. LBA-1a). Thus, early modifications to the 

cigarette were made so that it was more palatable, had a 

higher nicotine delivery and uptake, and could be marketed as “safe” (FTC 1964; Calfee 1985).

Filters, Tar Reduction, and Light and 

Low-Tar Cigarettes

The landmark 1964 Surgeon General’s report on 

smoking and health concluded that cigarette smoking 

contributed substantially to mortality from certain specific diseases, including lung cancer (U.S. Department of 

Health, Education, and Welfare 1964). Although the 1964 

report considered the topic, it found the evidence insufficient to assess the potential health benefits of cigarette filters. Cigarettes with filters became the norm by the 1960s, 

and marketing them with an overt message about harm 

reduction became the standard (National Cancer Institute 

[NCI] 1996). However, the Surgeon General convened 

another group of experts on June 1, 1966, to review the 

evidence on the role played by the tar and nicotine content in health. The group concluded that “[t]he preponderance of scientific evidence strongly suggests that the 

lower the ‘tar’ and nicotine content of cigarette smoke, 

the less harmful are the effects” (Horn 1966, p. 16,168). 

Subsequent studies have repeatedly failed to demonstrate 

health benefits of smoking light and low-tar cigarettes 

versus full-flavor cigarettes (Herning et al. 1981; Russell 

et al. 1982; Benowitz et al. 1983, NCI 2001).

Over the years, the tobacco industry used multiple 

methods to reduce the machine-tested yields of tar and 

nicotine in cigarettes as a way to claim “healthier” cigarettes. Beginning in the 1970s, tobacco companies advertised the tar and nicotine levels for their cigarettes, which 

encouraged smokers to believe, without substantiation, 
Introduction, Conclusions, and Historical Background Relative to E-Cigarettes 9

E-Cigarette Use Among Youth and Young Adults

they could reduce their risk of exposure to these constituents (Cummings et al. 2002; Pollay and Dewhirst 2002). 

In 1996, the FTC issued a statement that it would allow 

cigarette companies to include statements about tar and 

nicotine content in their advertising as long as they used a 

standardized machine-testing method (Peeler 1996).

The Role of Nicotine and Nicotine 

Delivery

Although the public health community understood early on that nicotine was the primary psychoactive ingredient in cigarette smoke, before the 1980s, 

little was known about the importance of nicotine in the 

addiction process beyond what the cigarette manufacturers had learned from their own research. Some scientists warned that due to nicotine addiction, a reduction 

in nicotine yields, along with decreases in tar, could lead 

smokers to change their smoking behavior, such as by 

smoking a greater number of cigarettes to maintain their 

nicotine intake or changing their behavior in more subtle 

ways, such as varying the depth of inhalation or smoking 

more of the cigarette (Jarvis et al. 2001; National Cancer 

Institute 2001; Thun and Burns 2001). Not until the 1970s 

and 1980s, as researchers studying other forms of drug 

abuse began to apply their research methods to cigarette 

smoking, did it become apparent that nicotine was similar 

in its addictive capability to other drugs of abuse, such as 

heroin and cocaine (USDHHS 1981, 1988). As described 

in the 1988 Surgeon General’s report and in subsequent 

research, symptoms associated with nicotine addiction 

include craving, withdrawal, and unconscious behaviors 

to ensure consistent intake of nicotine (USDHHS 1988; 

al’Absi et al. 2002; Hughes 2007).

Although the tobacco industry has long understood 

the importance of nicotine to maintain long-term cigarette smokers through addiction, public health officials 

did not fully appreciate this in a broad sense until the 

1988 Surgeon General’s report, The Health Consequences 

of Smoking: Nicotine Addiction (USDHHS 1988).

FDA and Nicotine Regulation

In 1988 (and again in 1994), the Coalition on 

Smoking OR Health and other public-interest organizations petitioned FDA to classify low-tar and nicotine 

products as drugs and to classify Premier, the shortlived “smokeless cigarette product” from R.J. Reynolds, 

as an alternative nicotine-delivery system (Stratton et al. 

2001). The Coalition on Smoking OR Health cited indirect 

claims made through advertising and marketing as evidence of R. J. Reynolds’s intent to have the product used 

for the mitigation or prevention of disease (Slade and 

Ballin 1993). Meanwhile, FDA launched an investigation 

into the practices of the tobacco industry, including the 

manipulation of nicotine delivery. FDA asserted its jurisdiction over cigarettes and smokeless tobacco and issued 

certain rules governing access to and promotion of these 

products (Federal Register 1996). On March 21, 2000, the 

U.S. Supreme Court ruled 5-4 that Congress had not yet 

given FDA the necessary statutory authority to issue any 

rules pertaining to tobacco products (Gottleib 2000; FDA 

v. Brown & Williamson Tobacco Corp. 2000). The subsequent debate over control of nicotine products, including 

their potential impact on youth, ultimately led to the passage of the 2009 Family Smoking Prevention and Tobacco 

Control Act, which gave FDA authority to regulate tobacco 

products. Thus, discussions about the introduction of 

novel nicotine-containing tobacco products in the market 

during the 1980s and 1990s helped shape the current regulation of tobacco and nicotine products.

New products introduced in the 1990s or later 

included modified tobacco cigarettes (e.g., Advance, 

Omni); cigarette-like products, also called cigalikes 

(e.g.,  Eclipse, Accord); and smokeless tobacco products 

(e.g., Ariva, Exalt, Revel, snus). Advance, made by Brown 

and Williamson, was test-marketed with the slogan “All 

of the taste ... Less of the toxins.” Vector launched a 

national advertising campaign for its Omni cigarette 

with the slogan “Reduced carcinogens. Premium taste.” 

In addition to the question of whether the claims were 

supported by sufficient evidence, scientists and tobacco 

control leaders raised concerns about the potential for 

adverse consequences associated with novel nicotine and 

tobacco products marketed for harm reduction, such as a 

reduction in cessation rates or increased experimentation 

by children (Warner and Martin 2003; Joseph et al. 2004; 

Caraballo et al. 2006). Studies have shown that smokers 

are interested in trying novel “reduced-exposure” products 

and perceive them to have lower health risks, even when 

advertising messages do not make explicit health claims 

(Hamilton et  al. 2004; O’Connor et al. 2005; Caraballo 

et al. 2006; Choi et al. 2012; Pearson et al. 2012).

At FDA’s request, the Institute of Medicine (IOM 

[now the National Academy of Medicine]) convened a 

committee of experts to formulate scientific methods and 

standards by which potentially reduced-exposure products 

(PREPs), whether the purported reduction was pharmaceutical or tobacco related, could be assessed. The committee concluded that “[f]or many diseases attributable to 

tobacco use, reducing risk of disease by reducing exposure to tobacco toxicants is feasible” (Stratton et al. 2001, 

p. 232). However, it also cautioned that “PREPs have not 
A Report of the Surgeon General

10 Chapter 1

yet been evaluated comprehensively enough (including to less harm reduction for a population (as well as less risk 

for a sufficient time) to provide a scientific basis for con- reduction for that individual) than would occur without 

cluding that they are associated with a reduced risk of dis- the PREP, and possibly to an adverse effect on the populaease compared to conventional tobacco use” (Stratton et al. tion” (Stratton et al. 2001, p. 235). Subsequently, in 2006, 

2001, p. 232). The committee added that “the major con- Judge Kessler cited these findings in her decision which 

cern for public health is that tobacco users who might demanded the removal of light and low-tar labeling due 

otherwise quit will use PREPs instead, or others may ini- to the misleading nature of these claims (United States v. 

tiate smoking, feeling that PREPs are safe. That will lead Philip Morris 2006).

The E-Cigarette

Invention of the E-Cigarette

An early approximation of the current e-cigarette 

appeared in a U.S. patent application submitted in 1963 by 

Herbert A. Gilbert and was patented in August 1965 (U.S. 

Patent No. 3,200,819) (Gilbert 1965). The application was 

for a “smokeless nontobacco cigarette,” with the aim of 

providing “a safe and harmless means for and method of 

smoking” by replacing burning tobacco and paper with 

heated, moist, flavored air. A battery-powered heating element would heat the flavor elements without combustion 

(Gilbert 1965). The Favor cigarette, introduced in 1986, 

was another early noncombustible product promoted 

as an alternative nicotine-containing tobacco product 

(United Press International 1986; Ling and Glantz 2005).

The first device in the recent innovation in 

e-cigarettes was developed in 2003 by the Chinese pharmacist Hon Lik, a former deputy director of the Institute of 

Chinese Medicine in Liaoning Province. Lik’s patent application described a kind of electronic atomizing cigarette 

(Hon 2013). With support from Chinese investors, in 2004 

the product was introduced on the Chinese market under 

the company name Ruyan (Sanford and Goebel 2014). The 

product gained some attention among Chinese smokers 

early on as a potential cessation device or an alternative 

cigarette product.

The e-cigarette was part of the U.S. market by the 

mid-2000s, and by 2010 additional brands started to 

appear in the nation’s marketplace, including Ruyan and 

Janty (Regan et al. 2013). Ruyan gained a U.S. patent for 

its product with the application stating that the product 

is “an electronic atomization cigarette that functions as 

substitutes (sic) for quitting smoking and cigarette substitutes.” (U.S. Patent No. 8,490,628 B2, 2013). In August 

2013, Imperial Tobacco Group purchased the intellectual 

property behind the Ruyan e-cigarette for $75 million. 

As of 2014 an estimated 90% of the world’s production 

of e-cigarette technology and products came from mainland China, mainly Guangdong Province and Zhejiang 

Province (Barboza 2014).

Sales of e-cigarettes in the United States have risen 

rapidly since 2007. Widespread advertising via television 

commercials and through print advertisements for popular brands, often featuring celebrities, has contributed 

to a large increase in e-cigarette use by both adults and 

youth since 2010 (Felberbaum 2013; King et al. 2013; 

Regan et al. 2013). Additionally, marketing through social 

media, as well as other forms of Internet marketing, has 

been employed to market these devices (Huang et al. 2014; 

Kim et al. 2014).

In 2013, an estimated 13.1 million middle school 

and high school students were aware of e-cigarettes 

(Wang et al. 2014). According to data from the National 

Youth Tobacco Survey, in 2011 the prevalence of current 

e-cigarette use (defined as use during at least 1 day in 

the past 30 days) among high school students was 1.5%; 

prevalence increased dramatically, however, to 16% by 

2015, surpassing the rate of conventional-cigarette use 

among high school students (CDC 2016b; see Chapter 

2). This equates to 2.4 million high school students and 

620,000 middle school students having used an e-cigarette 

at least one time in the past 30 days in 2015 (CDC 2016b).

These trends have led to substantial concern and 

discussion within public health communities, including 

state and national public health agencies, professional 

organizations, and school administrators and teachers. 

A primary concern is the potential for nicotine addiction 

among nonsmokers, especially youth and young adults, 

and that this exposure to nicotine among youth and young 

adults is harmful. The diversity and novelty of e-cigarette 

products on the market and ongoing product innovations make assessments of the biological effects of current 

e-cigarettes under actual conditions of use—such as their 

long-term harmfulness—difficult to measure. Unanswered 

questions remain about the risk profile of these devices, 

their potential use by young people as a first step to other 

nicotine products, and their total impact on public health. 

There are diverging opinions about the potential public 

health impact of these new products. Some public health 

scientists have highlighted the potential for alternative 
Introduction, Conclusions, and Historical Background Relative to E-Cigarettes 11

E-Cigarette Use Among Youth and Young Adults

nicotine products to serve as a substitute for conventional 

cigarettes and thus a harm reduction tool (Henningfield 

et al. 2003; Abrams 2014). Others have cautioned that 

the use of alternative nicotine products might become 

a bridge that may lead to greater tobacco product use—

including dual- or multiple-product use—or initiate nicotine addiction among nonsmokers, especially youth (Cobb 

et al. 2010; Wagener et al. 2012; Benowitz and Goniewicz 

2013; Britton 2013; Chapman 2013; Etter 2013; USDHHS 

2014). Current evidence is insufficient to reject either of 

these hypotheses.

E-Cigarette Products

Components and Devices

E-cigarette devices are composed of a battery, a reservoir for holding a solution that typically contains nicotine, a heating element or an atomizer, and a mouthpiece 

through which the user puffs (Figure 1.2). The device 

heats a liquid solution (often called e-liquid or e-juice) 

into an aerosol that is inhaled by the user. E-liquid typically uses propylene glycol and/or glycerin as a solvent for 

the nicotine and flavoring chemicals

Flavors and E-Cigarettes

The e-liquids in e-cigarettes are most often flavored; 

a study estimated that 7,700 unique flavors exist (Zhu 

et al. 2014) and that most of them are fruit or candy flavors (Figure 1.3). A content analysis of the products available via online retail websites documented that tobacco, 

mint, coffee, and fruit flavors were most common, followed by candy (e.g., bubble gum), unique flavors (e.g., 

Belgian waffle), and alcoholic drink flavors (e.g., strawberry daiquiri) (Grana and Ling 2014). Some retail stores 

are also manufacturers that create custom flavors, which 

increases the variety of flavors available.

The widespread availability and popularity of flavored e-cigarettes is a key concern regarding the potential 

public health implications of the products. The concern, among youth, is that the availability of e-cigarettes 

with sweet flavors will facilitate nicotine addiction and 

simulated smoking behavior—which will lead to the 

use of conventional tobacco products (Kong et al. 2015; 

Krishnan-Sarin et al. 2015). Flavors have been used for 

decades to attract youth to tobacco products and to mask 

the flavor and harshness of tobacco (USDHHS 2012). 

Industry documents show that tobacco companies marketed flavored little cigars and cigarillos to youth and to 

African Americans to facilitate their uptake of cigarettes 

(Kostygina et al. 2014). Companies also intended flavored 

smokeless tobacco products to facilitate “graduation” to 

unflavored products that more easily deliver more nicotine to the user (USDHHS 2012). Various studies have 

shown that youth are more likely than adults to choose 

flavored cigarettes and cigars (CDC 2015b). Concern over 

these findings led Congress to include a ban on characterizing flavors for cigarettes, other than tobacco or menthol, 

in the Tobacco Control Act. A similar concern exists about 

e-cigarettes, and this concern is supported by studies indicating that youth and young adults who have ever used 

e-cigarettes begin their use with sweet flavors rather than 

tobacco flavors (Kong et al. 2015; Krishnan-Sarin et al. 

2015). Notably, 81.5% of current youth e-cigarette users 

said they used e-cigarettes “because they come in flavors I 

like” (Ambrose et al. 2015).

E-Cigarette Devices

First-generation e-cigarettes were often similar in 

size and shape to conventional cigarettes, with a design 

that also simulated a traditional cigarette in terms of the 

colors used (e.g., a white body with tan mouthpiece). 

These devices were often called cigalikes, but there were 

other products designed to simulate a cigar or pipe. Other 

cigalikes were slightly longer or narrower than a cigarette; 

they may combine white with tan or may be black or colored brightly. These newer models use a cartridge design 

for the part of the device that holds the e-liquid, which is 

either prefilled with the liquid or empty and ready to be 

filled. The user then squeezes drops of the e-liquid onto a 

wick (or bit of cotton or polyfil) connected to the heating 

element and atomizer (Figure 1.4). As e-cigarettes have 

become more popular, their designs have become more 

diverse, as have the types of venues where they are sold 

(Noel et al. 2011; Zhu et al. 2014).

Second-generation devices include products that 

are shaped like pens, are comparatively larger and cylindrical, and are often referred to as “tank systems” in a nod 

to the transparent reservoir that holds larger amounts 

of e-liquid than previous cartridge-containing models. 

Third- and fourth-generation devices represent a diverse 

set of products and, aesthetically, constitute the greatest 

departure from the traditional cigarette shape, as many 

are square or rectangular and feature customizable and 

rebuildable atomizers and batteries. In addition, since the 

beginning of the availability of e-cigarettes and their component parts, users have been modifying the devices or 

building their own devices, which are often referred to 

as “mods.” The differences in design and engineering of 

the products are key factors in the size, distribution, and 

amount of aerosol particles and the variability in levels of 

chemicals and nicotine present in the e-liquid/aerosol and 

delivered to the user (Brown and Cheng 2014).
A Report of the Surgeon General

12 Chapter 1

Figure 1.2 Parts of an e-cigarette device

Source: Photo by Mandie Mills, CDC.
Introduction, Conclusions, and Historical Background Relative to E-Cigarettes 13

E-Cigarette Use Among Youth and Young Adults

Figure 1.3 Examples of e-liquid flavors

Source: Photo by Mandie Mills, CDC.

Figure 1.4 E-liquids being poured into an e-cigarette device

Source: Photo by Mandie Mills, CDC.

E-Cigarette Product Components 

and Risks

One of the primary features of the more recent generation of devices is that they contain larger batteries and are 

capable of heating the liquid to a higher temperature, potentially releasing more nicotine, forming additional toxicants, 

and creating larger clouds of particulate matter (Bhatnagar 

et al. 2014; Kosmider et al. 2014). For instance, one study 

demonstrated that, at high temperatures (150°C), exceedingly high levels of formaldehyde—a carcinogen (found to 

be 10 times higher than at ambient temperatures)—are 

present that are formed through the heating of the e-liquid 

solvents (propylene glycol and glycerin), although the level 

of tolerance of actual users to the taste of the aerosol heated 

to this temperature is debated (Kosmider et al. 2014; CDC 

2015a; Flavor and Extract Manufacturers Association of 

the United States 2015; Pankow et al. 2015). There is also 

concern regarding the safety of inhaling e-cigarette flavorings. Although some manufacturers have claimed their 

flavorants are generally recognized as safe for food additives (i.e., to be used in preparing foods for eating), little is 

known about the long-term health effects of inhaling these 

substances into the lungs (CDC 2015a).

Many devices can be readily customized by their 

users, which is also leading to the concern that these 

devices are often being used to deliver drugs other than 

nicotine (Brown and Cheng 2014). Most commonly 

reported in the news media, on blogs, and by user anecdote 
A Report of the Surgeon General

14 Chapter 1

is the use of certain types of e-cigarette-related products 

for delivering different forms of marijuana (Morean et al. 

2015; Schauer et al. 2016). The tank systems, for example, 

have been used with liquid tetrahydrocannabinol (THC) 

or hash oil. Some personal vaporizer devices can be used 

with marijuana plant material or a concentrated resin 

form of marijuana called “wax.” One study describes the 

use, in Europe, of e-cigarette devices to smoke marijuana 

(Etter 2015).

The various e-cigarette products, viewed as a group, 

lack standardization in terms of design, capacity for safely 

holding e-liquid, packaging of the e-liquid, and features 

designed to minimize hazards with use (Yang et al. 2014). 

All of these design features may have implications for the 

health impact of e-cigarette use. Notably, from 2010 to 

2014, calls to poison control centers in the United States 

about exposures related to e-cigarettes increased dramatically. According to the American Association of Poison 

Control Centers (2015), 271 cases were reported in 2011, 

but 3,783 calls were reported in 2014. Among all calls, 

51%  involved exposure among children younger than 

5 years of age (CDC 2014). Most poisonings appear to have 

been caused by exposure to nicotine-containing liquid 

(CDC 2014). The lack of a requirement for child-resistant 

packaging for e-liquid containers may have contributed to these poisonings. Since these data were released, 

one death in the United States has been confirmed in a 

child who drank e-liquid containing nicotine (Mohney 

2014). Additionally, serious adverse reactions, including 

at least two deaths, have been reported to FDA in cases 

that could be attributed to the use of e-cigarettes (FDA 

2013). This increase in poisonings prompted the Child 

Nicotine Poisoning Prevention Act of 2015 (2016), which 

was enacted in January 2016. This law requires any container of liquid nicotine that is sold, manufactured, distributed, or imported into the United States to be placed 

in packaging that is difficult to open by children under 

5 years of age.

Secondary risks are also of concern regarding 

e-cigarettes, including passive exposure to nicotine and 

other chemicals, and adverse events due to device malfunction. Nicotine is a neuroteratogen, and its use by 

pregnant women exposes a developing fetus to risks that 

are well documented in the 50th-anniversary Surgeon 

General’s report on smoking (USDHHS 2014) and include 

impaired brain development (England et al. 2015) and 

other serious consequences. Finally, another consequence 

of the lack of device regulation is the occurrence of battery 

failures and subsequent explosions. Explosions have typically occurred during charging, resulting in house and car 

fires, and sometimes causing injuries to those involved. 

From 2009 to late 2014, 25 incidents of explosions and 

fires involving e-cigarettes occurred in the United States 

(Chen 2013; U.S. Fire Administration 2014; FDA 2013).

E-Cigarette Companies

E-cigarette companies include manufacturers, 

wholesalers, importers, retailers, distributors, and some 

other groups that overlap with these entities (Barboza 2014; 

Whelan 2015). Currently, most of the products are manufactured in Shenzhen, Guangdong Province, China (Cobb 

et al. 2010; Grana et al. 2014; Zhu et al. 2014). One study 

placed the number of brands at 466 in January 2014 and 

found a net increase of 10.5 brands per month (Zhu et al. 

2014). All the major tobacco companies (e.g.,  Reynolds 

American, Altria; Table 1.1) and many smaller, independent companies are now in the business. When e-cigarettes 

first entered the U.S. market, they were sold primarily by 

independent companies via the Internet and in shopping 

malls at kiosks where those interested could sample the 

products. A unique feature of the e-cigarette industry, 

compared to other tobacco and nicotine products, is the 

recruitment of visitors to their websites as “affiliates” or 

distributors to help market the products and, in turn, 

receive commissions on sales (Grana and Ling 2014; Cobb 

et al. 2015). For example, some companies offer a way for 

users to earn a commission by advertising the products 

(e.g., a banner ad is placed on one’s website, and when 

someone clicks on the link and subsequently purchases 

a product, the website owner gets a percentage commission). Some companies also offer rewards programs for 

recruiting new customers or for brand loyalty, with website users earning points for free or reduced-price products (Richardson et al. 2015).

E-cigarettes are now in widespread national distribution through convenience stores, tobacco stores, pharmacies, “big box” retail chains such as Costco, online retailers, 

and shops devoted to e-cigarette products (often called 

“vape shops”) (Giovenco et al. 2015; Public Health Law 

Center 2015). The “vape shops” offer a place to buy customizable devices and e-liquid solutions in many flavors and 

sometimes include a café or other elements that promote 

socializing, essentially making such places like a lounge. 

With the rapid increase in distribution and marketing in 

the industry, sales have increased rapidly and were projected to reach $2.5 billion in 2014 and $3.5 billion in 2015, 

including projections for retail and online channels, as well 

as “vape shops” (Wells Fargo Securities 2015).
Introduction, Conclusions, and Historical Background Relative to E-Cigarettes 15

E-Cigarette Use Among Youth and Young Adults

Table 1.1 Multinational tobacco companies with e-cigarette brands

Company E-cigarette brand

Altria (NuMark) MarkTen, Green Smoke

Philip Morris International Heat-not-burn, IQOS brand (Vape Ranks 2014)

E-cigs, Nicolites by Nicocigs (Philip Morris International 2014)

Reynolds (Reynolds Vapor Company) VUSE

Lorillard (Lorillard Vapor Company) blu (until 2015)

Imperial Tobacco (Fontem Ventures) Puritane (formerly Ruyan)

blu (acquired in 2015)

British American Tobacco Vype

Swisher E-swisher

Japan Tobacco International (JTI) E-Lites, offered in the United Kingdom by Zandera Ltd., which 

was acquired by Japan Tobacco Inc. in 2014 (Japan Tobacco Inc. 

2014)

Ploom (tobacco pods in heat-not-burn) and Ploom PAX (used for 

vaporizing marijuana) (Japan Tobacco Inc. 2015)

The advertising and marketing of e-cigarette products has engendered skepticism among public health 

professionals and legislators, who have noted many similarities to the advertising claims and promotional tactics used 

for decades by the tobacco industry to sell conventional 

tobacco products (Campaign for Tobacco-Free Kids 2013; 

CDC 2016a). Indeed, several of the e-cigarette marketing 

themes have been reprised from the most memorable cigarette advertising, including those focused on freedom, 

rebellion, and glamor (Grana and Ling 2014). E-cigarette 

products are marketed with a variety of unsubstantiated 

health and cessation messages, with some websites featuring videos of endorsements by physicians (another 

reprisal of old tobacco industry advertising) (Grana and 

Ling 2014; Zhu et al. 2014). Unlike conventional cigarettes, 

for which advertising has been prohibited from radio and 

television since 1971, e-cigarette products are advertised on 

both radio and television, with many ads featuring celebrities. E-cigarettes also are promoted through sports and 

music festival sponsorships, in contrast to conventional 

cigarettes and smokeless tobacco products, which have 

been prohibited from such sponsorships since the Master 

Settlement Agreement in 1998. E-cigarettes also appear as 

product placements in television shows and movies (Grana 

et al. 2011; Grana and Ling 2014).

Another key avenue for e-cigarette promotion 

is social media, such as Twitter, Facebook, YouTube, 

and Instagram. As is true in the tobacco industry, the 

e-cigarette industry organizes users through advocacy 

groups (Noel et al. 2011; Harris et al. 2014; Saitta et al. 

2014; Caponnetto et al. 2015). The extensive marketing 

and advocacy through various channels broadens exposure to e-cigarette marketing messages and products; 

such activity may encourage nonsmokers, particularly 

youth and young adults, to perceive e-cigarette use as 

socially normative. The plethora of unregulated advertising is of particular concern, as exposure to advertising 

for tobacco products among youth is associated with cigarette smoking in a dose-response fashion (USDHHS 2012).

Federal Regulation of E-Cigarettes

A “Two-Pronged” Approach to 

Comprehensive Tobacco Control

Since the passage of the Tobacco Control Act in 

2009, FDA has had the authority to regulate the manufacturing, distribution, and marketing of tobacco products 

sold in the United States. FDA had immediate jurisdiction over cigarettes, roll-your-own cigarette tobacco, and 

smokeless tobacco. In May 2016, FDA asserted jurisdiction over products that meet the statutory definition of 

a tobacco product, including e-cigarettes, except accessories of these products (Federal Register 2016). That regulation is currently under litigation.
A Report of the Surgeon General

16 Chapter 1

The IOM’s 2007 report, Ending the Tobacco Problem: 

A Blueprint for the Nation, established a “two-pronged” 

strategy for comprehensive tobacco control: (1) full implementation of proven, traditional tobacco control measures 

such as clean indoor air laws, taxation, and countermarketing campaigns; and (2) “strong federal regulation of 

tobacco products and their marketing and distribution” 

(Bonnie et al. 2007, p. 1).

Included in FDA’s broad authority are the restriction of marketing and sales to youth, requiring disclosure of ingredients and harmful and potentially harmful 

constituents, setting product standards (e.g., requiring 

the reduction or elimination of ingredients or constituents), requiring premarket approval of new tobacco products and review of modified-risk tobacco products, and 

requiring health warnings. The standard for FDA to use 

many of its regulatory authorities is whether such an 

action is appropriate for the protection of public health 

(Federal Food, Drug, and Cosmetic Act, § 907(a)(3)(A)). 

The public health standard in the Tobacco Control Act 

also requires FDA to consider the health impact of certain 

regulatory actions at both the individual and population 

levels, including their impact on nonusers, and on initiation and cessation (Federal Food, Drug, and Cosmetic Act, 

§ 907(a)(3)(B)).

Importantly, the Tobacco Control Act preserves the 

authority of state, local, tribal, and territorial governments to enact any policy “in addition to, or more stringent than” requirements established under the Tobacco 

Control Act “relating to or prohibiting the sale, distribution, possession, exposure to, access to, advertising 

and promotion of, or use of tobacco products by individuals of any age” (Federal Food, Drug, and Cosmetic Act, 

§ 916(a)(1)). This preservation of state and local authority 

ensures the continuation of more local-level, comprehensive tobacco control. However, the statute expressly 

preempts states and localities from establishing or continuing requirements that are different from or in addition to FDA requirements regarding standards for tobacco 

products, premarket review, adulteration, misbranding, 

labeling, registration, good manufacturing practices, or 

modified-risk tobacco products (Federal Food, Drug, and 

Cosmetic Act, § 916(a)(2)(A)). But this express preemption provision does not apply to state and local authority 

to impose requirements relating to the “sale, distribution, 

possession, information reporting to the State, exposure 

to, access to, the advertising and promotion of, or use of, 

tobacco products by individuals of any age . . .” (Federal 

Food, Drug, and Cosmetic Act, § 916(a)(2)(b)). The interaction of these complex provisions related to federal preemption of state law has been the subject of challenges 

by the tobacco industry to state and local laws. Thus far, 

courts have upheld certain local ordinances restricting the 

sale of flavored tobacco products (National Association 

of Tobacco Outlets, Inc. v. City of Providence 2013; U.S. 

Smokeless Tobacco Manufacturing Co. v. City of New 

York 2013).

Legal Basis for Regulating 

E-Cigarettes as Tobacco Products

In the United States, e-cigarettes can be regulated 

either as products marketed for therapeutic purposes or 

as tobacco products. Since the advent of e-cigarettes in the 

United States around 2007, manufacturers have had the 

option to apply to FDA’s Center for Drug Evaluation and 

Research (CDER) or Center for Devices and Radiological 

Health (CDRH) for approval to market e-cigarettes for therapeutic purposes; as of August 2016, no e-cigarette manufacturers have received approval through this avenue.

In 2008 and early 2009, FDA detained multiple shipments of e-cigarettes from overseas manufacturers and 

denied them entry into the United States on the grounds 

that e-cigarettes were unapproved drug-device combination products (FDA 2011). Sottera, Inc., which now does 

business as NJOY, challenged that determination (Smoking 

Everywhere, Inc. and Sottera, Inc., d/b/a NJOY v. U.S. Food 

and Drug Administration, et al. 2010; Bloomberg Business 

2015). Between the filing of the lawsuit and a decision on 

the motion for preliminary injunction, Congress passed 

the Tobacco Control Act and the President signed it into 

law. The Tobacco Control Act defines the term “tobacco 

product,” in part, as any product, including component 

parts or accessories, “made or derived from tobacco” that is 

not a “drug,” “device,” or “combination product” as defined 

by the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 

321(rr)) (Family Smoking Prevention and Tobacco Control 

Act 2009, § 101(a)). The District Court subsequently 

granted a preliminary injunction relying on the Supreme 

Court’s decision in Brown and Williamson (1996) and the 

recently enacted Tobacco Control Act. FDA appealed the 

decision and the U.S. Court of Appeals for the D.C. Circuit 

held that e-cigarettes and, therefore, other products “made 

or derived from tobacco” are not drug/device combinations 

unless they are marketed for therapeutic purposes, but can 

be regulated by FDA as tobacco products under the Tobacco 

Control Act (Sottera, Inc. v. Food & Drug Administration 

2010).

On September 25, 2015, FDA proposed regulations 

to describe the circumstances in which a product made 

or derived from tobacco that is intended for human consumption will be subject to regulation as a drug, device, or 

a combination product. The comment period for this proposed regulation closed on November 24, 2015.
Introduction, Conclusions, and Historical Background Relative to E-Cigarettes 17

E-Cigarette Use Among Youth and Young Adults

Most e-cigarettes marketed and sold in the United 

States today contain nicotine made or derived from 

tobacco. Although some e-cigarettes claim that they 

contain nicotine not derived from tobacco, or that they 

contain no nicotine at all (Lempert et al. 2016), there may 

be reason to doubt some of these claims. Currently, synthetic nicotine and nicotine derived from genetically modified, nontobacco plants are cost-prohibitive for e-cigarette 

manufacturers, although technological advances could 

eventually increase the cost-effectiveness of using nicotine 

that was not derived from tobacco (Lempert et al. 2016). 

The health effects of passive exposure to e-cigarettes with 

no nicotine, as well as their actual use and the extent of 

exposure to these products, have just begun to be studied 

(Hall et al. 2014; Marini et al. 2014; Schweitzer et al. 2015) 

and some states and localities are taking steps to regulate e-cigarettes that do not contain nicotine or tobacco 

(Lempert et al. 2016).

Deeming Rule

The Tobacco Control Act added a new chapter to 

the Federal Food, Drug, and Cosmetic Act, which provides FDA with authority over tobacco products. The new 

chapter applied immediately to all cigarettes, cigarette 

tobacco, roll-your-own tobacco, and smokeless tobacco; 

and the law included “any other tobacco products that 

the Secretary of Health and Human Services by regulation deems to be subject to this chapter” (Federal Food, 

Drug, and Cosmetic Act, §901 (b)). Therefore, to regulate e-cigarettes as tobacco products, FDA was required to 

undertake a rulemaking process to extend its regulatory 

authority to include e-cigarettes.

Consequently, in May 2016, through its Center 

for Tobacco Products (CTP), FDA issued a rule—often 

referred to as the “deeming rule”—to extend its authority 

over all products meeting the definition of a tobacco 

product, except accessories of the newly deemed products. 

This rule extended FDA’s tobacco product authorities to 

include e-cigarettes and their components and parts (e.g., 

nicotine cartridges), but also to such products as cigars, 

pipe tobacco, nicotine gels, waterpipe/hookah tobacco, 

and dissolvables not already regulated as smokeless 

tobacco products (Federal Register 2016). This regulation 

is currently under litigation. The deeming rule subjects 

e-cigarettes to Tobacco Control Act provisions, including:

• Prohibitions on adulterated and misbranded 

products;

• Required disclosure of existing health information, 

including lists of ingredients and documents on 

health effects;

• Required registration of manufacturers;

• Required disclosure of a list of all tobacco products, including information related to labeling and 

advertising;

• Premarket review of new tobacco products 

(i.e., those not on the market on February 15, 2007);

• Restrictions on products marketed with claims 

about modified risk.

In addition to the aforementioned Tobacco Control 

Act provisions applicable to all deemed tobacco products, 

the Tobacco Control Act grants FDA authority to undertake a broad range of other actions on specific classes 

of products. In its deeming rule, FDA included the following additional actions for tobacco products, including 

e-cigarettes:

• Minimum age restrictions to prevent sales to minors;

• Requirements to include a nicotine warning; and

• Prohibitions on vending machine sales, unless in a 

facility that never admits youth.

Future Regulatory Options

E-cigarette manufacturers have the option to apply 

to FDA to authorize the marketing of their products or 

to be able to manufacture and sell tobacco products marketed with modified-risk claims, in addition to the existing 

option to apply to FDA’s CDER or CDRH for approval to 

market their products for therapeutic purposes. FDA also 

has authority to undertake a number of actions if the 

Secretary of USDHHS finds such actions to be appropriate 

for the protection of public health, including:

• Product standards, including restrictions on flavors;

• Restrictions on promotion, marketing, and advertising, and prohibitions on brand-name sponsorship 

of events;

• Minimum package sizes;

• Prohibitions on self-service displays;
A Report of the Surgeon General

18 Chapter 1

• Child-resistant packaging and the inclusion of 

health warnings; and

• Regulation of nicotine levels in products.

Despite this broad authority, FDA is prohibited from 

certain regulatory actions, even if those actions may be 

appropriate for the protection of public health. Specifically, 

FDA generally cannot restrict tobacco use in public places, 

levy taxes on tobacco products, prohibit sales by a specific 

category of retail outlet (e.g., pharmacies), completely eliminate nicotine in tobacco products, require prescriptions 

for tobacco products unless it is marketed for therapeutic 

purposes, or establish a federal minimum age of sale for 

tobacco products above 18 years of age. Thus, even if FDA 

fully exercises all of its existing authority over e-cigarettes, 

regulation will still need to be complemented at the state 

and local levels, including efforts previously shown to be 

effective for conventional tobacco products, such as comprehensive smokefree laws at the state and local levels, pricing 

strategies, raising the minimum age of sales to minors to 

21, and high-impact countermarketing campaigns. In the 

current context of rising rates of use by youth, localities 

and states can also implement policies and programs that 

minimize the individual- and population-level harms of 

e-cigarettes (see Chapter 5).

Summary

This chapter presents the major conclusions of 

this Surgeon General’s report and the conclusions of 

each chapter. E-cigarettes are presented within their historical context, with an overview of the components of 

these devices and the types of products. In 2016, FDA 

announced its final rule to regulate e-cigarettes under the 

Family Smoking Prevention and Tobacco Control Act. The 

chapter outlines options for the regulation of e-cigarettes, 

particularly as they relate to youth and young adults, 

based on successful smoking policies. The need to protect 

youth and young adults from initiating or continuing the 

use of nicotine-containing products forms a strong basis 

for the need to regulate e-cigarettes at the local, state, and 

national levels in the future.
Introduction, Conclusions, and Historical Background Relative to E-Cigarettes 19

E-Cigarette Use Among Youth and Young Adults

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25

Chapter 2 

Patterns of E-Cigarette Use Among U.S. Youth and 

Young Adults

Introduction 27

Sources of Data 27

Other Literature 27

Key Findings 28

Youth 28

Current Prevalence 28

Trends in Prevalence 28

Young Adults 37

Current Prevalence 37

Trends in Prevalence 37

E-Cigarette Use and Use of Other Tobacco Products 37

Cross-Sectional Studies 37

Longitudinal Studies 53

E-Cigarette Use and Other Substance Use 57

E-Cigarettes and Marijuana 58

Use of Flavored E-Cigarettes 58

Consumer Perceptions of E-Cigarettes 59

Perceived Harm of E-Cigarettes 59

Reasons for Use and Discontinuation 75

Evidence Summary 86

Conclusions 88

References 89

Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 27

E-Cigarette Use Among Youth and Young Adults

Introduction

This chapter documents patterns and trends in 

awareness of electronic cigarettes (e-cigarettes), their 

use, and perceptions about these devices among youth 

and young adults in the United States. Both the awareness of e-cigarettes and levels of their use have increased 

rapidly throughout the U.S. population. Understanding 

young people’s patterns of e-cigarette use is essential 

to determining the scope of potential benefits or harms 

that these products may have from a public health perspective. This chapter summarizes the patterns of use of 

e-cigarettes, identifies subgroups at higher risk for using

them, highlights the ways in which e-cigarettes are used

with other tobacco products, and identifies correlates of

e-cigarette use, including knowledge, attitudes, beliefs,

and sociodemographic characteristics. In most cases, the

term “e-cigarette(s)” is used, but when needed to accord

with usage in the cited literature, the acronym “ENDS”

(electronic nicotine delivery systems) is employed.

Sources of Data

Data summarized in this chapter come from nationally representative datasets that were federally funded and 

peer-reviewed literature of subnational and international 

surveillance studies of e-cigarette use that were mostly 

cross-sectional in design. Appendix 2.1. and Table A2.1-1 

in that appendix1

1All appendixes and appendix tables that are cross-referenced in this chapter are available only online at http://www.surgeongeneral.gov/

library/reports/

 describe all the years of data available 

for these data sources, but only selected years are used for 

this report. For youth, this report relies on data from the 

National Youth Tobacco Survey (NYTS) and the Monitoring 

the Future Study (MTF), as measures of e-cigarette 

use were available for at least two or more time points. 

For this reason, the report also relies on data from the 

National Adult Tobacco Survey (NATS) for young adults. 

More recently, the Youth Risk Behavior Surveillance 

System and other surveys from the National Center for 

Health Statistics have added measures of e-cigarette use 

to their surveys, but only one data point was available at 

the time this report was prepared. Only five longitudinal 

studies were available on this topic at the time this report 

was prepared (Leventhal et al. 2015; Primack et al. 2015; 

Barrington-Trimis et al. 2016; Unger et  al. 2016; Wills 

et al. 2016). Because e-cigarettes only became prevalent 

in the tobacco product marketplace in recent years, minimal data are available on their use before 2011. Given the 

paucity of surveillance information on e-cigarettes and the 

low prevalence of their use in the early years of their availability in the United States, peer-reviewed studies with 

smaller subnational samples are used in this chapter to 

complement national surveillance data. Surveillance of 

e-cigarette use presents a unique set of challenges, given

the emerging and dynamic market specific to these products (see Chapter 4 for more on the latter topic). Appendix

2.1 and Tables A2.2-1 and A2.2-2 in Appendix 2.2 summarize the key terms and measures used in this chapter.

Other Literature

This chapter also summarizes findings from peerreviewed literature on e-cigarettes that were identified 

through a systematic review of studies of these products 

from the United States and abroad. A literature search was 

conducted in April 2015 (Glasser et al. 2015) using the 

National Library of Medicine’s PubMed database and the 

following keywords: “e-cigarette*” OR “electronic cigarette” OR “electronic cigarettes” OR “electronic nicotine 

delivery” OR “vape” OR “vaping.” Articles were excluded 

from this review for any of five reasons: (1) the article was 

not available in English; (2) the article was not relevant 

to e-cigarettes; (3) the study included nonhuman subjects; (4) the study did not include original data; or (5) the 

study did not include findings specific to adolescents or 

young adults. More details about this review’s methodology are available in Glasser and colleagues’ (2015) report. 

The search was subsequently updated in November 2015, 

January 2016, and March 2016 during continued development of the report. For consistency, the same search 

strategy and databases were employed at all times. Studies 

on patterns of e-cigarette use behaviors for both youth and 

young adults are reviewed in the text and tables that follow. 

All other studies not explicitly described in the text are summarized in Appendix 2.3 and Tables A2.3-1 through A2.3-3.
A Report of the Surgeon General

28 Chapter 2

Key Findings

Youth

Current Prevalence

Ever Use

According to the 2015 National Youth Tobacco Survey 

(NYTS), an estimated 27.1% of U.S. adolescents, representing approximately 7,260,500 persons, had ever tried 

e-cigarettes (Centers for Disease Control and Prevention

[CDC], unpublished data [NYTS 2015]). This included

13.5% of middle school students and 37.7% of high school

students (Tables 2.1a and 2.1b). Among middle school students, use was comparable between boys and girls, but it

was higher among Hispanics compared with other racial/

ethnic groups (Table 2.1a). For high school students, use

was also comparable between boys and girls, but higher

among both White and Hispanic youth compared with

Black youth (Table 2.1b). According to data from the 2015

Youth Risk Behavior Survey (YRBS), a larger percentage

of high school students (44.9%) had ever used e-cigarettes

(Kann et al. 2016), while the Monitoring the Future (MTF)

survey does not collect data on ever use of e-cigarettes

(Johnston et al. 2016).

Past-30-Day Use

According to the 2015 NYTS, an estimated 620,000 

middle school students and 2,390,000 high school students 

had used e-cigarettes at least once in the past 30 days (CDC 

2016). This was an increase from the 2014 NYTS, which 

reported 450,000 middle school students and 2,010,000 high 

school students had used e-cigarettes in the past 30 days 

(CDC 2015c). Levels of past-30-day use were 5.3% for 

middle school students and 16% for high school students in 

2015 (Tables 2.2a and 2.2b), compared with 3.9% for middle 

school students and 13.4% for high school students in 2014. 

Sociodemographic differences in past-30-day use for middle 

and high school students had the same patterns as those for 

ever use (Tables 2.2a and 2.2b). In 2015, according to the 

YRBS, 24.1% of high school students had used e-cigarettes 

at least once in the past 30 days (Kann et al. 2016). The 2015 

MTF shows past-30-day prevalence of e-cigarette use among 

adolescents was 9.5% among 8th graders, 14% among 

10th graders, and 16% among 12th graders (Johnston et al. 

2016). Notably, data from NYTS, YRBS, and MTF show that 

in 2014 exclusive past-30-day use of e-cigarettes exceeded 

exclusive past-30-day use of conventional cigarettes for the 

first time since these types of data were collected (University 

of Michigan 2014; CDC 2015c).

Frequency of Use

Among middle school students, according to the 

2015 NYTS, 5.3% were current users of e-cigarettes, 

and 0.6% used e-cigarettes frequently (defined as using 

an e-cigarette 20 or more days in the past 30 days preceding the survey) (Table 2.1a). Among high school students, these estimates were 15.5% and 2.5%, respectively 

(Table  2.1b). Due to smaller sample sizes, confidence 

intervals were too wide to determine sociodemographic 

differences in these measures. These estimates are consistent with a report by CDC (2015b).

A recent analysis of 2014 MTF data, specific to high 

school seniors, showed the frequency of e-cigarette use 

(defined as the number of days in the past 30 days a student 

used an e-cigarette) increases with ever cigarette smoking 

(Warner et al. 2016). Among high school seniors who used 

at least 1 e-cigarette in the past 30 days, the frequency 

of e-cigarette use was almost twice as high (10.2  days) 

among those who regularly smoke conventional cigarettes, compared to those who had never smoked a conventional cigarette (5.8 days). However, the frequency of 

e-cigarette use did not vary substantially among current

cigarette smokers. Among high school seniors who used

at least 1 e-cigarette in the past 30 days, the frequency

of e-cigarette use averaged 8–10 days for “heavy cigarette

smokers” (those who smoked more than a half pack of

cigarettes per day), “light cigarette smokers” (those who

smoked 1–5 cigarettes per day), and “very light cigarette

smokers” (those who smoked fewer than 1 cigarette per

day) (Warner et al. 2016).

Susceptibility to Use

Among those who had never used an e-cigarette, 

32.1% of middle school students and 38.4% of high school 

students were susceptible to using e-cigarettes in the 

future. That is, these students did not have a firm resolve 

not to use e-cigarettes in the future. This is according to the 

2015 NYTS (Tables 2.1a and 2.1b). No differences in susceptibility to use e-cigarettes were observed by gender or race/

ethnicity for either middle school or high school students.

Trends in Prevalence

Ever Use

Overall, according to the NYTS, ever use of 

e-cigarettes among students in grades 6–12 increased

from 3.3% in 2011, to 6.8% in 2012, to 8.1% in 2013, to

19.8% in 2014, and then to 27% in 2015 (Figure 2.1). As
E-Cigarette Use Among Youth and Young Adults

Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 29

Table 2.1a Percentage of middle school students who have used e-cigarettes, by gender and race/ethnicity; National Youth Tobacco Survey (NYTS) 

2015

Ever usea Current useb

Frequent usec: 

Among current 

users

Frequent usec: 

Among all students

Susceptibility to 

used: Among never 

users

Susceptibility to 

used: Among all 

students

Characteristic % (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE

Overall 13.5 (11.8–15.5) 0.9 5.3 (4.6–6.2) 0.4 11.7 (8.6–15.8) 1.8 0.6 (0.4–0.9) 0.1 32.1 (29.7–34.7) 1.3 41.4 (38.3–44.5) 1.5

Gender

Female 12.2 (10.5–14.1) 0.9 4.8 (4.0–5.6) 0.4 11.0 (6.9–17.0) 2.5 0.5 (0.3–0.8) 0.1 33.1 (30.2–36.2) 1.5 41.4 (38.0–44.8) 1.7

Male 14.9 (12.9–17.2) 1.1 5.9 (4.7–7.2) 0.6 11.8 (8.3–16.5) 2.0 0.7 (0.5–1.0) 0.1 31.3 (28.2–34.6) 1.6 41.6 (37.9–45.4) 1.9

Race/ethnicity

White 12.2 (10.1–14.5) 1.1 4.4 (3.6–5.5) 0.5 10.8 (6.5–17.5) 2.7 0.5 (0.3–0.8) 0.1 29.7 (26.1–33.6) 1.9 38.0 (33.7–42.5) 2.2

Black or 

African 

American

11.7 (9.5–14.3) 1.2 4.1 (3.1–5.3) 0.6 14.0 (5.9–29.6) 5.7 — — 34.7 (30.7–39.0) 2.1 42.5 (39.0–46.2) 1.8

Hispanic or 

Latino

18.6 (15.9–21.5) 1.4 8.3 (6.8–10.0) 0.8 12.1 (7.5–18.9) 2.8 1.0 (0.6–1.6) 0.2 38.0 (35.2–40.8) 1.4 49.8 (46.9–52.7) 1.5

Othere 11.9 (8.2–17.1) 2.2 4.6 (2.7–7.7) 1.2 — — — — 30.4 (24.7–36.8) 3.1 39.5 (33.2–46.2) 3.3

Source: Centers for Disease Control and Prevention, unpublished data (data: NYTS 2015).

Notes: CI = confidence interval; SE = standard error. An em dash (—) indicates that data are statistically unstable because of a relative standard error >40%.

aIncludes those who reported using an e-cigarette, even once or twice.

bIncludes those who reported using e-cigarettes on 1 or more days in the past 30 days.

cIncludes those who responded “≥20 days” to the following question: “During the past 30 days, on how many days did you use electronic cigarettes or e-cigarettes?” 

See CDC (2015b).

dIncludes those who failed to respond “definitely not” to any of the following questions: (a) “Do you think that you will try an electronic cigarette or e-cigarette soon?”; 

(b) “If one of your best friends were to offer you an electronic cigarette or e-cigarette, would you use it?”; or (c) “Have you ever been curious about using an electronic

cigarette or e-cigarette, even once or twice?”

eIncludes non-Hispanic Asian, non-Hispanic Native Hawaiian/Other Pacific Islander, and non-Hispanic American Indian/Alaska Native.
A Report of the Surgeon General

30 Chapter 2

Table 2.1b Percentage of high school students who have used e-cigarettes, by gender and race/ethnicity; National Youth Tobacco Survey (NYTS) 2015

Ever usea Current useb

Frequent usec: 

Among current 

users

Frequent usec: 

Among all students

Susceptibility to 

used: Among never 

users

Susceptibility to 

used: Among all 

students

Characteristic % (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE

Overall 37.7 (35.3–40.2) 1.2 16 .0 (14.1–18.0) 1.0 15.5 (12.9–18.4) 1.4 2.5 (1.9–3.2) 0.3 38.4 (36.5–40.4) 1.0 61.1 (59.0–63.2) 1.0

Gender

Female 34.6 (31.9–37.3) 1.4 12.8 (11.0–15.0) 1.0 10.1 (7.2–14.0) 1.7 1.3 (0.9–1.8) 0.2 39.8 (37.4–42.2) 1.2 60.3 (58.1–62.5) 1.1

Male 40.7 (37.7–43.7) 1.5 19.0 (16.5–21.7) 1.3 19.1 (15.6–23.1) 1.9 3.6 (2.7–4.8) 0.5 36.9 (34.3–39.5) 1.3 61.8 (59.2–64.4) 1.3

Race/ethnicity

White 38.0 (35.1–41.0) 1.5 17.2 (14.7–19.9) 1.3 16.8 (13.4–20.8) 1.9 2.9 (2.1–3.9) 0.4 36.3 (33.4–39.4) 1.5 60.1 (57.4–62.7) 1.3

Black or 

African 

American

28.5 (25.5–31.8) 1.6 8.9 (7.4–10.8) 0.8 8.5 (3.9–17.4) 3.2 0.8 (0.3–1.7) 0.3 37.2 (32.2–42.5) 2.6 54.5 (51.0–57.9) 1.7

Hispanic or 

Latino

43.0 (38.9–47.2) 2.1 16.4 (14.1–19.0) 1.2 12.8 (9.3–17.3) 2.0 2.1 (1.4–3.1) 0.4 44.6 (41.2–48.0) 1.7 67.8 (64.3–71.1) 1.7

Othere 37.4 (24.8–52.1) 7.0 18.9 (10.3–32.2) 5.5 18.2 (11.2–28.2) 4.3 3.4 (2.1–5.7) 0.9 41.2 (35.4–47.3) 3.0 62.6 (54.0–70.5) 4.2

Source: Centers for Disease Control and Prevention, unpublished data (data: NYTS 2015).

Note: CI = confidence interval; SE = standard error.

aIncludes those who reported using an e-cigarette, even once or twice.

bIncludes those who reported using e-cigarettes on 1 or more days in the past 30 days.

cIncludes those who responded “≥20 days” to the following question: “During the past 30 days, on how many days did you use electronic cigarettes or e-cigarettes?” 

See CDC (2015b).

dIncludes those who failed to respond “definitely not” to any of the following questions: (a) “Do you think that you will try an electronic cigarette or e-cigarette soon?”; 

(b) “If one of your best friends were to offer you an electronic cigarette or e-cigarette, would you use it?”; or (c) “Have you ever been curious about using an electronic

cigarette or e-cigarette, even once or twice?”

eIncludes non-Hispanic Asian, non-Hispanic Native Hawaiian/Other Pacific Islander, and non-Hispanic American Indian/Alaska Native.
E-Cigarette Use Among Youth and Young Adults

Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 31

Table 2.2a Percentage of middle school students who used e-cigarettes in the past 30 daysa, by gender and race/ethnicity; National Youth Tobacco 

Survey (NYTS) 2011–2015

2011 2012 2013 2014 2015

Characteristic % (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE

Overall 0.6 (0.4–0.9) 0.1 1.1 (0.9–1.5) 0.1 1.1 (0.8–1.5) 0.2 3.9 (3.0–5.0) 0.5 5.3 (4.6–6.2) 0.4

Gender

Female 0.4 (0.2–0.7) 0.1 0.8 (0.5–1.1) 0.1 0.9 (0.6–1.4) 0.2 3.3 (2.5–4.3) 0.5 4.8 (4.0–5.6) 0.4

Male 0.7 (0.4–1.3) 0.2 1.5 (1.1–2.1) 0.3 1.4 (0.9–1.9) 0.2 4.5 (3.4–5.9) 0.6 5.9 (4.7–7.2) 0.6

Race/ethnicity

White 0.6 (0.3–1.0) 0.2 0.9 (0.6–1.3) 0.2 0.9 (0.6–1.4) 0.2 3.1 (2.2–4.2) 0.5 4.4 (3.6–5.5) 0.5

Black or African 

American

— — 1.1 (0.6–2.2) 0.4 1.4 (0.7–2.5) 0.4 3.8 (2.5–5.6) 0.7 4.1 (3.1–5.3) 0.6

Hispanic or 

Latino

0.6 (0.4–1.1) 0.2 2.0 (1.4–2.9) 0.4 1.8 (1.1–2.7) 0.4 6.2 (4.8–7.9) 0.8 8.3 (6.8–10.0) 0.8

Otherb — — — — — — 3.2 (1.6–6.3) 1.1 4.6 (2.7–7.7) 1.2

Source: Centers for Disease Control and Prevention, unpublished data (data: NYTS 2011–2015).

Notes: CI = confidence interval; SE = standard error. An em dash (—) indicates that data are statistically unstable because of a relative standard error >40%. Wording of 

questions used to measure e-cigarette use varied from 2011 to 2015.

aIncludes those who reported using e-cigarettes on 1 or more of the past 30 days. This is also considered “current use” in this survey.

bIncludes non-Hispanic Asian, non-Hispanic Native Hawaiian/Other Pacific Islander, and non-Hispanic American Indian/Alaska Native.
A Report of the Surgeon General

32 Chapter 2

Table 2.2b Percentage of high school students who used e-cigarettes in the past 30 daysa, by gender and race/ethnicity; National Youth Tobacco Survey 

(NYTS) 2011–2015

2011 2012 2013 2014 2015

Characteristic % (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE

Overall 1.5 (1.2–2.0) 0.2 2.8 (2.3–3.5) 0.3 4.5 (3.8–5.3) 0.4 13.4 (11.2–16.1) 1.2 16.0 (14.1–18.0) 1.0

Gender

Female 0.7 (0.5–1.0) 0.1 1.9 (1.5–2.4) 0.2 3.5 (2.8–4.3) 0.4 11.9 (9.7–14.5) 1.2 12.8 (11.0–15.0) 1.0

Male 2.3 (1.7–3.2) 0.4 3.7 (2.9–4.8) 0.5 5.5 (4.5–6.8) 0.6 15.0 (12.4–18.2) 1.4 19.0 (16.5–21.7) 1.3

Race/ethnicity

White 1.8 (1.3–2.4) 0.3 3.4 (2.7–4.2) 0.4 4.8 (3.8–6.1) 0.6 15.3 (12.4–18.8) 1.6 17.2 (14.7–19.9) 1.3

Black or African 

American

— — 1.1 (0.7–1.9) 0.3 2.7 (1.9–3.9) 0.5 5.6 (3.7–8.5) 1.2 8.9 (7.4–10.8) 0.8

Hispanic or 

Latino

1.3 (0.8–2.1) 0.3 2.7 (1.9–3.8) 0.5 5.3 (4.2–6.6) 0.6 15.3 (11.8–19.5) 1.9 16.4 (14.1–19.0) 1.2

Otherb — — — — 4.0 (2.3–6.9) 1.1 9.4 (6.8–12.9) 1.5 18.9 (10.3–32.2) 5.5

Source: Centers for Disease Control and Prevention, unpublished data (data: NYTS 2011–2015).

Notes: CI = confidence interval; SE = standard error. An em dash (—) indicates that data are statistically unstable because of a relative standard error >40%. Wording of 

questions used to measure e-cigarette use varied from 2011 to 2015.

a Includes those who reported using e-cigarettes on 1 or more of the past 30 days. This is also considered “current use” in this survey.

b Includes non-Hispanic Asian, non-Hispanic Native Hawaiian/Other Pacific Islander, and non-Hispanic American Indian/Alaska Native.
Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 33

E-Cigarette Use Among Youth and Young Adults

(Continued from last paragraph on page 28.)

discussed in Appendix 2.2 (see NYTS Measures—Special 

Issues), measures of e-cigarette use were changed for 

the 2014 NYTS, as signaled by the dotted line in the 

figure. Research conducted using the New Jersey Youth 

Tobacco Survey suggests that the NYTS measures used 

in 2011–2013 may potentially underestimate use, compared with the 2014 measure (Delnevo et al. 2016). For 

the 2011−2015 period, use of e-cigarettes was higher in 

each year among high school students than among middle 

school students (Tables 2.3a and 2.3b).

Figure 2.1 Trends in ever e-cigarette usea among U.S. middle and high school students; National Youth Tobacco 

Survey (NYTS) 2011–2015

Source: Centers for Disease Control and Prevention 2013a, 2014b; unpublished data (data: NYTS 2015).

Note: In 2014, modifications were made to the e-cigarette measure to enhance its accuracy, which may limit the comparability of this 

estimate to those collected in previous years. The dotted lines from 2013 to 2015 represent these differences.

aIncludes those who responded “1 or more” to the following question: During the last 30 days, on how many days did you use 

electronic cigarettes or e-cigarettes?

Middle school students. Trends in ever use of 

e-cigarettes among U.S. middle school students are presented in Table 2.3a and Figure 2.1, using data from the

2011–2015 NYTS. The prevalence of ever use increased

from 1.4% in 2011 to 2.7% in 2012, to 3.0% in 2013, to

10.1% in 2014, and then to 13.5% in 2015. The jump in

prevalence between 2013 and 2014 may be an artifact of a

change in how the use item was asked (see Appendix 2.2.

Key Measures of Use). Nonetheless, prevalence of use would

be expected to be minimal prior to 2011, suggesting that a

considerable increase in use was still observed during this

relatively short 4-year period. In 2015, among middle school 

students, an estimated 1,595,481 had ever tried e-cigarettes

(CDC, unpublished data [NYTS 2015]). From 2011 to 2013,

the prevalence of ever use did not differ significantly by 

gender or race/ethnicity. There remained no significant difference in ever use by gender in the 2014 or 2015 NYTS, but 

by 2014 and still in 2015, a greater percentage of Hispanic 

middle school students (18.6%) had tried e-cigarettes than 

White (12.2%) or Black (11.7%) students or students of 

other races/ethnicities (11.9%) (Table 2.3a).

High school students. Trends in ever use of 

e-cigarettes among U.S. high school students are presented in Tables 2.3b and Figure 2.1, using data from the

2011–2015 NYTS. The prevalence of ever use increased

from 4.7% in 2011 to 10% in 2012, to 11.9% in 2013,

to 27.3% in 2014, and then to 37.7% in 2015. In that year,

an estimated 5,624,876 high school students had ever

used e-cigarettes (CDC, unpublished data [NYTS 2015]).

In 2011–2013, male high school students had a higher

rate of ever use each year compared with female students,

but in 2014 the genders did not differ significantly in their

rates. From 2011 to 2015, White and Hispanic high school

students were more likely each year to be ever users than

were Black students: In 2015, these figures were 38% and

43%, respectively, for White and Hispanic students compared with 28.5% for Black students.
A Report of the Surgeon General

34 Chapter 2

Table 2.3a Percentage of middle school students who have ever used e-cigarettesa, by gender and race/ethnicity; National Youth Tobacco Survey 

(NYTS) 2011–2015

2011 2012 2013 2014 2015

Characteristic % (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE

Overall 1.4 (1.0–2.0) 0.2 2.7 (2.2–3.2) 0.2 3.0 (2.5–3.5) 0.2 10.1 (8.5–11.9) 0.8 13.5 (11.8–15.5) 0.9

Gender

Female 1.2 (0.8–1.6) 0.2 2.4 (1.9–3.0) 0.3 2.8 (2.3–3.5) 0.3 9.9 (7.8–12.6) 1.2 12.2 (10.5–14.1) 0.9

Male 1.7 (1.1–2.7) 0.4 3.0 (2.4–3.6) 0.3 3.1 (2.5–3.9) 0.3 10.3 (8.6–12.3) 0.9 14.9 (12.9–17.2) 1.1

Race/ethnicity

White 1.5 (0.9–2.3) 0.3 2.6 (2.1–3.3) 0.3 3.0 (2.4–3.7) 0.3 8.9 (7.2–11.1) 1.0 12.2 (10.1–14.5) 1.1

Black or African 

American

1.2 (0.7–2.0) 0.3 2.3 (1.3–4.2) 0.7 2.7 (1.9–3.7) 0.5 9.7 (7.9–11.9) 1.0 11.7 (9.5–14.3) 1.2

Hispanic or Latino 1.6 (1.1–2.3) 0.3 3.3 (2.3–4.6) 0.6 3.9 (2.9–5.2) 0.6 14.6 (12.2–17.4) 1.3 18.6 (15.9–21.5) 1.4

Otherb — — 1.0 (0.5–2.2) 0.4 — — 6.5 (3.9–10.9) 1.7 11.9 (8.2–17.1) 2.2

Source: Centers for Disease Control and Prevention, unpublished data (data: NYTS 2011–2015).

Notes: CI = confidence interval; SE = standard error. An em dash (—) indicates that data are statistically unstable because of a relative standard error >40%. Wording of 

questions used to measure e-cigarette use varied from 2011 to 2015.

aIncludes those who reported ever trying e-cigarettes.

bIncludes non-Hispanic Asian, non-Hispanic Native Hawaiian/Other Pacific Islander, and non-Hispanic American Indian/Alaska Native.
E-Cigarette Use Among Youth and Young Adults

Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 35

Table 2.3b Percentage of high school students who have ever used e-cigarettesa, by gender and race/ethnicity; National Youth Tobacco Survey (NYTS) 

2011–2015

2011 2012 2013 2014 2015

Characteristic % (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE

Overall 4.7 (3.8–5.7) 0.5 10.0 (8.6–11.6) 0.7 11.9 (10.5–13.5) 0.8 27.3 (24.4–30.5) 1.5 37.7 (35.3–40.2) 1.2

Gender

Female 3.5 (2.7–4.4) 0.4 8.0 (6.7–9.5) 0.7 9.9 (8.3–11.7) 0.8 24.5 (21.4–27.9) 1.6 34.6 (31.9–37.3) 1.4

Male 5.9 (4.7–7.3) 0.7 12.0 (10.2–14.1) 1.0 13.8 (12.1–15.8) 0.9 30.1 (27.2–33.3) 1.5 40.7 (37.7–43.7) 1.5

Race/ethnicity

White 5.8 (4.6–7.4) 0.7 12.3 (10.5–14.4) 1.0 14.7 (12.8–16.9) 1.0 29.7 (26.2–33.4) 1.8 38.0 (35.1–41.0) 1.5

Black or African 

American

1.5 (0.9–2.4) 0.4 4.0 (3.1–5.1) 0.5 4.9 (3.6–6.6) 0.7 17.6 (14.1–21.8) 1.9 28.5 (25.5–31.8) 1.6

Hispanic or 

Latino

3.7 (2.5–5.5) 0.7 8.5 (6.6–10.8) 1.0 10.4 (8.6–12.5) 1.0 29.9 (25.4–34.9) 2.4 43.0 (38.9–47.2) 2.1

Otherb 2.8 (1.7–4.6) 0.7 6.0 (3.3–10.8) 1.8 8.3 (5.3–12.8) 1.8 18.7 (14–24.5) 2.6 37.4 (24.8–52.1) 7.0

Source: Centers for Disease Control and Prevention, unpublished data (data: NYTS 2011–2015).

Notes: CI = confidence interval; SE = standard error. Wording of questions used to measure e-cigarette use varied from 2011 to 2015.

aIncludes those who reported ever trying e-cigarettes.

bIncludes non-Hispanic Asian, non-Hispanic Native Hawaiian/Other Pacific Islander, and non-Hispanic American Indian/Alaska Native.
A Report of the Surgeon General

36 Chapter 2

Past-30-Day Use

According to the NYTS, past-30-day use of 

e-cigarettes among students in grades 6−12 in the

United States increased from 1.1% in 2011 to 2.1% in

2012, to 3.1% in 2013, to 9.3% in 2014, and then 11.3%

in 2015 (CDC 2013b; Ambrose et al. 2014; Lippert 2015;

CDC, unpublished data) (Figure 2.2). In 2015, approximately 3,038,000 middle and high school students were

past-30-day users of e-cigarettes (CDC, unpublished

data [NYTS 2015]). Across all years, past-30-day use of

e-cigarettes was higher among high school students than

middle school students (Figure 2.2; Tables 2.2a and 2.2b).

In the MTF, estimates were stable from 2014 to 2015;

among 8th, 10th, and 12th graders, past-30-day use went

from 8.7% to 9.5%, 16.2% to 14%, and 17.1% to 16.2%,

respectively (University of Michigan, Institute for Social

Research, unpublished data). Differences in trends in past30-day use between the NYTS and MTF may be due to differences in age groups (e.g., the NYTS includes all grades

in middle school and all grades in high schools) and the

way in which these measures were asked on the instruments (see Table A2.2-1 in Appendix 2.2).

Figure 2.2 Trends in past-30-day e-cigarette usea among U.S. middle and high school students; National Youth 

Tobacco Survey (NYTS) 2011–2015

Source: Centers for Disease Control and Prevention 2013a, 2014b; unpublished data (data: NYTS 2015).

Note: In 2014, modifications were made to the e-cigarette measure to enhance its accuracy, which may limit the comparability of this 

estimate to those collected in previous years. The dotted lines from 2013 to 2015 represent these differences.

aIncludes those who responded “1 or more” for the following question: “During the last 30 days, on how many days did you use 

electronic cigarettes or e-cigarettes?”

Middle school students. Trends in past-30-day use of 

e-cigarettes among middle school students in the United

States are presented in Table 2.2a and Figure 2.2, again

using data from the 2011–2015 NYTS. The prevalence of

such use in this population increased from 0.6% in 2011

to 1.1% in 2012 and 2013, to 3.9% in 2014, and then to

5.3% in 2015 (Table 2.2a) (CDC 2016). Between 2011 and

2015, there were no significant differences in prevalence

by gender; unstable estimates (see notes to the table)

precluded an examination of differences in past-30-day

e-cigarette use by race/ethnicity for 2011–2013. In 2014,

the prevalence of past-30-day use was higher among

Hispanics (6.2%) than Whites (3.1%), a trend that was also

seen in 2015 with 8.3% of Hispanics and 4.4% of Whites

reporting past-30-day use. From 2011 to 2015, increases

were seen among females (0.4% to 4.8%), males (0.7% to

5.9%), Whites (0.6% to 4.4%), Hispanics (0.6% to 8.3%),

and Blacks (1.1% in 2012 to 4.1%) (Table 2.2a) (CDC 2013b; 

CDC 2015c; CDC 2016).

High school students. Trends in past-30-day use 

of e-cigarettes among high school students are also presented in Table 2.2b and Figure 2.2, again using data from 

the 2011−2015 NYTS. The prevalence of such use in this 

population increased from 1.5% in 2011 to 2.8% in 2012, 
Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 37

E-Cigarette Use Among Youth and Young Adults

to 4.5% in 2013, to 13.4% in 2014, and then to 16% in 

2015. From 2011 to 2013 and in 2015, males were significantly more likely each year to be past-30-day users than 

were females, but this difference was not significant in 

2014 (Table 2.2b). From 2012 to 2015, Black high school 

students were less likely each year to be past-30-day 

users than were White or Hispanic high school students (Table  2.2b). During 2011–2015, large increases 

in past-30-day use were seen among females (0.7% to 

12.8%), males (2.3% to 19%), Whites (1.8% to 17.2%), 

and Hispanics (1.3% to 16.4%) (Table 2.2b) (CDC 2013b, 

2015c, 2016).

Young Adults

Current Prevalence

According to the 2013–2014 National Adult Tobacco 

Survey (NATS), among young U.S. adults aged 18–24 years, 

the prevalence of ever use and current use of e-cigarettes 

was 35.8% and 13.6%, respectively (Table 2.4a). These 

percentages were significantly higher than for the same 

measures among adults aged 25 years or over (16.4% and 

5.7%, respectively) (Table 2.4b). Among young adults, 

ever and current use were both higher among males than 

females and for Whites than in other racial/ethnic groups 

(Table  2.4a). By educational attainment, among young 

adults, both ever and current use were lowest among 

those with a college degree (Table 2.4a). Among all young 

adults, 2% reported using e-cigarettes “every day”; while 

among current users in this age group, 15% reported this 

frequency (Table 2.4a). Use of e-cigarettes “every day” 

among older adults (≥25 years of age) was 1.3% overall 

and 22% among current users (Table 2.4b). Among young 

adults, sociodemographic differences in frequent use followed the same pattern as those for ever and current use 

(Table 2.4a).

Trends in Prevalence

According to the Styles (also known as HealthStyles 

or Summer Styles) survey, the prevalence of ever use of 

e-cigarettes among young adults aged 18–24 years was

6.9% in 2011, 4.1% in 2012, 7.8% in 2013, and 14.3% in

2014, a year that saw the addition of other products to

this measure, including e-hookahs and e-pipes or e-cigars

(Figure 2.3). Although the prevalence of ever use of

e-cigarettes among young adults remained consistent

from 2010 to 2013, it doubled from 2013 to 2014, presumably reflecting in part the addition of new products

to the definition of e-cigarettes. In 2010, young adults

(18–24 years) were more likely than older adults (25–44

and 45–64 years of age) to be ever users of e-cigarettes

(King et al. 2015). In 2014, ever use of e-cigarettes or similar products was statistically equivalent between young 

adults (18–24 years old) at 14.3%, adults 25–44 years old 

at 15%, and adults 45–64 years old at 11.9% (p  >0.05) 

(CDC, unpublished data [Styles 2014]).

E-Cigarette Use and Use of Other

Tobacco Products

Evidence from both national and regional studies 

suggests that e-cigarette use is strongly associated with 

other tobacco use, especially the use of combustible products (including conventional cigarettes, cigar products, 

and hookahs). However, many youth and young adults 

use e-cigarettes exclusively, too. Estimates from crosssectional surveys such as the NYTS, MTF, and NATS are 

presented below for youth and young adults, followed by 

longitudinal studies that examine whether e-cigarette use 

precedes the use of other tobacco products (Leventhal 

et al. 2015; Primack et al. 2015; Barrington-Trimis et al. 

2016; Unger et al. 2016; Wills et al. 2016).

Cross-Sectional Studies

Youth

Current prevalence. Using data from the 2015 MTF 

survey, Figure 2.4 and Table 2.5 show past-30-day use of 

e-cigarettes and conventional cigarettes, including both

exclusive and combined use of these products, among

8th-, 10th-, and 12th-grade students. In the 2015 MTF

survey, 10.4% of 12th graders used e-cigarettes only,

5.3%  used conventional cigarettes only, and 5.8% used

both e-cigarettes and conventional cigarettes at least once

in the past 30 days (Table 2.5) (MTF 2015a,b). For all grade

levels, exclusive use of e-cigarettes was more prevalent

(6.8%, 10.4%, and 10.4% of 8th, 10th, and 12th graders,

respectively) than exclusive use of conventional cigarettes

alone (1.4%, 2.2%, 5.3%, respectively). In the 8th and

10th grades, the combined or dual use of e-cigarettes and

conventional cigarettes was also more prevalent than the

use of conventional cigarettes alone (2.4% vs. 1.4%, and

3.5% vs. 2.2% for 8th and 10th graders, respectively); while 

in the 12th grade, the prevalence in the two categories was

nearly identical (5.8% vs. 5.3%). As grade level increases,

the ratio of any e-cigarette use to any conventional cigarette use decreases. Among 12th graders, dual use of these

products was higher among boys than girls and among

Whites than Blacks. In all grade levels, dual use was much

higher among students who planned to attend fewer

than 4 years of college compared to those who planned

to attend 4 years of college. No other sociodemographic
A Report of the Surgeon General

38 Chapter 2

Table 2.4a Percentage of young adults (18–24 years of age) who have used e-cigarettes, by gender, race/ethnicity, and education; National Adult 

Tobacco Survey (NATS) 2013–2014

Ever usea Current useb

Frequent usec: Among 

current users

Frequent usec: 

Among all young adults

Characteristic % (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE

Overall 35.8 (34.1–37.6) 0.9 13.6 (12.5–14.8) 0.6 15.0 (12.1–18.5) 1.6 2.0 (1.6–2.6) 0.2

Gender

Female 28.4 (26.1–30.8) 1.2 9.8 (8.3–11.5) 0.8 10.0 (6.5–15.1) 2.2 1.0 (0.6–1.5) 0.2

Male 42.9 (40.4–45.3) 1.2 17.1 (15.4–19.0) 0.9 17.8 (13.9–22.5) 2.2 3.0 (2.3–4.0) 0.4

Race/ethnicity

White 39.7 (37.4–41.9) 1.2 16.1 (14.5–17.8) 0.9 15.3 (11.7–19.7) 2.0 2.5 (1.9–3.2) 0.4

Black or African 

American

23.1 (19.0–27.8) 2.3 5.4 (3.7–7.9) 1.1 — — — —

Hispanic or Latino 36.6 (32.6–40.7) 2.1 13.4 (10.9–16.4) 1.4 12.0 (6.8–20.2) 3.3 1.6 (0.9–2.8) 0.5

Otherd 30.8 (25.8–36.3) 2.7 10.8 (8.1–14.2) 1.6 21.5 (11.6–36.4) 6.3 2.3 (1.2–4.4) 0.8

Education

< High school 44.8 (38.9–50.9) 3.1 15.2 (11.5–19.7) 2.1 9.8 (4.8–18.8) 3.4 1.5 (0.7–3.0) 0.5

High school 39.4 (36.7–42.2) 1.4 14.9 (13.1–17.0) 1.0 17.6 (13.0–23.4) 2.6 2.6 (1.9–3.6) 0.4

Some collegee 34.3 (31.6–37.0) 1.4 14.7 (12.8–16.8) 1.0 14.8 (10.2–21.0) 2.7 2.2 (1.5–3.2) 0.4

College degreef 16.9 (14.2–20.0) 1.5 4.5 (3.1–6.4) 0.8 — — — —

Source: Centers for Disease Control and Prevention, unpublished data (data: NATS 2013–2014).

Notes: CI = confidence interval; SE = standard error. An em dash (—) indicates that data are statistically unstable because of a relative standard error >40%.

aIncludes those who reported they had heard of e-cigarettes and tried e-cigarettes.

bIncludes those who reported they had heard of, tried, and used e-cigarettes every day, some days, or rarely at the time of the interview.

cIncludes those who reported they had heard of e-cigarettes, tried e-cigarettes, and reported using e-cigarettes every day at the time of the interview.

dIncludes non-Hispanic Asian, non-Hispanic Native Hawaiian/Other Pacific Islander, non-Hispanic American Indian/Alaska Native, and multiracial.

eIncludes some college, no degree; associate’s degree, academic program; associate’s degree, unspecified; certificate; diploma; or associate’s degree.

f

Includes bachelor’s degree, master’s/professional school degree, or doctoral degree.
E-Cigarette Use Among Youth and Young Adults

Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 39

Table 2.4b Percentage of adults (≥25 years of age) who have used e-cigarettes, by gender, race/ethnicity, and education; National Adult Tobacco Survey 

(NATS) 2013–2014

Ever usea Current useb

Frequent usec: Among 

current users

Frequent usec: 

Among all adults

Characteristic % (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE

Overall 16.4 (15.9–16.8) 0.2 5.7 (5.5–6.0) 0.1 22.0 (20.1–24.0) 1.0 1.3 (1.1–1.4) 0.1

Gender

Female 14.7 (14.2–15.3) 0.3 5.0 (4.7–5.4) 0.2 20.6 (18.1–23.3) 1.3 1.0 (0.9–1.2) 0.1

Male 18.3 (17.6–18.9) 0.3 6.6 (6.1–7.0) 0.2 23.0 (20.2–25.9) 1.5 1.5 (1.3–1.7) 0.1

Race/ethnicity

White 16.2 (15.8–16.7) 0.2 6.0 (5.7–6.4) 0.2 23.9 (21.7–26.3) 1.2 1.4 (1.3–1.6) 0.1

Black or African 

American

15.1 (13.9–16.5) 0.7 3.8 (3.2–4.5) 0.3 15.2 (10.2–22.2) 3.0 0.6 (0.4–0.9) 0.1

Hispanic or Latino 15.6 (14.3–17.0) 0.7 4.9 (4.1–5.8) 0.4 15.8 (10.4–23.4) 3.3 0.8 (0.5–1.2) 0.2

Otherd 21.0 (19.2–22.9) 0.9 8.0 (6.7–9.4) 0.7 19.4 (14.0–26.2) 3.1 1.5 (1.1–2.1) 0.3

Education

<High school 18.2 (16.8–19.7) 0.8 5.2 (4.4–6.1) 0.4 20.8 (15.2–27.7) 3.2 1.1 (0.8–1.5) 0.2

High school 20.6 (19.7–21.6) 0.5 7.6 (7.0–8.3) 0.3 19.2 (16.1–22.7) 1.7 1.5 (1.2–1.8) 0.1

Some collegee 19.7 (18.9–20.5) 0.4 7.4 (6.8–7.9) 0.3 24.5 (21.4–27.8) 1.6 1.8 (1.6–2.1) 0.1

College degreef 8.7 (8.2–9.1) 0.2 2.8 (2.5–3.1) 0.1 22.0 (18.1–26.4) 2.1 0.6 (0.5–0.8) 0.1

Source: Centers for Disease Control and Prevention, unpublished data (data: NATS 2013–2014).

Note: CI = confidence interval; SE = standard error.

aIncludes those who reported they had heard of and tried e-cigarettes.

bIncludes those who reported they had heard, tried, and used e-cigarettes every day, some days, or rarely at the time of the interview.

cIncludes those who reported they had heard of, tried, and reported using e-cigarettes every day at the time of the interview.

dIncludes non-Hispanic Asian, non-Hispanic Native Hawaiian/Other Pacific Islander, non-Hispanic American Indian/Alaska Native, and multiracial.

eIncludes some college, no degree; associate’s degree, academic program; associate’s degree, unspecified; certificate; diploma; or associate’s degree.

f

Includes bachelor’s degree, master’s/professional school degree, or doctoral degree.
A Report of the Surgeon General

40 Chapter 2

Figure 2.3 Trends in ever e-cigarette usea among U.S. adults by age group; Styles 2010–2014

Source: King et al. (2015) (data: HealthStyles 2010–2013); Centers for Disease Control and Prevention, unpublished data (data: 

HealthStyles 2014).

Note: In 2014, modifications were made to the e-cigarette measure to enhance its accuracy, which may limit the comparability of 

this estimate to those collected in previous years. The dotted lines from 2013 to 2014 represent these differences.

aIncludes those who responded “electronic cigarettes or e-cigarettes” to the following question, “Have you ever tried any of the 

following products, even just one time? Electronic cigarettes or e-cigarettes, such as Ruyan or NJOY?”

Figure 2.4 Percentage of students in grades 8, 10, and 12 who used e-cigarettes and cigarettes in the past 30 days; 

Monitoring the Future (MTF) 2015

Source: University of Michigan, Institute for Social Research, unpublished data (data: MTF 2015).

Note: Questions on e-cigarette use were asked on four of six questionnaire forms. Data presented here are based on those four 

forms only.
E-Cigarette Use Among Youth and Young Adults

Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 41

Table 2.5 Percentage of students in grades 8, 10, and 12 who used e-cigarettes, cigarettes, or both products in the past 30 days, by sociodemographic characteristics; 

Monitoring the Future (MTF) 2015

8th grade 10th grade 12th grade

Neither: % 

(95% CI)

E-cigarettes

only: %

(95% CI)

Cigarettes 

only: % 

(95% CI)

Both: % 

(95% CI)

Neither: % 

(95% CI)

E-cigarettes

only: %

(95% CI)

Cigarettes 

only: % 

(95% CI)

Both: % 

(95% CI)

Neither: % 

(95% CI)

E-cigarettes

only: %

(95% CI)

Cigarettes 

only: % 

(95% CI)

Both: % 

(95% CI)

Overall 89.4 

(88.4–90.5)

6.8 

(5.8–7.8)

1.4 

(0.9–1.8)

2.4 

(1.9–2.9)

83.9 

(81.9–85.9)

10.4 

(9.0–11.8)

2.2 

(1.7–2.7)

3.5 

(2.8–4.3)

78.5 

(76.7–80.3)

10.4 

(9.1–11.8)

5.3 

(4.6–6.0)

5.8 

(5.0–6.6)

Gender

Female 90.2 

(88.7–91.7)

6.2 

(4.9–7.5)

1.4 

(0.7–2.0)

2.2 

(1.6–2.9)

85.6 

(83.6–87.6)

8.6 

(7.2–10.1)

2.4 

(1.6–3.1)

3.4 

(2.5–4.3)

84.4 

(82.8–86.0)

7.1 

(6.2–8.0)

4.7 

(3.6–5.7)

3.8 

(3.1–4.6)

Male 88.9 

(87.3–90.4)

7.2 

(6.0–8.5)

1.4 

(0.7–2.0)

2.5 

(1.7–3.3)

82.2 

(79.6–84.7)

12.2 

(10.2–14.2)

2.0 

(1.3–2.7)

3.6 

(2.6–4.7)

72.9 

(70.2–75.6)

14.1 

(11.8–16.3)

5.6 

(4.6–6.6)

7.5 

(6.1–8.9)

Race/ 

ethnicity

White 90.1 

(88.6–91.6)

6.2 

(4.9–7.4)

1.2 

(0.6–1.8)

2.6 

(1.7–3.4)

82.1 

(79.5–84.7)

11.2 

(9.2–13.2)

2.3 

(1.6–2.9)

4.4 

(3.4–5.4)

75.2 

(72.7–77.7)

12.0 

(10.4–13.6)

5.8 

(4.7–6.9)

7.1 

(5.9–8.3)

African 

American

91.2 

(88.2–94.1)

5.3 

(2.7–7.8)

2.1 

(0.6–3.7)

1.5 

(0.0–2.9)

89.9 

(85.7–94.1)

6.6 

(3.6–9.5)

1.8 

(0.4–3.1)

1.7 

(0.4–3.1)

87.7 

(85.1–90.3)

5.2 

(3.8–6.6)

5.1 

(3.3–6.8)

2.0 

(1.1–3.0)

Hispanic 88.7 

(85.8–91.5)

8.2 

(6.1–10.4)

0.9 

(0.2–1.6)

2.2 

(1.2–3.2)

84.6 

(81.5–87.6)

10.5 

(7.6–13.4)

2.4 

(0.9–4.0)

2.5 

(0.8–4.2)

80.9 

(78.0–83.7)

10.3 

(8.0–12.5)

4.4 

(3.2–5.5)

4.5 

(3.1–6.0)

College 

plans

None or 

<4 years

76.8 

(71.0–82.5)

10.1 

(6.1–14.0)

4.9 

(1.7–8.1)

8.3 

(4.8–11.8)

66.3 

(61.1–71.5)

15.4 

(11.3–19.4)

7.0 

(3.8–10.2)

11.3 

(7.6–15.1)

65.1 

(61.2–68.9)

13.0 

(9.7–16.3)

10.2 

(8.2–12.3)

11.7 

(9.5–13.9)

Complete 

4 years

90.5 

(89.4–91.5)

6.5 

(5.5–7.4)

1.1 

(0.7–1.5)

2.0 

(1.5–2.5)

85.7 

(83.6–87.7)

9.8 

(8.3–11.4)

1.7 

(1.3–2.2)

2.8 

(2.1–3.5)

81.6 

(79.9–83.2)

9.9 

(8.6–11.1)

4.1 

(3.4–4.8)

4.5 

(3.8–5.2)
A Report of the Surgeon General

42 Chapter 2

8th grade 10th grade 12th grade

Neither: % 

(95% CI)

E-cigarettes

only: %

(95% CI)

Cigarettes 

only: % 

(95% CI)

Both: % 

(95% CI)

Neither: % 

(95% CI)

E-cigarettes

only: %

(95% CI)

Cigarettes 

only: % 

(95% CI)

Both: % 

(95% CI)

Neither: % 

(95% CI)

E-cigarettes

only: %

(95% CI)

Cigarettes 

only: % 

(95% CI)

Both: % 

(95% CI)

Parental 

educationa

1–2 (Low) 88.1 

(83.9–92.2)

5.9 

(3.3–8.4)

1.8 

(0.3–3.2)

4.3 

(2.1–6.6)

77.2 

(72.0–82.4)

12.6 

(9.0–16.2)

4.8 

(1.5–8.0)

5.4 

(3.1–7.8)

77.3 

(73.4–81.2)

10.1 

(7.3–13.0)

7.9 

(5.4–10.4)

4.7 

(3.1–6.3)

2.5–3 86.2 

(83.3–89.1)

9.4 

(6.7–12.1)

1.8 

(0.6–3.1)

2.6 

(1.2–3.9)

81.7 

(78.3–85.2)

10.6 

(8.1–13.0)

2.5 

(1.3–3.7)

5.2 

(3.2–7.1)

75.2 

(72.4–78.1)

11.1 

(9.0–13.3)

7.2 

(5.5–8.8)

6.5 

(5.0–7.9)

3.5–4 89.6 

(87.5–91.8)

7.3 

(5.5–9.2)

1.3 

(0.3–2.3)

0.8 

(1.7–2.7)

83.5 

(80.3–86.7)

10.0 

(7.7–12.3)

2.8 

(1.7–3.9)

3.7 

(2.5–5.0)

78.7 

(75.9–81.5)

9.9 

(7.9–11.8)

4.6 

(3.6–5.6)

6.8 

(5.3–8.4)

4.5–5 91.0 

(89.1–92.8)

6.2 

(4.5–7.9)

1.3 

(0.4–2.1)

1.5 

(0.6–2.5)

86.1 

(83.5–88.8)

9.7 

(7.5–11.8)

1.4 

(0.7–2.0)

2.9 

(1.7–4.1)

78.6 

(75.7–81.5)

11.2 

(9.1–13.2)

4.4 

(3.3–5.5)

5.8 

(4.4–7.2)

5.5–6 

(High)

91.9 

(89.4–94.5)

5.2 

(3.3–7.0)

1.0 

(0.0–2.1)

1.9 

(0.4–3.4)

87.6 

(83.6–91.6)

9.2 

(6.3–12.2)

1.0 

(0.2–1.8)

2.2 

(0.7–3.7)

82.7 

(79.7–85.7)

10.4 

(8.1–12.7)

3.2 

(2.1–4.3)

3.7 

(2.2–5.2)

Source: University of Michigan, Institute for Social Research, unpublished data (data: MTF 2015).

Notes: Questions on e-cigarette use were asked on four of six questionnaire forms. Data presented here are based on those four forms only.

aParental education is an average score of mother’s education and father’s education.

Table 2.5 Continued
Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 43

E-Cigarette Use Among Youth and Young Adults

(Continued from last paragraph on page 37.)

differences were observed among dual users (Table 2.5). 

For 10th and 12th graders, exclusive use of e-cigarettes 

was higher among boys than girls.

Tables 2.6a and 2.6b present data from the 2015 NYTS 

for middle and high school students. These data represent 

the percentages of tobacco users who were either lifetime 

or past-30-day users of e-cigarettes, by tobacco-use category (e.g., cigarettes only, other combustibles only). In 

these data, a correlation among the increasing levels of 

tobacco use, increasing complexity of poly-tobacco use, and 

e-cigarette use is apparent, with ever use and past-30-day

use of e-cigarettes emerging as least prevalent among never

tobacco users and most prevalent among the highest category of poly-tobacco users (conventional cigarettes plus

other combustibles and noncombustibles) for both age

groups. As an example, past-30-day e-cigarette use was

rare (2.8%) among middle school students who did not

use other tobacco products in that time period. However,

using the standard of past-30-day-use for each category, the

level of such use grew from 44.9% among those who had

used cigarettes only; to 61.3% among those who had used

cigarettes and other combustibles only; to 74.6% among

those who had used cigarettes, other combustibles, and

other noncombustibles only (Table 2.6a). These data are

consistent with results from the 2013–2014 PATH study

(n  =  13,651 youth, 12–17 years old), which showed that

52.6% of past-30-day tobacco users also used e-cigarettes

(Kasza et al. 2016).

According to the 2015 NYTS, among high school students, past-30-day use of e-cigarettes was also rare (3.4%) 

among never users of other tobacco products (Table 2.6b). 

In contrast, 18.4% of ever smokers of cigarettes only; 

36.3% of ever smokers of cigarettes and other combustible 

products only; and 55% of ever users of cigarettes, other 

combustibles, and other noncombustible products only 

had used e-cigarettes in the past 30  days. Although the 

survey found that just 7.3% of high school students were 

past-30-day exclusive users of e-cigarettes, many types of 

tobacco product users in the past 30 days were found to 

have used e-cigarettes in that period: 41.1% of cigaretteonly smokers; 58.8% of cigarette smokers and smokers of 

other combustible tobacco products only; and 77% of cigarette, other combustible, and noncombustible product 

users only. Similarly, 27.4% of high school students who 

had not used tobacco products in the past 30 days had ever 

tried e-cigarettes, as had 80.8% of past-30-day cigaretteonly smokers and 95.5% of those who had used cigarettes, 

other combustible, and other noncombustible tobacco 

products only (Table 2.6b).

Figure 2.5 presents data from the 2015 NYTS on the 

prevalence of past-30-day use of various tobacco products 

among middle and high school students. Although the 

overall level of tobacco use was lower in middle school, 

the patterns of poly-tobacco use were similar between the 

two groups, albeit with a larger proportion of poly-tobacco 

use in high school. An estimated 6.6% of high school students and 1.8% of middle school students were dual users 

of combustible tobacco products and e-cigarettes in 2015. 

Combined use of combustible tobacco, noncombustible 

tobacco, and e-cigarettes in the past 30 days was rare, 

with this pattern found for just 0.7% of middle school 

and 2.6%  of high school students in 2015 (Figure 2.5). 

Longitudinal data are needed to follow individuals over 

time, ideally for several years, to more precisely examine 

both the trajectories into and out of cigarette and 

e-cigarette use and to determine if dual use is a steady state 

or a pathway-to-persistent-use-of-combustible-tobacco

state (Cobb et al. 2015). The small number of such studies

that currently exist are discussed below.

Trends in prevalence. Tables 2.7a and 2.7b and 

Figures 2.6 and 2.7 present patterns of ever e-cigarette 

and poly-tobacco use over time, using the NYTS data 

from 2011 to 2015. Among both middle school and high 

school students, the exclusive use of combustible products declined over time, while both the exclusive use of 

e-cigarettes and the dual use of e-cigarettes with combustible products increased, especially from 2013 to 2015.

Middle school students. In 2011, an estimated 

21% of middle school students had ever used some form 

of tobacco in their lifetimes, compared to just 1.4% of 

middle school students who had ever used e-cigarettes 

(Table 2.7a). By 2015, 13.5% of middle school students 

had ever tried a tobacco product, while 3.5% had tried 

e-cigarettes. In that year, 4.5% of middle school students

were ever users of e-cigarettes only; 6.2% were ever users

of e-cigarettes and combustible products only; and 2.2%

were ever users of combustible products, noncombustible

products, and e-cigarettes. This means that 70% of middle

school students who had ever used e-cigarettes had

also experimented with a combustible tobacco product,

although which came first is unknown. In 2015, for

past-30-day use, exclusive e-cigarette use was 2.6% and

exclusive combustible tobacco use was 1.2%. Also in 2015,

the prevalence of past-30-day dual use of e-cigarettes and

any other combustible or noncombustible product was

similar to those estimates, at 2.7% (1.8% for e-cigarettes

plus combustibles only, 0.2% for noncombustibles and

e-cigarettes only, and 0.7% for e-cigarettes plus combustibles and noncombustibles only). In 2015, ever use of cigarettes in combination with combustibles (6.2%) was equal

to or higher than ever use of e-cigarettes only (4.5%) or

combustibles only (4.4%) (Table 2.7a).

High school students. In 2011, an estimated 47.2% of 

high school students had ever used other tobacco products in their lifetimes, compared to 4.7%  who had ever 

used e-cigarettes (Table 2.7b). By 2015, 50.4% of high
A Report of the Surgeon General

44 Chapter 2

Table 2.6a Lifetime and past-30-day e-cigarette use among U.S. middle school students, by other tobacco product 

use; National Youth Tobacco Survey (NYTS) 2015

Lifetime e-cigarette usea

Past-30-day 

e-cigarette useb

Nc % (95% CI) SE % (95% CI) SE

Ever other tobacco used (n = 1,757) 8,162

Never 6,942 5.3 (4.5–6.2) 0.4 1.6 (1.3–2.0) 0.2

Cigarettes only 343 54.3 (46.7–61.7) 3.8 20.8 (15.7–27.0) 2.8

Other combustibles only 261 59.0 (51.5–66.1) 3.7 24.8 (19.0–31.7) 3.2

Noncombustibles only 89 30.7 (23.2–39.3) 4.1 — —

Cigarettes + other combustibles only 300 70.6 (62.9–77.3) 3.6 35.0 (27.5–43.3) 4.0

Cigarettes + noncombustibles only 67 69.5 (54.5–81.3) 6.9 21.7 (12.7–34.6) 5.5

Other combustibles + noncombustibles only 27 80.3 (56.1–92.9) 9.2 39.4 (20.3–62.3) 11.2

Cigarettes + other combustibles + noncombustibles 

only

133 84.1 (73.3–91.1) 4.4 45.0 (34.7–55.7) 5.3

Past-30-day other tobacco usee (n = 417) 8,145

No 7,728 10.5 (9.1–12.0) 0.7 2.8 (2.3–3.4) 0.3

Cigarettes only 70 80.6 (68.3–89.0) 5.2 44.9 (32.0–58.6) 6.8

Other combustibles only 153 82.8 (74.0–89.1) 3.8 69.2 (59.1–77.8) 4.7

Noncombustibles only 50 49.0 (34.9–63.3) 7.3 23.1 (12.7–38.2) 6.4

Cigarettes + other combustibles only 63 77.3 (58.8–89.0) 7.6 61.3 (43.9–76.2) 8.4

Cigarettes + noncombustibles only 18 87.2 (65.2–96.1) 7.2 67.8 (40.0–87.0) 12.6

Other combustibles + noncombustibles only 20 87.5 (63.2–96.6) 7.7 64.8 (42.2–82.3) 10.6

Cigarettes + other combustibles + noncombustibles 

only

43 85.8 (67.5–94.6) 6.5 74.6 (43.4–91.8) 12.7

Source: Centers for Disease Control and Prevention, unpublished data (data: NYTS 2015).

Notes: CI = confidence interval; SE = standard error. Cigarettes Only includes those who reported trying cigarettes but not any other 

tobacco product. Other combustibles includes cigars, pipes, and hookah or bidis. Noncombustibles includes smokeless tobacco, dissolvables, or snus. Other Combustibles Only includes those who reported trying other combustibles but not cigarettes nor noncombustibles. 

Noncombustibles Only includes those who reported trying noncombustibles but not cigarettes nor other combustibles. Cigarettes and 

Other Combustibles Only includes those who reported trying cigarettes and other combustibles but not noncombustibles. Cigarettes 

and Noncombustibles Only includes those who reported trying cigarettes and noncombustibles but not other combustibles. Other 

Combustibles and Noncombustibles Only includes those who reported trying other combustibles and noncombustibles but not cigarettes. 

Cigarettes, Other Combustibles, and Noncombustibles includes those who reported trying a product from each group.

aIncludes those who responded “yes” to the following question, “Have you ever used an electronic cigarette or e-cigarette, even once 

or twice?”

bIncludes those who responded “1 or more days” to the following question, “During the past 30 days, on how many days did you use 

electronic cigarettes or e-cigarettes?”

cIncludes all respondents categorized into each group. It does not exclude those missing for e-cigarette status.

dIncludes those who reported trying at least one of the following products (e-cigarettes not included in the definitions): Cigarettes Only;

Other Combustibles Only; Noncombustibles Only; Cigarettes and Other Combustibles Only; Cigarettes and Noncombustibles Only; 

Other Combustibles and Noncombustibles Only; and Cigarettes, Other Combustibles, and Noncombustibles.

eIncludes those who reported using at least one of the following products on 1 of the past 30 days (e-cigarettes were not included in the 

definitions): Cigarettes Only; Other Combustibles Only; Noncombustibles Only; Cigarettes and Other Combustibles Only; Cigarettes and 

Noncombustibles Only; Other Combustibles and Noncombustibles Only; and Cigarettes, Other Combustibles, and Noncombustibles.
Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 45

E-Cigarette Use Among Youth and Young Adults

Table 2.6b Lifetime and past-30-day e-cigarette use among U.S. high school students, by other tobacco product use; 

National Youth Tobacco Survey (NYTS) 2015

Lifetime e-cigarette usea

Past-30-day 

e-cigarette useb

Nc % (95% CI) SE % (95% CI) SE

Ever other tobacco used (n = 5,094) 9,422

Never 5,326 13.1 (11.7–14.8) 0.8 3.4 (2.5–4.4) 0.5

Cigarettes only 675 54.7 (48.5–60.6) 3.0 18.4 (13.7–24.4) 2.7

Other combustibles only 947 60.0 (54.4–65.3) 2.7 21.7 (18.0–25.9) 2.0

Noncombustibles only 137 39.8 (30.8–49.6) 4.7 20.2 (12.5–31.0) 4.6

Cigarettes + other combustibles only 1,307 79.6 (74.7–83.8) 2.3 36.3 (31.5–41.3) 2.5

Cigarettes + noncombustibles only 131 61.5 (48.7–72.9) 6.2 25.5 (18.5–34.0) 3.9

Other combustibles + noncombustibles only 171 69.5 (57.1–79.6) 5.7 35.3 (26.1–45.8) 5.0

Cigarettes + other combustibles + noncombustibles 

only

728 89.2 (82.6–93.5) 2.7 55.0 (47.5–62.4) 3.8

Past-30-day other tobacco usee (n = 2,389) 9,416

No 7,542 27.4 (25.2–29.7) 1.1 7.3 (6.1–8.8) 0.7

Cigarettes only 288 80.8 (74.2–86.0) 2.9 41.1 (32.2–50.6) 4.7

Other combustibles only 701 77.2 (71.2–82.3) 2.8 50.4 (45.0–55.8) 2.7

Noncombustibles only 192 69.6 (54.6–81.4) 6.8 31.2 (23.0–40.9) 4.5

Cigarettes + other combustibles only 353 87.1 (77.5–93.0) 3.8 58.8 (49.1–67.8) 4.7

Cigarettes + noncombustibles only 62 76.9 (59.8–88.2) 7.2 50.8 (27.9–73.5) 12.3

Other combustibles + noncombustibles only 108 88.7 (78.8–94.3) 3.8 74.1 (61.3–83.9) 5.7

Cigarettes + other combustibles + noncombustibles 

only

170 95.9 (87.2–98.8) 2.4 77.0 (66.6–84.8) 4.6

Source: Centers for Disease Control and Prevention, unpublished data (data: NYTS 2015).

Notes: CI = confidence interval; SE = standard error. Cigarettes Only includes those who reported trying cigarettes but not any other 

tobacco product. Other combustibles includes cigars, pipes, and hookah or bidis. Noncombustibles includes smokeless tobacco, dissolvables, or snus. Other Combustibles Only includes those who reported trying other combustibles but not cigarettes nor noncombustibles. 

Noncombustibles Only includes those who reported trying noncombustibles but not cigarettes nor other combustibles. Cigarettes and 

Other Combustibles Only includes those who reported trying cigarettes and other combustibles but not noncombustibles. Cigarettes 

and Noncombustibles Only includes those who reported trying cigarettes and noncombustibles but not other combustibles. Other 

Combustibles and Noncombustibles Only includes those who reported trying other combustibles and noncombustibles but not cigarettes. 

Cigarettes, Other Combustibles, and Noncombustibles includes those who reported trying a product from each group.

aIncludes those who responded “yes” to the following question, “Have you ever used an electronic cigarette or e-cigarette, even once 

or twice?”

bIncludes those who responded “1 or more days” to the following question, “During the past 30 days, on how many days did you use 

electronic cigarettes or e-cigarettes?”

cIncludes all respondents categorized into each group. It does not exclude those missing for e-cigarette status.

dIncludes those who reported trying at least one of the following products (e-cigarettes not included in the definitions): Cigarettes Only;

Other Combustibles Only; Noncombustibles Only; Cigarettes and Other Combustibles Only; Cigarettes and Noncombustibles Only; 

Other Combustibles and Noncombustibles Only; and Cigarettes, Other Combustibles, and Noncombustibles.

eIncludes those who reported using at least one of the following products on 1 of the past 30 days (e-cigarettes were not included in the 

definitions): Cigarettes Only; Other Combustibles Only; Noncombustibles Only; Cigarettes and Other Combustibles Only; Cigarettes and 

Noncombustibles Only; Other Combustibles and Noncombustibles Only; and Cigarettes, Other Combustibles, and Noncombustibles.
A Report of the Surgeon General

46 Chapter 2

Figure 2.5 Past-30-day use of various tobacco products among U.S. middle and high school students; National 

Youth Tobacco Survey (NYTS) 2015

Source: Centers for Disease Control and Prevention 2015b; unpublished data (data: NYTS 2015).

aIncludes exclusive use of e-cigarettes. It does not include use of any other product.

bIncludes exclusive use of smokeless tobacco, snus, and/or dissolvable tobacco. It does not include use of combustible products or 

e-cigarettes.

cIncludes the use of cigarettes, cigars, pipes, bidis, kreteks, and/or hookahs. It includes participants who reported use of combustible

and noncombustible products but not e-cigarettes.
E-Cigarette Use Among Youth and Young Adults

Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 47

Table 2.7a Percentage of middle school students who have ever used tobacco, by type of product; National Youth Tobacco Survey (NYTS) 2011–2015

2011 2012 2013 2014 2015

Characteristic % (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE

Any lifetimea tobacco use 21.0 (19.2–22.9) 0.9 17.9 (15.9–20.0) 1.0 17.6 (15.6–19.9) 1.1 19.1 (16.7–21.8) 1.3 19.4 (17.0–22.0) 1.2

Any lifetime e-cigarette useb 1.4 (1.0–2.0) 0.2 2.7 (2.2–3.2) 0.2 3.0 (2.5–3.5) 0.2 10.1 (8.5–11.9) 0.8 13.5 (11.8–15.5) 0.9

Ever tobacco usec

E-cigarettes only 0.3 (0.2–0.6) 0.1 0.4 (0.3–0.5) 0.1 0.5 (0.3–0.9) 0.1 2.9 (2.3–3.5) 0.3 4.5 (3.9–5.2) 0.3

Combustibles and e-cigarettes only 0.4 (0.3–0.6) 0.1 1.1 (0.9–1.4) 0.1 1.5 (1.1–1.9) 0.2 4.5 (3.9–5.3) 0.4 6.2 (5.4–7.2) 0.5

Noncombustibles and e-cigarettes only ND ND — — — — 0.3 (0.1–0.6) 0.1 0.4 (0.2–0.7) 0.1

Combustibles, noncombustibles, and

e-cigarettes

0.5 (0.3–0.9) 0.1 1.1 (0.8–1.4) 0.1 0.8 (0.6–1.2) 0.1 2.2 (1.45–3.2) 0.4 2.2 (1.7–2.9) 0.3

Combustibles only 13.9 (12.5–15.4) 0.7 10.7 (9.5–12.1) 0.7 11.6 (10.1–13.3) 0.8 6.9 (5.6–8.4) 0.7 4.4 (3.7–5.2) 0.4

Noncombustibles only 1.5 (1.1–1.9) 0.2 1.2 (0.9–1.6) 0.2 0.8 (0.6–1.1) 0.1 0.8 (0.5–1.2) 0.2 1.0 (0.7–1.4) 0.2

Combustibles and noncombustibles 

only 

4.3 (3.5–5.1) 0.4 3.4 (2.8–4.0) 0.3 2.4 (1.8–3.2) 0.3 1.5 (1.1–2.1) 0.2 0.7 (0.4–1.1) 0.2

Any past-30-day tobacco used 7.5 (6.4–8.8) 0.6 6.7 (5.8–7.7) 0.5 6.5 (5.43–7.8) 0.6 7.7 (6.7–8.9) 0.6 7.4 (6.3–8.7) 0.6

Any past-30-day e-cigarette usee 0.6 (0.4–0.9) 0.1 1.1 (0.9–1.5) 0.1 1.1 (0.8–1.5) 0.2 3.9 (3.0–5.0) 0.5 5.3 (4.6–6.2) 0.4

Past-30-day tobacco use

E-cigarettes onlyf 0.2 (0.1–0.4) 0.1 0.3 (0.2–0.4) 0.1 0.4 (0.2–0.8) 0.1 1.9 (1.4–2.5) 0.3 2.6 (2.2–3.2) 0.3

Combustibles and e-cigarettes only 0.1 (0.1–0.3) 0.0 0.5 (0.3–0.7) 0.1 0.4 (0.3–0.6) 0.1 1.3 (1.0–1.7) 0.2 1.8 (1.4–2.2) 0.2

Noncombustibles and e-cigarettes only — — — — — — 0.1 (0.1–0.2) 0.0 0.2 (0.1–0.3) 0.0

Combustibles, noncombustibles, and 

e-cigarettes

0.2 (0.1–0.3) 0.1 0.4 (0.2–0.5) 0.1 0.2 (0.1–0.4) 0.1 0.6 (0.4–0.8) 0.1 0.7 (0.4–1.1) 0.1

Combustibles only 4.5 (3.7–5.5) 0.4 3.7 (3.2–4.3) 0.3 4.0 (3.3–4.9) 0.4 2.7 (2.1–3.3) 0.3 1.2 (0.9–1.6) 0.2

Noncombustibles only 0.9 (0.6–1.3) 0.2 0.7 (0.5–1.0) 0.1 0.6 (0.3–0.9) 0.2 0.7 (0.4–1.2) 0.2 0.6 (0.3–1.2) 0.2

Combustibles and noncombustibles 

only 

1.6 (1.3–2.0) 0.2 1.2 (0.9–1.5) 0.2 0.8 (0.5–1.1) 0.1 0.5 (0.4–0.8) 0.1 0.3 (0.1–0.6) 0.1

Source: Centers for Disease Control and Prevention, unpublished data (data: NYTS 2011–2015).

Notes: CI = confidence interval; ND = no data for this cell; SE = standard error. An em dash (—) indicates that data are statistically unstable because of a relative standard 

error >40%. Wording of questions used to measure e-cigarette use varied from 2011 to 2015. Cigarettes were not included in this analysis. Combustibles includes cigars, pipes, 

hookahs, or bidis. Noncombustibles includes smokeless tobacco, dissolvables, or snus. Combustibles and E-Cigarettes Only includes those who reported trying e-cigarettes and 

combustibles but not noncombustibles. Noncombustibles and E-Cigarettes Only includes those who reported trying e-cigarettes and noncombustibles but not combustibles.
A Report of the Surgeon General

48 Chapter 2

Combustibles, Noncombustibles, and E-Cigarettes includes those who reported trying e-cigarettes, noncombustibles, and combustibles. Combustibles Only includes those 

who reported trying combustibles but not noncombustibles or e-cigarettes. Noncombustibles Only includes those who reported trying noncombustibles but not combustibles or 

e-cigarettes. Combustibles and Noncombustibles Only includes those who reported trying noncombustibles and combustibles but not e-cigarettes.

aIncludes those who reported having tried at least one tobacco product in their lives (e-cigarettes, combustibles, and noncombustibles).

bIncludes those who reported having tried e-cigarettes in their lives.

cIncludes those who reported having tried at least one tobacco product in their lives.

dIncludes those who reported using at least one other tobacco product on at least 1 of the past 30 days.

eIncludes those who reported using e-cigarettes on at least 1 of the past 30 days.

f

Includes those who reported using e-cigarettes only on at least 1 of the past 30 days.

Table 2.7a Continued
E-Cigarette Use Among Youth and Young Adults

Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 49

Table 2.7b Percentage of high school students who have ever used tobacco, by type of product; National Youth Tobacco Survey (NYTS) 2011–2015

2011 2012 2013 2014 2015

Characteristic % (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE

Any lifetimea tobacco use 47.2 (44.0–50.4) 1.6 45.7 (43.0–48.5) 1.4 46.0 (43.3–48.7) 1.4 47.1 (44.5–49.8) 1.3 50.4 (47.9–52.9) 1.3

Any lifetime e-cigarette useb 4.7 (3.8–5.7) 0.5 10.0 (8.6–11.6) 0.7 11.9 (10.5–13.5) 0.8 27.3 (24.4–30.5) 1.5 37.7 (35.3–40.2) 1.2

Ever tobacco usec

E-cigarettes only 0.1 (0.1–0.2) 0.0 0.2 (0.2–0.4) 0.0 0.3 (0.2–0.6) 0.1 3.7 (2.9–4.8) 0.5 7.4 (6.6–8.4) 0.5

Combustibles and e-cigarettes 

only

1.6 (1.3–2.0) 0.2 4.2 (3.5–5.0) 0.4 6.0 (5.2–6.9) 0.4 14.5 (13.2–16.0) 0.7 20.0 (18.6–21.6) 0.8

Noncombustibles and e-cigarettes 

only

— — — — — — 0.3 (0.1–0.4) 0.1 0.6 (0.4–0.8) 0.1

Combustibles, noncombustibles, 

and e-cigarettes

2.8 (2.2–3.6) 0.4 5.2 (4.3–6.2) 0.5 5.2 (4.2–6.3) 0.5 8.3 (7.0–9.7) 0.7 9.1 (7.6–10.9) 0.8

Combustibles only 29.1 (27.3–30.9) 0.9 25.1 (23.1–27.1) 1.0 25.2 (22.7–27.8) 1.3 15.8 (14.3–17.5) 0.8 10.2 (8.8–11.8) 0.8

Noncombustibles only 1.8 (1.3–2.4) 0.3 1.3 (1.0–1.8) 0.2 1.5 (1.1–1.9) 0.2 1.2 (0.9–1.7) 0.2 0.9 (0.7–1.2) 0.1

Combustibles and 

noncombustibles only 

 11.8 (9.8–13.9) 1.1 9.7 (8.6–10.9) 0.6 7.8 (6.6–9.3) 0.7 3.3 (2.6–4.2) 0.4 2.2 (1.6–3.0) 0.4

Any past-30-day tobacco used 24.0 (22.0–26.5) 1.2 23 (21.5–25.2) 0.9 22.9 (21.1–24.9) 0.9 24.6 (22.6–26.7) 1.0 25.3 (23.1–27.6) 1.1

Any past-30-day e-cigarette usee 1.5 (1.2–2.0) 0.2 2.8 (2.3–3.5) 0.3 4.5 (3.8–5.3) 0.4 13.4 (11.2–16.1) 1.2 16.0 (14.1–18.0) 1.0

Past-30-day tobacco use

E-cigarettes onlyf 0.1 (0.1–0.2) 0.0 0.3 (0.2–0.4) 0.1 0.7 (0.5–0.9) 0.1 4.4 (3.4–5.7) 0.6 5.9 (4.9–7.0) 0.5

Combustibles and e-cigarettes 

only

0.7 (0.5–0.9) 0.1 1.4 (1.1–1.8) 0.2 2.6 (2.1–3.2) 0.3 5.8 (4.9–6.8) 0.5 6.6 (5.7–7.7) 0.5

Noncombustibles and 

e-cigarettes only

ND ND — — — — 0.6 (0.4–0.8) 0.1 0.7 (0.5–0.9) 0.1

Combustibles, noncombustibles, 

and e-cigarettes

0.6 (0.4–0.9) 0.1 1.1 (0.8–1.4) 0.1 1.1 (0.8–1.4) 0.1 2.5 (2.0–3.2) 0.3 2.6 (2.1–3.3) 0.3

Combustibles only 15.6 (14.5–16.8) 0.6 14.4 (13.2–15.6) 0.6 13.5 (12.4–14.8) 0.6 8.1 (7.2–9.2) 0.5 6.8 (5.9–7.8) 0.5

Noncombustibles only 2.3 (1.7–3.0) 0.3 1.9 (1.4–2.4) 0.2 1.6 (1.2–2.2) 0.3 1.5 (1.1–2.0) 0.2 1.5 (1.0–2.2) 0.3

Combustibles and 

noncombustibles only 

4.9 (4.0–6.1) 0.5 4.3 (3.7–5.2) 0.4 3.4 (2.7–4.3) 0.4 1.6 (1.2–2.2) 0.2 1.1 (0.7–1.8) 0.2

Source: Centers for Disease Control and Prevention, unpublished data (data: NYTS 2011–2015).
A Report of the Surgeon General

50 Chapter 2

Notes: CI = confidence interval; ND = no data for this cell; SE = standard error. An em dash (—) indicates that data are statistically unstable because of a relative standard 

error >40%. Wording of questions used to measure e-cigarette use varied from 2011 to 2015. Cigarettes were not included in this analysis. Combustibles includes cigars, pipes, 

hookahs, or bidis. Noncombustibles includes smokeless tobacco, dissolvables, or snus. Combustibles and E-Cigarettes Only includes those who reported trying e-cigarettes and 

combustibles but not noncombustibles. Noncombustibles and E-Cigarettes Only includes those who reported trying e-cigarettes and noncombustibles but not combustibles.

Combustibles, Noncombustibles, and E-Cigarettes includes those who reported trying e-cigarettes, noncombustibles, and combustibles. Combustibles Only includes those 

who reported trying combustibles but not noncombustibles or e-cigarettes. Noncombustibles Only includes those who reported trying noncombustibles but not combustibles or 

e-cigarettes. Combustibles and Noncombustibles Only includes those who reported trying noncombustibles and combustibles but not e-cigarettes.

aIncludes those who reported having tried at least one tobacco product in their lives (e-cigarettes, combustibles, and noncombustibles).

bIncludes those who reported having tried e-cigarettes in their lives.

cIncludes those who reported having tried at least one tobacco product in their lives.

dIncludes those who reported using at least one other tobacco product on at least 1 of the past 30 days.

eIncludes those who reported using e-cigarettes on at least 1 of the past 30 days.

f

Includes those who reported using e-cigarettes only on at least 1 of the past 30 days.

Table 2.7b Continued
Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 51

E-Cigarette Use Among Youth and Young Adults

Figure 2.6 Percentage of U.S. middle school students who have ever used tobaccoa, by type of product; National 

Youth Tobacco Survey (NYTS) 2011–2015

Source: Centers for Disease Control and Prevention, unpublished data (data: NYTS 2011–2015).

Notes: For more information see Table 2.10a. In 2014, modifications were made to the e-cigarette measure to enhance its accuracy, 

which may limit the comparability of this estimate to those collected in previous years. The dotted lines from 2013 to 2015 represent 

these differences.

aIncludes those who reported having tried at least one other tobacco product in their lives.

bIncludes exclusive use of only e-cigarettes. It does not include use of any other product. Ever e-cigarette use includes those who 

responded “electronic cigarettes or e-cigarettes, such as Ruyan or NJOY” to the following question: “Which of the following tobacco 

products have you ever tried, even just one time?”

cIncludes exclusive use of only cigarettes, cigars, pipes, bidis, kreteks, and/or hookahs. It does not include use of noncombustible 

products or e-cigarettes. They were defined using the following questions: Conventional cigarettes: “Have you ever tried cigarette 

smoking, even one or two puffs?” and “During the past 30 days, on how many days did you smoke cigarettes?”; cigars: “Have you 

ever tried smoking cigars, cigarillos, or little cigars, such as Black and Milds, Swisher Sweets, Dutch Masters, White Owl, or Phillies 

Blunts, even one or two puffs?” and “During the past 30 days, on how many days did you smoke cigars, cigarillos, or little cigars?”; 

pipes: “Have you ever tried smoking tobacco in a pipe, even one or two puffs?” and “During the past 30 days, on how many days did 

you smoke tobacco in a pipe?”; and hookahs, kreteks, and bidis: “Which of the following tobacco products have you ever tried, even 

just one time? (CHOOSE ALL THAT APPLY)” and “During the past 30 days, which of the following products have you used on at 

least 1 day? (CHOOSE ALL THAT APPLY).”

dIncludes exclusive use of only smokeless tobacco, snus, and/or dissolvable tobacco. It does not include use of combustible products 

or e-cigarettes. They were defined using the following questions: Smokeless tobacco: “Have you ever used chewing tobacco, snuff, 

or dip, such as Red Man, Levi Garrett, Beechnut, Skoal, Skoal Bandits, or Copenhagen, even just a small amount?” and “During the 

past 30 days, on how many days did you use chewing tobacco, snuff, or dip?”; and dissolvables and snus: “Which of the following 

tobacco products have you ever tried, even just one time? (CHOOSE ALL THAT APPLY)” and “During the past 30 days, which of the 

following products have you used on at least 1 day? (CHOOSE ALL THAT APPLY).”
A Report of the Surgeon General

52 Chapter 2

Figure 2.7 Percentage of U.S. high school students who have ever used tobaccoa, by type of product; National Youth 

Tobacco Survey (NYTS) 2011–2015

Source: Centers for Disease Control and Prevention, unpublished data (data: NYTS 2011–2015).

Notes: For more information see Table 2.10b. In 2014, modifications were made to the e-cigarette measure to enhance its accuracy, 

which may limit the comparability of this estimate to those collected in previous years. The dotted lines from 2013 to 2015 represent 

these differences.

aIncludes those who reported having tried at least one other tobacco product in their lives.

bIncludes exclusive use of only e-cigarettes. It does not include use of any other product. Ever e-cigarette use includes those who 

selected “electronic cigarettes or e-cigarettes, such as Ruyan or NJOY” for the following question: “Which of the following tobacco 

products have you ever tried, even just one time?”

cIncludes exclusive use of only cigarettes, cigars, pipes, bidis, kreteks, and/or hookahs. It does not include use of noncombustible 

products or e-cigarettes. They were defined using the following questions: Conventional cigarettes: “Have you ever tried cigarette 

smoking, even one or two puffs?” and “During the past 30 days, on how many days did you smoke cigarettes?”; cigars: “Have you 

ever tried smoking cigars, cigarillos, or little cigars, such as Black and Milds, Swisher Sweets, Dutch Masters, White Owl, or Phillies 

Blunts, even one or two puffs?” and “During the past 30 days, on how many days did you smoke cigars, cigarillos, or little cigars?”; 

pipes: “Have you ever tried smoking tobacco in a pipe, even one or two puffs?” and “During the past 30 days, on how many days did 

you smoke tobacco in a pipe?”; and hookahs, kreteks, and bidis: “Which of the following tobacco products have you ever tried, even 

just one time? (CHOOSE ALL THAT APPLY)” and “During the past 30 days, which of the following products have you used on at 

least 1 day? (CHOOSE ALL THAT APPLY).”

dIncludes exclusive use of only smokeless tobacco, snus, and/or dissolvable tobacco. It does not include use of combustible products 

or e-cigarettes. They were defined using the following questions: Smokeless tobacco: “Have you ever used chewing tobacco, snuff, 

or dip, such as Red Man, Levi Garrett, Beechnut, Skoal, Skoal Bandits, or Copenhagen, even just a small amount?” and “During the 

past 30 days, on how many days did you use chewing tobacco, snuff, or dip?”; and dissolvables and snus: “Which of the following 

tobacco products have you ever tried, even just one time? (CHOOSE ALL THAT APPLY)” and “During the past 30 days, which of the 

following products have you used on at least 1 day? (CHOOSE ALL THAT APPLY).”
Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 53

E-Cigarette Use Among Youth and Young Adults

(Continued from last paragraph on page 43.)

school students had ever tried a tobacco product, and 

37.7% had ever used an e-cigarette. In 2015, 7.4% of high 

school students had ever used e-cigarettes exclusively; 

20% were ever dual users of e-cigarettes and combustible 

products; 0.6% were ever dual users of noncombustible 

products and e-cigarettes only; and 9.1% were ever poly 

users of combustibles, noncombustibles, and e-cigarettes. 

However, the order of the use (i.e., which product came 

first) remains unknown. In 2015, 5.9% of high school students were exclusive past-30-day users of e-cigarettes; 6.6% 

were past-30-day dual users of e-cigarettes and combustible tobacco products; 0.7% were past-30-day dual users 

of e-cigarettes and noncombustible tobacco products only; 

and 2.6% were past-30-day poly users of e-cigarettes, combustible, and noncombustible tobacco products. Exclusive 

use of combustible products (6.8%) remained as prevalent 

as past-30-day dual use of e-cigarettes and combustible 

products (6.6%) among high school students (Table 2.7b).

Young Adults2

2As opposed to the situation in youth, cigarettes are the most commonly used tobacco product among young adults. Therefore, this

chapter does not assess co-use of e-cigarettes and other tobacco products among young adults.

Current prevalence. Using data from the 2013–2014 

NATS, current exclusive and combined use of e-cigarettes 

and cigarettes are presented in Figure 2.8 and Table 2.8a 

for young adults (18–24 years old), and in Figure 2.8 and 

Table 2.8b for adults 25 years of age and older. For both 

age groups, exclusive use of regular cigarettes was the 

most prevalent pattern of behavior (9.6%, young adults; 

13%, adults), followed by dual use of cigarettes and 

e-cigarettes (7.5%, young adults; 4.2%, adults), and exclusive use of e-cigarettes (6.1%, young adults; 1.6%, adults).

Among young adults, combined use of the two products

and exclusive use of e-cigarettes were both higher among

males than females; combined use was higher among

Whites than in Hispanics or Blacks; and both combined

use of the two products and exclusive use of e-cigarettes

were lowest among those with a college degree.

Figure 2.8 Percentage of young adults who currently use e-cigarettesa and conventional cigarettes; National Adult 

Tobacco Survey (NATS) 2013–2014

Source: Centers for Disease Control and Prevention, unpublished data (data: NATS 2013–2014).

aCurrent e-cigarette use was defined as those who reported they had heard of e-cigarettes and had tried e-cigarettes, and reported 

using e-cigarettes every day, some days, or rarely at the time of the interview.

Longitudinal Studies

Understanding the role that e-cigarettes play in 

the initiation of tobacco product use, especially conventional cigarettes and other combustible tobacco products, such as cigars and hookahs, is extremely important 

for informing public health policy, planning, and practice. It is unclear what impact e-cigarette use will have 

on the overall toll of tobacco use on public health (Cobb 

et al. 2015). Some researchers and policymakers are concerned about the order in which the initiation of tobacco 

products takes place, positing that the use of e-cigarettes
A Report of the Surgeon General

54 Chapter 2

Table 2.8a Percentage of young adults (18–24 years of age) who currently use e-cigarettesa, cigarettesb, or bothc products, by gender, race/ethnicity, 

and education: National Adult Tobacco Survey (NATS) 2013–2014

Neitherd E-cigarettes onlye Cigarettes onlyf Bothc

Characteristic % (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE

Overall 76.8 (75.3–78.3) 0.8 6.1 (5.3–7.0) 0.4 9.6 (8.6–10.7) 0.5 7.5 (6.6–8.4) 0.5

Gender

Female 81.8 (79.7–83.7) 1.0 4.0 (3.1–5.2) 0.5 8.4 (7.1–9.9) 0.7 5.8 (4.7–7.2) 0.6

Male 72.3 (70.1–74.4) 1.1 8.1 (6.9–9.4) 0.6 10.6 (9.2–12.2) 0.8 9.0 (7.7–10.4) 0.7

Race/ethnicity

White 72.8 (70.7–74.8) 1.1 6.3 (5.3–7.5) 0.6 11.2 (9.8–12.8) 0.8 9.7 (8.4–11.2) 0.7

Black or African American 84.8 (80.8–88.2) 1.9 2.9 (1.7–4.9) 0.8 9.8 (7.0–13.5) 1.6 2.5 (1.4–4.4) 0.7

Hispanic or Latino 80.5 (77.0–83.6) 1.7 7.5 (5.7–9.7) 1.0 6.1 (4.3–8.5) 1.1 5.9 (4.2–8.3) 1.1

Otherg 79.8 (75.5–83.5) 2.1 5.7 (3.8–8.6) 1.2 9.4 (6.9–12.5) 1.4 5.1 (3.4–7.6) 1.0

Education

<High school 67.4 (61.7–72.6) 2.8 5.8 (3.7–9.1) 1.3 17.3 (13.4–22.1) 2.2 9.4 (6.6–13.3) 1.7

High school 74.4 (71.9–76.7) 1.2 6.5 (5.3–7.8) 0.6 10.7 (9.2–12.5) 0.8 8.5 (7.0–10.1) 0.8

Some collegeh 78.2 (75.8–80.4) 1.2 7.3 (5.9–9.0) 0.8 7.2 (5.9–8.7) 0.7 7.3 (6.1–8.8) 0.7

College degreei 92.5 (90.2–94.4) 1.1 2.3 (1.4–3.9) 0.6 3.1 (2.0–4.7) 0.7 2.1 (1.2–3.5) 0.6

Source: Centers for Disease Control and Prevention, unpublished data (data: NATS 2013–2014).

Note: CI = confidence interval; SE = standard error.

aIncludes those who reported they had heard of, tried, and used e-cigarettes every day, some days, or rarely at the time of the interview.

bIncludes those who smoked at least 100 cigarettes and reported using cigarettes every day or some days at the time of the interview.

cIncludes those who reported currently using both e-cigarettes and conventional cigarettes.

dIncludes those who reported currently using neither conventional cigarettes nor e-cigarettes.

eIncludes those who reported currently using e-cigarettes but not conventional cigarettes.

f

Includes those who reported currently using conventional cigarettes but not electronic e-cigarettes.

gIncludes non-Hispanic Asian, non-Hispanic Native Hawaiian/Other Pacific Islander, non-Hispanic American Indian/Alaska Native, and multiracial.

hIncludes some college, no degree; associate’s degree, academic program; associate’s degree, unspecified; certificate; diploma; or associate’s degree.

i

Includes bachelor’s degree, master’s/professional school degree, or doctoral degree.
E-Cigarette Use Among Youth and Young Adults

Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 55

Table 2.8b Percentage of adults (≥25 years of age) who currently use e-cigarettesa, cigarettesb, or bothc products, by gender, race/ethnicity, and 

education: National Adult Tobacco Survey (NATS) 2013–2014

Neitherd E-cigarettes onlye Cigarettes onlyf Bothc

Characteristic % (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE

Overall 81.3 (80.8–81.7) 0.2 1.6 (1.5–1.7) 0.1 13.0 (12.6–13.4) 0.2 4.2 (3.9–4.4) 0.1

Gender

Female 83.4 (82.8–84.0) 0.3 1.3 (1.1–1.4) 0.1 11.5 (11.0–12.0) 0.3 3.8 (3.5–4.1) 0.2

Male 78.8 (78.1–79.5) 0.4 2.0 (1.7–2.2) 0.1 14.6 (14.0–15.3) 0.3 4.6 (4.2–5.0) 0.2

Race/ethnicity

White 82.1 (81.6–82.6) 0.3 1.6 (1.5–1.8) 0.1 11.9 (11.5–12.3) 0.2 4.4 (4.1–4.7) 0.1

Black or African American 76.2 (74.6–77.7) 0.8 0.9 (0.7–1.3) 0.2 20.0 (18.6–21.5) 0.7 2.9 (2.4–3.5) 0.3

Hispanic or Latino 83.2 (81.6–84.6) 0.8 1.5 (1.1–2.0) 0.2 12.0 (10.7–13.3) 0.7 3.4 (2.7–4.2) 0.4

Otherg 77.5 (75.6–79.4) 1.0 2.5 (1.9–3.3) 0.4 14.5 (13.0–16.1) 0.8 5.5 (4.4–6.7) 0.6

Education

<High school 71.3 (69.5–73.1) 0.9 1.0 (0.7–1.4) 0.2 23.5 (21.8–25.2) 0.9 4.2 (3.5–5.1) 0.4

High school 75.4 (74.4–76.4) 0.5 1.8 (1.5–2.2) 0.2 16.9 (16.1–17.8) 0.4 5.9 (5.3–6.5) 0.3

Some collegeh 79.2 (78.4–80.0) 0.4 2.0 (1.8–2.3) 0.1 13.4 (12.7–14.1) 0.3 5.3 (4.9–5.8) 0.2

College degreei 92.5 (92.1–93.0) 0.2 1.2 (1.0–1.4) 0.1 4.7 (4.3–5.0) 0.2 1.6 (1.4–1.8) 0.1

Source: Centers for Disease Control and Prevention, unpublished data (data: NATS 2013–2014).

Note: CI = confidence interval; SE = standard error.

aIncludes those who reported they had heard of, tried, and used e-cigarettes every day, some days, or rarely at the time of the interview.

bIncludes those who smoked at least 100 cigarettes and reported using cigarettes every day or some days at the time of the interview.

cIncludes those who reported currently using both e-cigarettes and conventional cigarettes.

dIncludes those who reported currently using neither conventional cigarettes nor e-cigarettes.

eIncludes those who reported currently using e-cigarettes but not conventional cigarettes.

f

Includes those who reported currently using conventional cigarettes but not e-cigarettes.

gIncludes non-Hispanic Asian, non-Hispanic Native Hawaiian/Other Pacific Islander, non-Hispanic American Indian/Alaska Native, and multiracial.

hIncludes some college, no degree; associate’s degree: academic program; associate’s degree, unspecified; certificate; diploma; or associate’s degree.

i

Includes bachelor’s degree, master’s/professional school degree, or doctoral degree.
A Report of the Surgeon General

(Continued from last paragraph on page 53.)

could increase the likelihood that adolescents and young 

adults who have never used any tobacco products, but initiate e-cigarettes, will become lifetime users of conventional cigarettes or other tobacco products in sufficiently 

large numbers, resulting in a net harm to public health 

(USDHHS 2012). Other researchers suggest that the order 

of product initiation for tobacco products is unimportant 

and that experimentation with a variety of substances may 

be a marker of a common vulnerability to tobacco, alcohol, 

marijuana, and other substance-use behaviors (Vanyukov 

et al. 2012). Regardless, both of these perspectives on the 

effect of e-cigarette use on youth and young adults require 

longitudinal data to understand how current behaviors 

may affect health outcomes.

Five longitudinal studies to date suggest that 

e-cigarette use among youth (Leventhal et al. 2015;

Barrington-Trimis et al. 2016; Wills et al. 2016) and youth

and young adults (Primack et al. 2015; Unger et al. 2016)

might lead to initiation of the use of combustible tobacco

products in the future. The first study to appear was by

Leventhal and colleagues (2015). In this study, a cohort of

9th graders in Los Angeles, California, was followed up at

both 6 and 12 months, into 10th grade. Those who at baseline had never used combustible tobacco, but were ever

users of an e-cigarette, were more likely to use combustible tobacco products at both follow-up points (odds ratio

[OR]  =  4.27, 95% confidence interval [CI], 3.19–5.71).

Product-specific analyses showed that e-cigarette use in

9th grade was associated with the use of cigars (OR = 4.85,

95% CI, 3.38–6.96), hookahs (OR  =  3.25, 95% CI,

2.29–4.62), and cigarettes (OR = 2.65, 95% CI, 1.73–4.05)

in 10th grade. It was also associated with the number

of different combustible products used in 10th  grade

(OR  =  4.26, 95% CI, 3.16–5.74) (all ORs presented here

were averaged across the two time points). In these

analyses, Leventhal and colleagues (2015) adjusted for

demographic characteristics (age, gender, race/ethnicity,

highest parental education), social factors (peer smoking,

parental smoking), and intrapersonal factors (depression,

impulsivity, delinquent behaviors) linked with cigarette

smoking in previous research.

Primack and colleagues (2015), in a national cohort 

study, followed youth and young adults, 16–26 years of age, 

for 1 year. At baseline, only 16 participants (2.3%) had ever 

used e-cigarettes. In adjusted models that included only 

those who did not use conventional cigarettes at baseline and adjusted for gender, age, race/ethnicity, maternal 

educational level, sensation seeking, parental cigarette 

smoking, and peer cigarette smoking, baseline e-cigarette 

use was independently associated with progression to cigarette smoking (OR = 8.3, 95% CI, 1.2–58.6) and susceptibility to cigarette smoking (OR = 8.5, 95% CI, 1.3–57.2). 

Susceptibility was defined as a lack of a firm commitment 

56 Chapter 2

not to smoke using established measures of this construct 

(Evans et al. 1995; Pierce et al. 1996).

Wills and colleagues (2016) followed a cohort of 

2,338 students in grades 9 and 10 in Hawaii for 1 year. At 

baseline, 31% of the sample had ever used an e-cigarette, 

and 15% had ever used a conventional cigarette. One 

year later, these increased to 38% and 21%, respectively. 

Of those who had not used either of these products at 

baseline, 10%  initiated exclusive e-cigarette use 1 year 

later; 2% initiated exclusive conventional cigarette use; 

and 4% initiated use of both products. Students who 

had never smoked a conventional cigarette at baseline 

but had used an e-cigarette at baseline were three times 

more likely to smoke conventional cigarettes 1 year later 

(adjusted OR  =  2.87, p  <0.001). By comparison, among 

those who smoked conventional cigarettes at baseline, 

use of e-cigarettes at that same point in time was not 

related to any reduction in the use of conventional cigarettes 1  year later (p  >0.05). Moreover, students were 

more likely to transition from never use to dual use of 

both products 1 year later if they were older, Caucasian 

or Native Hawaiian (compared with Asian-American), 

more rebellious, and perceived e-cigarettes as healthier 

(adjusted OR  =  2.05, 2.15, 3.10, 3.32, 2.59, respectively, 

all p <0.001).

Barrington-Trimis and colleagues (2016) followed a 

cohort of 11th and 12th grade students in California for 

more than 1 year (median 15.6 months). In this cohort, 

at baseline, 146 were ever e-cigarette users and 152 were 

never e-cigarette users; none had ever smoked a cigarette. 

Among never e-cigarette users at baseline, 16 participants 

(10.5%) reported using cigarettes at follow-up; among 

ever e-cigarette users at baseline, 59 participants (40.4%) 

reported the same (OR = 6.17; 95% CI, 3.30–11.60). 

After adjusting for cigar, pipe, or hookah use at baseline, 

the relationship attenuated only somewhat (OR = 5.48; 

95% CI, 2.69–11.20). When stratified by susceptibility to 

cigarette smoking at baseline (defined, like Primack and 

colleagues [2015], as the lack of a firm commitment not 

to smoke using established measures of this construct 

[Evans et al. 1995; Pierce et al. 1996]), the relationship 

was actually stronger among those who were not susceptible (OR = 9.69; 95% CI, 4.02–23.40) compared to those 

who were susceptible (OR = 2.12; 95% CI, 0.79–5.74). The 

latter relationship was not statistically significant. In additional analyses that were restricted to those who reported 

no use of any combustible tobacco product at baseline, 

e-cigarette users were more likely to initiate use of any

combustible tobacco product at follow-up (OR  =  4.98;

95%  CI, 2.37–10.4), including the use of cigarettes

(OR  =  4.29; 95% CI; 1.84–10.0), hookahs (OR  =  2.86;

95% CI, 1.21–6.78), cigars (OR = 4.39; 95% CI, 1.72–11.2),

and pipes (OR = 8.21; 95% CI, 1.20–56.2). The models used 
Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 57

E-Cigarette Use Among Youth and Young Adults

by Barrington-Trimis and colleagues (2016) adjusted for 

a variety of demographic characteristics (grade, gender, 

race/ethnicity, highest parental education) and social factors (peer and parental smoking). Additionally, gender, 

race/ethnicity (Hispanic White, non-Hispanic White, 

other), grade (11th or 12th), and ever use of hookahs were 

tested as potential effect modifiers of these associations, 

but no evidence was found for the same.

Unger and colleagues (2016) followed a cohort of 

1,332 Hispanic young adults in California who provided 

survey data in 2014 and 2015. At baseline, these participants were an average of 22.7 years old. E-cigarette 

use at baseline was significantly associated with cigarette smoking (OR  =  3.32; 95% CI, 1.55–7.10, among 

non-cigarette smokers at baseline) and marijuana use 

(OR  =  1.97; 95% CI, 1.01–3.86, among non-marijuana 

users at baseline) at follow-up. Among those who did not 

smoke cigarettes at baseline (n = 1,056), 42 reported past 

month e-cigarette use in 2014; 26% of those who smoked 

e-cigarettes at baseline became cigarette smokers in 2015,

compared to 7% of those who did not smoke e-cigarettes.

Further, among those who did not smoke marijuana at

baseline (n = 1,028), 68 reported past month e-cigarette

use in 2014; 24% of those who smoked e-cigarettes at

baseline became marijuana smokers in 2015, compared to

12% of those who did not smoke e-cigarettes. Moreover,

in this study, e-cigarette use at baseline was not associated with cessation of cigarette smoking (OR = 1.31;

95% CI, 0.73– 2.36) or marijuana use (OR = 1.05; 95%

CI. 0.54–2.01) at follow-up. Among those who did smoke

cigarettes at baseline (n = 276), 76% reported past month

e-cigarette use in 2014; and 63% of those who smoked

e-cigarettes at baseline were still smoking cigarettes at

follow-up, compared to 58% of those who did not smoke

e-cigarettes. Covariates in these regression models

included age, gender, past month use of alcohol, and past 

month use of other tobacco products (hookah, cigars, 

little cigars, smokeless tobacco).

Despite the several strengths of these studies, 

including their longitudinal nature, they had weaknesses 

as well. Rigotti (2015) notes, for example, that the study 

by Leventhal and colleagues (2015) could not distinguish between those who merely began experimenting 

with a combustible product and those who became regular smokers at follow-up. The same could be said for 

the studies by Barrington-Trimis and colleagues (2016), 

Primack and colleagues (2015), and Wills and colleagues 

(2016). Similarly, the single exposure measure of the 

independent variable (i.e., any e-cigarette use) in these 

studies did not allow the authors to assess whether there 

was a dose–response relationship between the extent of 

prior e-cigarette use and subsequent use of combustible 

tobacco products. In addition, the studies by Primack and 

colleagues (2015) and Wills and colleagues (2016) did not 

assess prior use at baseline of other tobacco products, 

marijuana, or alcohol. Though it is not highlighted prominently in their article, Leventhal and colleagues (2015) 

showed a bidirectional relationship between e-cigarette 

use and other combustible tobacco product use in their 

study: Use of other combustible tobacco products at 

baseline was significantly associated with the onset of 

e-cigarette use in two follow-ups. This hypothesis was not

tested by Barrington-Trimis and colleagues (2016), Wills

and colleagues (2016), or Primack and colleagues (2015).

However, at the 1-year follow-up, Wills and colleagues

(2016) did consider other demographics, personality, and

psychosocial predictors of exclusive e-cigarette use and

dual use of conventional cigarettes and e-cigarettes.

Concerns about the samples for the two studies 

can be raised as well. The samples in the studies by 

Barrington-Trimis and colleagues (2016) and Leventhal 

and colleagues (2015) were limited to youth in California; 

the study by Primack and colleagues (2015) suffered 

from a small sample size, with only 16 e-cigarette users 

at baseline (Leventhal et al. 2015; Primack et al. 2015); 

and the study by Wills and colleagues (2016) was limited 

to 9th- and 10th-grade students in Hawaii. Additional 

studies are still needed in the future to further elucidate 

any causal relationship in either direction between the use 

of e-cigarettes and other types of tobacco products, such 

as combustibles.

E-Cigarette Use and Other

Substance Use

Few studies have investigated the co-occurrence 

of e-cigarette use and other risk behaviors in adolescents and young adults. The available evidence suggests 

that e-cigarette use is associated not only with the use of 

other tobacco products, but also with alcohol and other 

substance use, such as marijuana. This is consistent with 

the common liability model for substance use and other 

risky behaviors (Vanyukov et al. 2012). Because nearly all 

currently available studies on this topic focus on regional, 

international, and at-risk samples, the conclusions from 

most studies cannot be generalized to the U.S. population 

as a whole, however.

In the only nationally representative study examining the associations between e-cigarettes, alcohol, and 

other drug use in young adults 18–24 years of age, the 

odds of alcohol use were nine times as high and the odds 

of everyday/some-day marijuana use were three-and-a-half 

times as high among past-30-day e-cigarette users as 

they were for those who had not used these products in 
A Report of the Surgeon General

58 Chapter 2

that period (Cohn et al. 2015). Elsewhere, in a nonprobability sample of college students 17–25 years of age, 

66% of current e-cigarette users and 67% of current dual 

users were heavy drinkers, defined as consuming at least 

once, five or more drinks (men) or four or more drinks 

(women) in a single sitting during the course of 1 month 

(Littlefield et al. 2015). In another study, this one of college students in New York, past-30-day use of e-cigarettes 

was positively associated with current binge drinking and 

tobacco product use, and it was less common among those 

20–23 years of age (versus those 18 years of age), females, 

non-Hispanic non-Whites (compared with non-Hispanic 

Whites), and those reporting better-than-average school 

performance (Saddleson et al. 2015).

Data from a longitudinal cohort study of children 

with alcoholic parents found that adolescents (both middle 

and late adolescence) who used cigarettes, marijuana, or 

alcohol were significantly more likely to have ever used 

e-cigarettes. Among those who had used marijuana,

e-cigarette use was associated with greater use of marijuana during the previous 30 days (Lessard et al. 2014).

In a cross-sectional pilot study of seventh-grade students

in Southern California, ever use of e-cigarettes was 11%,

compared to 6.8% for cigarettes, 38.1% for alcohol, and

39% for cigarettes or alcohol. In this study, 80% of ever

users of e-cigarettes had used alcohol, and 42.2% had used

conventional cigarettes (Pentz et al. 2015).

In a 2013 sample of students (n = 2,002) in two states 

in the southeastern United States, 53.4% of e-cigarette 

users also used marijuana (Berg et al. 2015). Elsewhere, 

in a sample of young adults (18–23 years of age) at colleges and universities that was taken in 2013 in upstate 

New York (n = 1,437), 54.2% of past-30-day marijuana 

users, 23.9% of past-30-day alcohol users, and 40.3% of 

past-30-day binge drinkers had ever used e-cigarettes 

(Saddleson et al. 2015). In Switzerland, among a sample 

of eighth graders, nearly 60% of regular e-cigarette users 

“had been drunk” at least once in the past 30 days (defined 

as an affirmative response to the question, “have you been 

drunk in the previous 30 days”), and 44.8% had used marijuana at least once during that period (Suris et al. 2015).

There are several limitations to these observational 

studies. For example, when considering the associations 

derived from these observational studies, the order of initiation of the products of interest cannot be inferred. In 

addition, some biases cannot be ruled out because of the 

nature of the samples, and patterns of associations may 

reflect an underlying common liability to use substances 

and take part in other risky behaviors. Some studies 

adjusted for risk taking, sensation seeking, and impulsivity, while others did not.

E-Cigarettes and Marijuana

Because of their design, e-cigarettes may facilitate 

drug use among youth and young adults, as these products can be used as a delivery system for cannabinoids 

and other illicit drugs (Giroud et al. 2015; Morean et al. 

2015; Schauer et al. 2016). The aerosolization of cannabis 

is a relatively new technology used to deliver inhaled tetrahydrocannabinol (THC) and other cannabinoids while 

reducing the toxic byproducts of smoked cannabis, which 

are primarily caused by combustion (Abrams et al. 2007). 

Laboratory studies of prototype aerosolizers have 

demonstrated that they can provide a relatively effective 

mode of delivering THC, with plasma THC concentrations 

similar to those obtained from smoking a standard marijuana cigarette (Abrams et al. 2007; Giroud et al. 2015). 

In addition, thermal metered-dose cannabis inhalers 

have been developed for medical applications; their technology is similar to that of e-cigarettes (Eisenberg et al. 

2014). While the first generation of cannabis aerosolizers 

was developed to aerosolize dry cannabis, the widespread 

availability of e-cigarettes and rapid advances in their 

technology have led to the development of liquid/oil forms 

of cannabis/THC that can be used with e-cigarettes in a 

fashion similar to that employed when they are filled with 

nicotine (Giroud et al. 2015). Articles explaining how to 

acquire and use THC-containing liquid using e-cigarette 

technology are accessible on the Internet and are strongly 

suggestive of relatively widespread awareness and use 

(Gray 2013).

The actual prevalence of users of marijuana aerosolizers and their experiences remain unclear and understudied (Van Dam and Earleywine 2010; Malouff et al. 

2014). In one of the few published studies on this issue 

specific to youth, Morean and colleagues (2015) found 

that, among high school students in Connecticut, vaporizing cannabis was common among ever e-cigarette users 

(18%), ever cannabis users (18.4%), and ever dual users 

(26.5%). This finding suggests a need for more specific 

surveillance measures that take into account the use of 

drugs other than nicotine in e-cigarettes.

Use of Flavored E-Cigarettes

The liquid that is vaporized in an e-cigarette is available to consumers in a wide variety of flavors, including 

tobacco, mint/menthol, and fruit flavors. Although characterizing “flavors” are prohibited in cigarettes (with the 

exception of menthol and tobacco) by the Family Smoking 

Prevention and Tobacco Control Act of 2009, this practice is not currently prohibited in other tobacco products, like e-cigarettes. Retail sales data suggest that the 
59

consumption of flavored e-cigarettes and tobacco products, such as flavored cigars, has increased in recent years 

(Delnevo et  al. 2015; Giovenco et al. 2015), and recent 

studies show that youth and young adults may find these 

flavored products more appealing than their unflavored 

counterparts (Table 2.9) (Ambrose et al. 2015; KrishnanSarin et al. 2015; McDonald and Ling 2015).

Data on the use of flavored e-cigarettes among 

youth and young adults is presented in Table 2.9. In the 

2015 NYTS, participants were asked about any current use 

of e-cigarettes that were “flavored to taste like menthol 

(mint), alcohol (wine, cognac), candy, fruit, chocolate, or 

other sweets” (CDC 2015a, 1066). Among middle and high 

school students who were past-30-day users of e-cigarettes, 

1.26 million, or 44.6%, had used a flavored e-cigarette in 

that timeframe (CDC, unpublished data [NYTS 2015]); 

this included 42.6% of middle school students and 45.1% 

of high school students (Table 2.9) (CDC 2015a). The use 

of flavored e-cigarettes did not differ by gender and was 

lowest among Blacks (Table  2.9) (CDC  2015a). The use 

of flavored e-cigarettes was highest among young adults, 

according to the 2013–2014 NATS (Table 2.9): among 

those who reported using e-cigarettes every day or some 

days, 91.6% of young adults (18–24 years old) reported 

using an e-cigarette flavored to taste like menthol, mint, 

clover, spice, candy, fruit, chocolate, or other sweets. 

On the other hand, 66.6% of adults (≥25  years of age) 

who reported using e-cigarettes every day or some days 

had used flavored e-cigarettes. No gender differences were 

noted for young adults, but Blacks, as with middle and 

high school students, reported the lowest rate of using flavored e-cigarette products.

Data from the 2013–2014 wave of the PATH 

study revealed that a majority of adolescents who used 

e-cigarettes use flavors. Of those who had ever tried

e-cigarettes, 81% used flavors the first time they tried an

e-cigarette; of past-30-day users, 85.3% regularly used

flavored e-cigarettes (Ambrose et al. 2015). Ambrose and

colleagues (2015) also reported that 81.5% of respondents aged 12–17 reported that they used e-cigarettes

because “they come in flavors I like.” Elsewhere, among

8th, 10th, and 12th graders in the 2015 MTF study, about

40% said that the primary reason they used e-cigarettes

was “because they tasted good.” In contrast, about 10%

said they used e-cigarettes to quit smoking conventional

cigarettes (University of Michigan 2015). In the 2015 MTF

study, about two-thirds of 8th-, 10th-, and 12th-grade

students said that they used “just flavouring” in their

vaporizer when they “last used” a vaporizer, while only

20% reported that they used nicotine (Miech et al. 2016).

While the findings specific to nicotine are unexpected, it

is important to note that these data are self-reported. It

is questionable whether youth know what nicotine is, let

alone whether it is contained in the e-cigarette products 

that they are using. Moreover, even if youth were accurately reporting nicotine strength according to the label 

on the package, a study by Buettner-Schmidt and colleagues (2016) found that more than half of the labels on 

assessed e-cigarette products did not accurately reflect 

actual nicotine content in the product. Therefore, further 

research on nicotine content using objective measures 

(e.g., retail sales data) is warranted. Both the PATH and 

MTF studies, however, reinforce that flavorings may play 

an important role in the initiation of e-cigarette use.

Other regional studies have reinforced the popularity of flavored e-cigarette use among youth. Table 2.10 

summarizes these data on the use of flavored e-cigarettes 

among youth and young adults. Krishnan-Sarin and colleagues (2015), for example, found that sweet-flavored 

e-cigarettes were popular among middle and high school

students. In another study, which examined nonsmoking

middle and high school students and college-aged adults

in New Haven County, Connecticut, Kong and colleagues

(2015) found that “appealing flavors” was the second most

common reason cited for experimenting with e-cigarettes,

and in a qualitative study of young adults living in New

York City, flavors were identified as an attractive aspect of

e-cigarettes (McDonald and Ling 2015). In a study examining nonsmoking teens and adult smokers, the e-cigarette 

flavors tested appealed more to adults than to teens; nonsmoking teens demonstrated equally low levels of interest

in tobacco, fruit, and candy flavors (Shiffman et al. 2015).

It should be noted, however, that this study was funded by

NJOY, an e-cigarette company and, therefore, may have

suffered from commercial bias. Additional concerns about

this study concerning selection bias, validity of the survey

measures, and reliability of the findings have been raised

(Glantz 2015).

Consumer Perceptions of 

E-Cigarettes

Perceived Harm of E-Cigarettes

In the general population of U.S. adults, e-cigarettes 

have been perceived to be generally less harmful (Pearson 

et al. 2012; Czoli et al. 2014; Gallus et al. 2014; Richardson 

et al. 2014; Berg et al. 2015; Pokhrel et al. 2015) and less 

addictive (Dockrell et al. 2013; Li et al. 2013; Brown et al. 

2014; Farsalinos et al. 2015; Harrell et al. 2015; Hendricks 

et al. 2015; Kadimpati et al. 2015; Wackowski and Delnevo 

2015) than conventional cigarettes. The perceived harm 

of e-cigarettes relative to conventional cigarettes was 

lowest among those who were current smokers, followed 

by former smokers and then nonsmokers (Pearson et al.
A Report of the Surgeon General

60 Chapter 2

Table 2.9 Percentage of youth (middle and high school students), young adults (18–24 years of age), and adults (≥25 years of age) using tobacco 

products who reported using flavored e-cigarette products, by gender and race/ethnicity; National Youth Tobacco Survey (NYTS)a and 

National Adult Tobacco Survey (NATS)b

NYTS 2015a (youth): 

Middle school students

NYTS 2015a (youth): High 

school students

NATS 2013–2014b (young 

adults): 18–24 years of age

NATS 2013–2014b

(adults): ≥25 years of age

Characteristic % (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE

Overall 42.6 (36.1–49.3) 3.3 45.1 (40.4–49.9) 2.4 91.6 (87.0–94.6) 1.9 66.6 (63.4–69.5) 1.6

Gender

Female 45.5 (36.2–55.2) 4.8 46.8 (40.5–53.2) 3.2 90.1 (78.6–95.7) 4.1 68.2 (63.7–72.3) 2.2

Male 40.2 (32.2–48.7) 4.2 44.0 (39.3–48.8) 2.4 92.2 (87.0–95.4) 2.1 65.2 (60.7–69.4) 2.2

Race/ethnicity

White 52.5 (42.0–62.8) 5.3 51.4 (45.7–57.0) 2.9 90.9 (84.7–94.7) 2.5 61.2 (57.5–64.8) 1.9

Black or African American 32.9 (18.5–51.6) 8.6 20.4 (12.8–31.0) 4.5 100 (100–100)c 0.0c 92.0 (82.1–96.6) 3.5

Hispanic or Latino 28.5 (20.5–38.1) 4.4 38.8 (32.7–45.3) 3.2 89.8 (75.3–96.2)c 5.0c 85.9 (76.6–91.9) 3.8

Otherd 57.3 (39.4–73.5) 8.9 34.1 (24.8–44.9) 5.1 94.4 (82.1–98.4)c 3.5c 67.4 (57.0–76.3) 5.0

Source: Centers for Disease Control and Prevention, unpublished data (data: NYTS 2015; NATS 2013–2014).

Note: CI = confidence interval; SE = standard error.

aFlavored e-cigarette product use in NYTS was determined by the response to the question, “Which of the following tobacco products that you used in the past 30 days 

were flavored to taste like menthol (mint), alcohol (wine, cognac), candy, fruit, chocolate, or other sweets?” Participants could select from a list of options to designate the 

flavored tobacco product(s) they used. (Among those who reported any use of e-cigarettes in the preceding 30 days.) Those who selected e-cigarettes were coded as “yes” 

for flavored e-cigarettes. Those who did not select e-cigarettes were categorized as “no” for flavored e-cigarettes. Excludes 82 current e-cigarette users whose answers were 

missing for all flavored tobacco response options.

bFlavored e-cigarette product use in NATS was determined by the response to the question, “Were any of the electronic cigarettes that you used in the past 30 days flavored 

to taste like menthol, mint, clover, spice, candy, fruit, chocolate, or other sweets?” (Among those who reported using e-cigarettes every day or some days.) Those who selected 

“yes” were categorized as “yes” for flavored e-cigarettes. Those who selected “no” were categorized as “no” for flavored e-cigarettes. Excludes five every-day or some-day 

users who reported not using any noncigarette tobacco product in the past 30 days.

cSample size <50. No estimates had a relative SE >.40.

dIncludes non-Hispanic Asian, non-Hispanic Native Hawaiian/Other Pacific Islander, and non-Hispanic American Indian/Alaska Native. For young adults and adults, this group 

also includes multiracial.
E-Cigarette Use Among Youth and Young Adults

Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 61

Table 2.10 Summary of studies on e-cigarette flavors among youth and young adults

Study Design/population Measures Outcomes/findings

Ambrose et al. (2015) • Cross-sectional

• Wave 1 of PATH study

• Household-based, nationally representative survey

of 13,651 youth 12–17 years of age

• For each product ever used, youth

were asked if it was flavored to

taste like menthol, mint, clove,

spice, candy, fruit, chocolate,

alcohol (such as wine or cognac),

or other sweets

• 81% of e-cigarette ever users used a

flavored product at first use

• 85.3% of past-30-day e-cigarette users

used a flavored product

• 81.5% of past-30-day users cited “because

they come in flavors I like” as a reason for

using e-cigarettes

Berg et al. (2015) • Cross-sectional

• Recruitment through Facebook targeting of

tobacco and marijuana users and nonusers

• 2014

• 1,567 participants, 18–34 years of age, living in the

United States

• E-cigarette use (ever tried,

number of days in past 30 days)

• Flavors used or of interest

• Most commonly used flavor was fruit

flavors (67%), which was most commonly

reported by never cigarette smokers.

• Current smokers were most likely to

report using tobacco flavors, but least

likely to report using caramel, vanilla,

chocolate, cream, or candy flavors.

CDC (2015a) • Cross-sectional

• 2014 NYTS data

• Three-stage cluster sampling procedure

• Nationally representative sample of 22,007 U.S.

middle and high school students

• Participants were asked about any

current use of tobacco products

that were “flavored to taste like

menthol (mint), alcohol (wine,

cognac), candy, fruit, chocolate, or

other sweets”

• Participants could select from a

list of options

• Among current e-cigarette users,

63.3% used a flavored product

Kong et al. (2015) • Cross-sectional

• 18 focus groups, schoolwide survey

• Recruitment by flyers and active recruitment

sessions

• Years sample drawn: 2012–2013

• New Haven County, Connecticut

• Youth: Middle and high school students; focus

group n = 127 (youth); survey n = 4,780

• Young adults: New Haven County, Connecticut,

college students; focus group n = 127

(young adults); survey n = 625

• Why did you try an e-cigarette? • 43.8% of e-cigarette ever users

experimented with e-cigarettes for the

availability of appealing flavors

• School-level differences:

χ2(2, N = 1,157) = 18.63, p ≤0.001

• Compared with college students, high

school students were more likely to

experiment with e-cigarettes because of

flavors (47% vs. 32.8%):

χ2(1, N = 1,116) = 13.61, p ≤0.001
A Report of the Surgeon General

62 Chapter 2

Study Design/population Measures Outcomes/findings

Krishnan-Sarin et al. (2015) • Cross-sectional

• School-based survey

• Recruitment by selected district reference groups

• Year sample drawn: 2013

• Youth: Connecticut middle (n = 1,166) and high

school (n = 3,614) students

• Young adults: n/a

• Which of the following flavors of

e-cigarettes have you tried?

• Most e-cigarette ever users preferred

sweet flavors:

– Sweet flavors: 56.8%

– Menthol: 8.7%

– Combos: 7.7%

– Tobacco: 3%

– Other: 2.8%

• Menthol and tobacco flavors used mostly

by e-cigarette users who were also

cigarette smokers.

– Menthol preference:

| 3.5% (never smokers)

| 5.5% (ever smokers)

| 18.6 (current smokers)

– Tobacco preference:

| 0.5% (never smokers)

| 2.4% (ever smokers)

| 7.1% (current smokers)

McDonald and Ling (2015) • Focus groups and semistructured interviews

• Recruitment from bars through screener surveys

• Years sample drawn: 2012–2013

• Youth: n/a

• Young adults: 87 young adults, 18–27 years of

age, in the boroughs of Manhattan, Brooklyn, and

Queens in New York City

• Attraction to flavors • Flavors were an attractive e-cigarette

characteristic

Shiffman et al. (2015) • Cross-sectional

• Participants drawn from online research panel

• Year sample drawn: 2014

• Youth: Nonsmoking teenagers, 13–17 years of age

• Young adults: n/a

• Interest in e-cigarettes paired with

various flavor descriptors

• Nonsmoking teens’ interest in

e-cigarettes was very low

(mean = 0.41 ± 0.14 [SE] on 0–10 scale).

• Teen interest did not vary by flavor

(p = .75)

Table 2.10 Continued
E-Cigarette Use Among Youth and Young Adults

Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 63

Study Design/population Measures Outcomes/findings

Ford et al. (2016) • Cross-sectional in-home survey

• Wave 7 of the Youth Tobacco Policy Survey (YTPS)

• Random location quota sampling

• 1,205 youth, 11–16 years of age, in the United

Kingdom

• Awareness of e-cigarettes

• E-cigarette use

• E-cigarette flavor awareness

• Perceptions of harm

• 12% had tried e-cigarettes

• 2% were regular users (confined to

adolescents who had also smoked

tobacco)

• 82% were aware of at least one

promotional channel (82%)

• 69% were aware that e-cigarettes came in

different flavours

• Brand awareness was low

• E-cigarettes were perceived as harmful

(mean = 3.54, SD = 1.19)

Vasiljevic et al. (2016) • Randomized controlled trial

• Participants exposed to advertisements of candylike flavored e-cigarettes, non-flavoured cigarettes,

or control

• Youth: 598 English children, 11–16 years of age

• Appeal of using e-cigarettes

• Appeal of e-cigarette ads

• Interest in buying and trying

e-cigarettes following ad exposure

• Exposure to e-cigarette ads did not seem

to increase the appeal of tobacco smoking

in children.

• Exposure to flavoured e-cigarette ads

(compared with non-flavoured ads)

increased the appeal and interest in

buying and trying e-cigarettes in children.

Note: NYTS = National Youth Tobacco Survey; PATH = Population Assessment of Tobacco and Health Study; SD = standard deviation; SE = standard error.

Table 2.10 Continued
A Report of the Surgeon General

64 Chapter 2

(Continued from last paragraph on page 59.)

2012; Richardson et al. 2014). In a nationally representative sample of U.S. adults, young adults 18–34 years of age 

were more likely than their older counterparts to perceive 

e-cigarettes as being less harmful than conventional cigarettes (Tan and Bigman 2014).

Common theories of health behavior, such as 

the Theory of Reasoned Action and the Health Belief 

Model, posit that perceptions of harm influence tobaccouse behavior, with lower perceived harm encouraging 

higher levels of experimentation and current tobacco 

use (Primack et al. 2008). Monitoring both absolute perceived harm and perceived harm relative to conventional 

cigarettes could be an indicator of later product adoption. Table 2.11 presents studies of the perceived harm of 

e-cigarettes among adolescents and young adults that are

included in this chapter.

Youth

Table 2.12a presents NYTS data from middle 

school and high school students on the perceived harm 

of using e-cigarettes on some days but not every day. 

In 2015, 61.9%  of these students, overall, believed that 

e-cigarettes caused “little or some harm” under such conditions; 14.5%, “no harm”; and 23.6%, “a lot of harm.”

However, when these data are stratified by students’ history of e-cigarette use, important differences become

clear. Notably, 34.2% of past-30-day e-cigarette users

believed e-cigarettes cause “no harm,” compared with

22.4% of ever e-cigarette users and only 9.5% of never

e-cigarette users. Conversely, 29.4% of never e-cigarette

users believed that e-cigarettes cause “a lot of harm,”

compared with 8.3% of ever e-cigarette users and 6.8% of

past-30-day e-cigarette users. These important differences

by e-cigarette use status, which suggest perceptions of no

harm related to e-cigarette use, were consistent for both

middle school students and high school students (Tables

2.12b and 2.12c).

Three studies that used data from the 2012 NYTS 

examined the correlates of U.S. adolescents’ opinions about 

the perceived harm of e-cigarettes relative to the harm of 

conventional cigarettes. Non-Hispanic Whites, students 

who lived with a smoker (Cardenas et al. 2015) or had 

a family member who used tobacco (Amrock et al. 2015), 

and past-30-day users of tobacco products other than cigarettes were more likely to believe that e-cigarettes were 

safer than conventional cigarettes (Amrock et al. 2015). 

Conversely, girls and students 17  years of age or older 

were more likely to believe that e-cigarettes were more 

harmful than regular cigarettes (Amrock et al. 2015). The 

perceived harm of e-cigarettes decreased with increasing 

levels of cigarette smoking, such that in 2012, 25% of adolescent never smokers, 41.3% of adolescent ever smokers, 

and 54.2% of adolescent past-30-day smokers believed that 

e-cigarettes were less harmful than cigarettes (Ambrose

et al. 2014). Prior use of e-cigarettes was also associated

with perceived harm of that product. Among students

who had ever tried e-cigarettes in 2012, 71.8% believed

that they were less harmful than cigarettes, 12.1% equally

harmful, and 5% more harmful. These estimates were

similar to those for students who had used e-cigarettes in

the past 30 days (Amrock et al. 2015). In addition, susceptibility to cigarette smoking among never smokers was

associated with perceptions of low harm for e-cigarettes

(Ambrose et al. 2014).

Although not all studies reviewed in this section 

included “don’t know” as a response option for questions on the harms of e-cigarettes, those that did, found 

that a large number of students were unsure of the relative harmfulness of e-cigarettes compared to conventional cigarettes (Ambrose et al. 2014; Amrock et al. 

2015). In fact, among U.S. adolescents responding to the 

2012 NYTS, “don’t know” was the most common response 

(41.1–53.3%) across all the demographic subgroups 

examined (gender, age, and race/ethnicity) (Amrock et al. 

2015). In this sample, more never smokers (57.4%) than 

ever smokers (37.5%) or past-30-day smokers (24%) had 

not heard of or did not know enough about e-cigarettes to 

make a judgment of harm (Ambrose et al. 2014). Future 

studies will benefit from examining the effect of harm perception on the use of e-cigarettes and other tobacco-use 

behaviors among adolescents.

Young Adults

Table 2.12d presents data from the 2013−2014 

NATS on beliefs about harm from e-cigarettes among 

young adults (18–24 years old). Just over half (53.8%) of 

young adults believed that e-cigarettes were “moderately 

harmful,” 26.8% believed they were “very harmful,” and 

19.4% believed they caused “no harm.” Levels of belief in 

moderate harm were quite similar by type of e-cigarette 

use: 52.8% of never users, 56.8% of ever (but not current) users, and 53.6% of current users. Ever and current 

users were more likely than never users to report that 

e-cigarettes were “not at all harmful,” while never users

were more likely than the other two groups to report that

e-cigarettes were “very harmful.”

Published studies on perceived harm of e-cigarettes 

from regional samples, primarily of college and university students, are presented in Table 2.11. A large survey 

(n = 4,444) of college students in North Carolina conducted 

in 2009 found that, as with adolescents, perceived harm 

of e-cigarettes, compared with conventional cigarettes, 

was lower among college students who had ever used 

e-cigarettes (45%) than among those who had never used
E-Cigarette Use Among Youth and Young Adults

Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 65

Table 2.11 Summary of studies on perceptions of e-cigarette harm among youth and young adults

Study Design/population Measures Outcomes/findings Comments

Choi et al. (2012) • Focus groups

• Recruitment by (1) online

advertisements, (2) flyers on one

4-year and two 2-year college

campuses, (3) announcements in

student life newsletter at a 2-year

college, and (4) recruitment booth on

a 2-year college campus

• Year sample drawn: 2010

• Youth: n/a

• Young adults: Individuals in

Minneapolis-St. Paul, MN, enrolled

in or who had graduated from

4-year colleges, or those who were

enrolled in or had graduated from

2-year colleges, or those who had not

enrolled in postsecondary education;

N = 66

• Perceived harmfulness relative

to cigarettes

• No consensus among participants

• Lack of information on

(1) ingredients, (2) health impact,

and (3) mechanism used to vaporize

nicotine

• Some noted e-cigarettes to be as

harmful as cigarettes (“all one

product, in different forms”)

• Generalizability

• Limited sample size

Adkison et al. (2013) • Parallel prospective cohort

• Telephone interview and web-based

surveys

• Probability sampling methods

(random-digit dialing)

• Years sample drawn: 2010–2011

(Wave 8), 2008–2009 (Wave 7, where

available)

• Youth: n/a

• Young adults: current smokers,

≥18 years of age; N = 5,939 (Canada:

n = 1,581; United States: n = 1,520;

United Kingdom: n = 1,325;

Australia: n = 1,513)

• Are electronic cigarettes more

harmful than, less harmful

than, or equally harmful as

regular cigarettes to one’s

health?

• Not explicitly reported for young

adults

• Inclusion of only

current and former

cigarette smokers

• Limited set of

questions
A Report of the Surgeon General

66 Chapter 2

Study Design/population Measures Outcomes/findings Comments

Faletau et al. (2013) • Qualitative exploratory

• Structured focus groups and

individual interviews

• Recruited from two low

socioeconomic primary schools

in East and South Auckland, New

Zealand

• Year sample drawn: 2011

• Youth: Maori, Tongan, Samoan,

Cook Island, and Niuean children,

6–10 years of age; N = 20

• Young adults: n/a

• Viewed tobacco cigarette and

electronic cigarette videos

• Still allows smokers to smoke,

despite its function as a cessation aid

• Generalizability

• Unknown if

saturation was

reached in

children between

focus groups

and individual

interviews

Sutfin et al. (2013) • Cross-sectional

• Web-based survey (part of a

randomized group trial)

• Stratified random sample

• Year sample drawn: 2009

• Youth: n/a

• Young adults: undergraduate students

attending eight universities in North

Carolina; N = 4,857 (completers of

e-cigarette question, n = 4,444).

• Compared with a regular

cigarette, how harmful do you

think e-cigarettes are?

– Less harmful

– As harmful

– More harmful

– Do not know

• Among the overall sample:

– 17% indicated “as harmful”

– 23% indicated “less harmful”

– 2% indicated “more harmful”

– 50% indicated “do not know”

• Among ever e-cigarette users:

– 17% indicated “as harmful”

– 45% indicated “less harmful”

– 3% indicated “more harmful”

– 23% indicated “do not know”

• Among never e-cigarette users:

– 16% indicated “as harmful”

– 22% indicated “less harmful”

– 2% indicated “more harmful”

– 51% indicated “do not know”

• Ever e-cigarette use significantly

associated with harm perceptions

(p <0.001)

• Low response rate

• Generalizability

• Inability to

differentiate former

smokers from

experimenters

• Cross-sectional

analysis

Table 2.11 Continued
E-Cigarette Use Among Youth and Young Adults

Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 67

Study Design/population Measures Outcomes/findings Comments

Ambrose et al. (2014) • NYTS

• Cross-sectional

• School-based survey

• Three-stage cluster sampling

• Year sample drawn: 2012

• Youth: U.S. middle and high school

students (grades 6–12); N = 24,658

• Young adults: n/a

• Do you believe that electronic

cigarettes or e-cigarettes, such

as Ruyan or NJOY, are less

harmful, equally harmful, or

more harmful than regular

cigarettes?

• 30.6% (CI, 29.3–31.9%)

of respondents believed

e-cigarettes are less harmful

than cigarettes: never smokers:

25% (CI, 23.9–26.2%); ever smokers:

41.3% (CI, 39.1–43.6%); current

smokers: 54.2% (CI, 51.0–57.4%)

• Female and Hispanics were less

likely to perceive e-cigarettes as less

harmful than cigarettes compared

with males and Whites, across all

smoking statuses

• Current smokers that had ever used

e-cigarettes were more than twice as

likely to perceive e-cigarettes as less

harmful, compared with smokers

who had never used e-cigarettes

(AOR = 2.48; CI, 1.87–3.29)

• Never smokers who had ever used

e-cigarettes were almost six times

as likely to perceive e-cigarettes

as less harmful, compared with

never smokers who had never used

e-cigarettes (AOR = 5.88;

CI, 3.07–11.25)

• Perceived graduated

risk

• Self-reported items

• Social desirability

bias

• Generalizability

Table 2.11 Continued
A Report of the Surgeon General

68 Chapter 2

Study Design/population Measures Outcomes/findings Comments

Czoli et al. (2014) • Cross-sectional

• Survey

• Recruitment through online panel

of commercial market research

company

• Year sample drawn: 2012

• Youth: Canadian youth recruited

from online panel, 16–30 years of age;

n = 1,188

• Young adults: Canadian young adults

recruited from same online panel (see

above)

• Is this product harmful to your

health?

• Have you ever experienced

any side-effects or adverse

outcome(s) while using

e-cigarettes?

• Mean score for agreement with

e-cigarettes as harmful to your

health (higher score indicates greater

agreement):

– Among cigarette nonsmokers:

5.5 (e-cigarette nonuser) vs. 4.4

(e-cigarette ever user)

– Among former smokers: 5.2

(e-cigarette nonuser) vs. 3.6

(e-cigarette ever user)

– Among current smokers: 2.6

(e-cigarette nonuser) vs. 3.5

(e-cigarette ever user)

• Cross-sectional

analysis

• Generalizability

Gallus et al. (2014) • Cross-sectional

• In-person survey

• Representative multistage sampling

• Year sample drawn: 2013

• Youth: n/a

• Young adults: Italians ≥15 years of

age; N = 3,000

• Indicate your opinion (true/

false) concerning e-cigarettes

on the following:

– (1) Are not harmful for health

– (2) Are less harmful than

traditional cigarettes because

they do not contain nicotine

– (3) Are less harmful

because there is no tobacco

combustion

– (4) Are less harmful because

they contain only nicotine

– (5) Are more harmful than

traditional cigarettes

– (6) Are an efficient tool to

quit smoking

– (7) Allow smoking even

where it is forbidden

• Findings not explicitly reported for

young adults

• Unstable estimates

due to small sample

of e-cigarette users

• Unvalidated survey

Table 2.11 Continued
E-Cigarette Use Among Youth and Young Adults

Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 69

Study Design/population Measures Outcomes/findings Comments

Tan and Bigman (2014) • Cross-sectional

• Health Information National Trends

Survey 4 Cycle 2

• Collected between October 2012 and

January 2013

• U.S. adults ≥18 years of age

• N = 3,630, 29.8% 18–34 years of age

• Compared to smoking

cigarettes, would you say that

electronic cigarettes are:

– Much less harmful

– Less harmful

– Just as harmful

– More harmful

– Much more harmful

– I’ve never heard of electronic

cigarettes

• Compared with younger respondents

(18–34 years of age), older

respondents had 38%–72% lower

odds of believing that e-cigarettes are

less harmful than regular cigarettes

—

Tucker et al. (2014) • Cross-sectional

• Paper-based survey

• Probability-based sampling

• Year sample drawn: not reported

• Youth: n/a

• Young adults: homeless young adults,

17–25 years of age; N = 292 (subset of

lifetime e-cigarette users, n = 83)

• Rate whether they perceive

e-cigarettes to be less harmful,

more harmful, or just as

harmful as smoking cigarettes

• 44.9% viewed e-cigarettes as less

harmful than conventional cigarettes

• 26.6% viewed e-cigarettes as just as

harmful as conventional cigarettes

• 3.7% viewed e-cigarettes as more

harmful than conventional cigarettes

• 24.8% did not know the relative

harm

• Did not collect

information on

youth’s attitudes

about alternate

tobacco products

besides e-cigarettes

• Did not collect

information on the

conditions under

which they used

various products

Amrock et al. (2015) • NYTS

• Cross-sectional

• School-based survey

• Three-stage cluster sampling

• Year sample drawn: 2012

• Youth: U.S. middle and high school

students (grades 6–12); N = 24,658

• Young adults: n/a

• Do you believe that electronic

cigarettes or e-cigarettes, such

as Ruyan or NJOY, are less

harmful, equally harmful, or

more harmful than regular

cigarettes?

• 34.2% (CI, 32.8–35.6%) of

adolescents considered e-cigarettes

to be less harmful than cigarettes

• Females were less likely than males

to perceive e-cigarettes as less

harmful than cigarettes

• Lifetime e-cigarette users were more

likely than never users to report

e-cigarettes as less harmful than

cigarettes (71.8% vs. 31%)

• Past-30-day e-cigarette users were

more likely than nonrecent users to

report e-cigarettes as less harmful

than cigarettes (73.8% vs. 33.1%)

• Missingness

• Perceived graduated

risk

• Self-reported items

• Social desirability

bias

• Generalizability

Table 2.11 Continued
A Report of the Surgeon General

70 Chapter 2

Study Design/population Measures Outcomes/findings Comments

Berg et al. (2015) • Cross-sectional

• Online-based survey

• Recruitment by random selection

• Year sample drawn: 2013

• Youth: n/a

• Young adults: U.S. university

students; n = 2,002

• How harmful to your health do

you think electronic cigarettes

are?

• How addictive do you think

electronic cigarettes are?

• How socially acceptable among

your peers do you think

electronic cigarettes are?

• Respondents considered e-cigarettes

among the least harmful

(4.26 ±1.95), addictive

(4.29 ± 2.08), and socially acceptable

(4.12 ± 2.03) of the products

considered

• Electronic cigarettes were among the

most positively perceived products

(11.56 ± 4.22)

• Predictors of more favorable

perceptions included:

– Being male (p = 0.03)

– Parental tobacco smoking

(p = 0.02)

– More friends who smoke cigarettes

(p <0.001)

– More friends who use hookah

(p <0.001)

– More friends who use electronic

cigarettes (p = 0.04)

• Recent cigarette smoking (p <0.001).

• Generalizability

• Responder bias

• Cross-sectional

analysis

Camenga et al. (2015) • Focus groups

• Purposive sampling

• Years sample drawn: 2012–2013

• Youth: middle and high school

students in Connecticut; n = 68

• Young adults: college students in

Connecticut; n = 59

• Discuss the comparison

between e-cigarettes and

cigarettes.

• Compared with nonsmokers, college

and high school smokers were

more likely to believe the use of

e-cigarettes could lead to a persistent

“craving” that would prevent

successful smoking cessation

• Compared with nonsmokers, college

and high school smokers were more

likely to believe that e-cigarette use

would maintain nicotine addiction

• Transferability

• Generalizability

• Limited definition

of e-cigarettes

Table 2.11 Continued
E-Cigarette Use Among Youth and Young Adults

Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 71

Study Design/population Measures Outcomes/findings Comments

Cardenas et al. (2015) • Cross-sectional

• School-based survey

• Three-stage cluster sampling

• Year sample drawn: 2012

• Youth: U.S. middle and high school

students; full sample size not

reported; subsample of children who

never tried smoking cigarettes,

n = 14,861

• Young adults: n/a

• Do you believe that electronic

cigarettes or e-cigarettes, such

as Ruyan or NJOY, are less

harmful, equally harmful, or

more harmful than regular

cigarettes?

• Participants who lived with a

smoker were more likely to report

e-cigarettes are less harmful than

regular cigarettes (16.2% vs. 24.8%)

• E-cigarette users were more likely to

believe e-cigarettes are less harmful

than regular cigarettes

(70.9% vs. 27.5%)

• No limitations

reported

Chaffee et al. (2015) • Cross-sectional

• Year sample drawn: 2014

• Youth: male high school students

from San Francisco; n = 104

• Participants were asked to

estimate the probability

(0–100%) that specific health

or social outcomes would

happen to them as a result

of e-cigarette use (e.g., heart

attack, lung cancer, get into

trouble, upset family, etc.)

• Ever use of electronic cigarettes

was associated with lower perceived

probabilities that unfavorable

outcomes would happen

—

Lotrean (2015) • Cross-sectional

• 2013

• Students 19–24 years of age from

Cluj-Napoca, Romania; n = 480

• Belief that e-cigarettes are less

dangerous than cigarettes:

agree, partially agree, disagree,

partially disagree, don’t know

• 55.9% of the total sample agreed

or partially agreed that e-cigarettes

are less dangerous, 35.8% did not

know, and 8.3% disagreed or partially

disagreed

• More smokers than nonsmokers or

ex-smokers agreed or partially agreed

that e-cigarettes are less dangerous

(62.3% vs. 58.7% and 33.3%,

respectively)

• Very small sample

• Measures not clearly

defined

Table 2.11 Continued
A Report of the Surgeon General

72 Chapter 2

Study Design/population Measures Outcomes/findings Comments

McDonald and Ling 

(2015)

• Focus groups and semistructured

interviews

• Recruitment from bars through

screener surveys

• Years sample drawn: 2012–2013

• Youth: n/a

• Young adults: young adults in the

boroughs of Manhattan, Brooklyn,

and Queens in New York City,

18–27 years of age; N = 87

• Perceived risks • Little knowledge of the devices

• Belief that e-cigarettes contain

harmless “water vapor” rather than

smoke

• Belief that “water vapor” is less

harmful or even “good” for users

• No limitations

reported

Roditis and HalpernFelsher (2015)

• Focus groups

• Recruitment from after-school

programs in urban Northern

California

• 2–6 participants in each group

• 24 adolescents: 9 female, 15 male

• Perceived risks and benefits

associated with conventional

cigarettes versus e-cigarettes

• Little knowledge of risks of

e-cigarette use

• Belief that e-cigarettes have no

nicotine

—

Cooper et al. (2016) • Cross-sectional

• Drawn from 2014 Texas Youth

Tobacco Survey, a school-based

survey

• Youth: students in grades 6–12 from

27 counties in Texas; N = 13,602

• “How dangerous do you think it

is for a person your age to use

electronic cigarettes?”

• Those in the e-cigarette-only group

viewed conventional cigarettes as

more harmful than did those in the

dual user group

• No differences in how harmful those

in the e-cigarette-only group and the

dual user group rated e-cigarettes

• Those in the cigarette-only group

rated e-cigarettes as more harmful

than did those in the dual user group

—

Note: Studies in this table are sorted by year of publication and then alphabetically. AOR = adjusted odds ratio; CI = confidence interval; NYTS = National Youth Tobacco Survey.

Table 2.11 Continued
Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 73

E-Cigarette Use Among Youth and Young Adults

Table 2.12a Percentage of middle school and high school students who reported that using e-cigarettes on some days 

but not every day caused no harm, little/some harm, or a lot of harma, by e-cigarette smoking status; 

National Youth Tobacco Survey (NYTS) 2015

No harm Little/some harm A lot of harm

Characteristic n % (95% CI) n % (95% CI) n % (95% CI)

Overall 2,511 14.5 (13.4–15.8) 10,471 61.9 (60.3–63.5) 4,070 23.6 (22.2–25.0)

E-cigarette use

Neverb 1,200 9.5 (8.4–10.8) 7,528 61.0 (59.4–62.6) 3,653 29.4 (28.0–30.9)

Ever, but not past 30 daysc 601 22.4 (20.3–24.6) 1,748 69.3 (66.4–72.1) 249 8.3 (7.0–9.9)

Past 30 daysd 641 34.2 (31.2–37.3) 1,089 59.0 (55.9–62.0) 126 6.8 (5.4–8.7)

Source: Centers for Disease Control and Prevention, unpublished data (data: NYTS 2015).

Notes: CI = confidence interval. There were 325 youth excluded due to missing responses for e-cigarette use.

aIncludes responses to the question, “How much do you think people harm themselves when they use e-cigarettes some days but not 

every day?” Responses for “little harm” and “some harm” were combined.

bIncludes those who reported never trying e-cigarettes.

cIncludes those who reported trying e-cigarettes but not using e-cigarettes on 1 or more days in the past 30 days.

dIncludes those who reported using e-cigarettes on 1 or more days in the past 30 days.

Table 2.12b Percentage of middle school students who reported that using e-cigarettes on some days but not every 

day caused no harm, little/some harm, or a lot of harma, by e-cigarette smoking status; National Youth 

Tobacco Survey (NYTS) 2015

No harm Little/some harm A lot of harm

Characteristic n % (95% CI) n % (95% CI) n % (95% CI)

Overall 1,089 13.5 (11.9–15.4) 4,579 57.6 (56.1–59.2) 2,260 28.8 (27.1–30.6)

E-cigarette use

Neverb 658 9.9 (8.3–11.6) 3,927 58.0 (56.5–59.4) 2,141 32.2 (30.5–33.9)

Ever, but not past 30 daysc 211 31.9 (27.7–36.3) 383 60.6 (55.7–65.4) 60 7.5 (5.4–10.4)

Past 30 daysd 193 41.5 (35.6–47.6) 220 50.0 (44.3–55.7) 38 8.5 (6.0–12.0)

Source: Centers for Disease Control and Prevention, unpublished data (data: NYTS 2015).

Notes: CI = confidence interval. There were 132 middle students excluded due to missing responses for e-cigarette use.

aIncludes responses to the question, “How much do you think people harm themselves when they use e-cigarettes some days but not 

every day?” Responses for “little harm” and “some harm” were combined.

bIncludes those who reported never trying e-cigarettes.

cIncludes those who reported trying e-cigarettes but not using e-cigarettes on 1 or more days in the past 30 days.

dIncludes those who reported using e-cigarettes, on 1 or more days in the past 30 days.
A Report of the Surgeon General

74 Chapter 2

Table 2.12c Percentage of high school students who reported that using e-cigarettes on some days but not every 

day caused no harm, little/some harm, or a lot of harma, by e-cigarette smoking status; National Youth 

Tobacco Survey (NYTS) 2015

No harm Little/some harm A lot of harm

Characteristic n % (95% CI) n % (95% CI) n % (95% CI)

Overall 1,422 15.3 (14.0–16.7) 5,892 65.3 (63.2–67.3) 1,810 19.4 (18.0–20.9)

E-cigarette use

Neverb 542 9.2 (7.8–10.9) 3,601 64.3 (62.0–66.7) 1,512 26.4 (24.6–28.3)

Ever, but not past 30 daysc 390 19.5 (17.5–21.8) 1,365 71.9 (68.6–74.9) 189 8.6 (6.9–10.6)

Past 30 daysd 448 32.3 (28.8–35.9) 869 61.3 (57.8–64.8) 88 6.4 (4.8–8.4)

Source: Centers for Disease Control and Prevention, unpublished data (data: NYTS 2015).

Notes: CI = confidence interval. There were 166 high school students excluded due to missing responses for e-cigarette use.

aIncludes responses to the question, “How much do you think people harm themselves when they use e-cigarettes some days but not 

every day?” Responses for “little harm” and “some harm” were combined.

bIncludes those who reported never trying e-cigarettes.

cIncludes those who reported trying e-cigarettes but not using electronic cigarettes on 1 or more days in the past 30 days.

dIncludes those who reported using e-cigarettes, on 1 or more days in the past 30 days.

Table 2.12d Percentage of young adults (18–24 years of age) who reported that e-cigarettes were not at all harmful, 

moderately harmful, or very harmfula, by e-cigarette smoking status; National Adult Tobacco Study 

(NATS) 2013–2014

Not at all harmful Moderately harmful Very harmful

Characteristic n % (95% CI) n % (95% CI) n % (95% CI)

Overall 796 19.4 (17.9–20.9) 2,260 53.8 (51.9–55.7) 1,053 26.8 (25.1–28.6)

E-cigarette use

Neverb 359 14.3 (12.7–16.2) 1,423 52.8 (50.4–55.2) 814 32.9 (30.6–35.2)

Ever, but not currentc 210 22.9 (19.7–26.4) 520 56.8 (52.7–60.8) 186 20.3 (17.2–23.8)

Currentd 227 36.4 (31.8–41.2) 317 53.6 (48.6–58.5) 53 10.0 (7.2–13.9)

Source: Centers for Disease Control and Prevention, unpublished data (data: NATS 2013–2014).

Notes: CI = confidence interval. There were three young adults who were excluded because of missing responses for both ECIGEVER 

and ECIGNOW.

aIncludes responses to the question, “How harmful do you think using e-cigarettes are to a person’s health?”

bIncludes those who reported having never tried e-cigarettes or having never heard of them.

cIncludes those who reported having heard of e-cigarettes and tried e-cigarettes but reported using them “not at all” at the time of 

the interview.

dIncludes those who reported having heard of e-cigarettes, tried e-cigarettes, and using e-cigarettes some days, every day, or rarely at 

the time of the interview.
Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 75

E-Cigarette Use Among Youth and Young Adults

(Continued from last paragraph on page 64.)

e-cigarettes (22%) (Sutfin et al. 2013). Just over half of the

participants in this study who had never tried e-cigarettes,

however, said that they did not know enough to judge the

relative harm of e-cigarettes compared to conventional

cigarettes. In this study and another study, lack of knowledge about the perceived harm of e-cigarettes relative to

conventional cigarettes was associated with lower odds of

using e-cigarettes (Sutfin et  al. 2013; Choi and Forster

2014b). In the study by Choi and Forster (2014b), lower

perceived harm of e-cigarettes and the belief at baseline

that e-cigarettes can help people quit smoking were both

associated at follow-up with a higher likelihood of having

tried e-cigarettes.

Reasons for Use and Discontinuation

Reasons for Use

Table 2.13 summarizes studies of reasons for using 

and discontinuing e-cigarettes. The most commonly cited 

reasons for use by adolescent and young adult e-cigarette 

users included curiosity (Schmidt et al. 2014; Biener and 

Hargraves 2015; Biener et al. 2015; Kong et al. 2015; 

McDonald and Ling 2015; Suris et al. 2015; Sutfin et al. 

2015), flavorings/taste (Ambrose et al. 2015; University of 

Michigan 2015), use as a less harmful/less toxic alternative 

to conventional cigarettes (Peters et al. 2013; Tucker et al. 

2014; Ambrose et al. 2015; Kong et al. 2015; McDonald 

and Ling 2015; Sutfin et al. 2015), and avoidance of indoor 

smoking restrictions or disturbing people with secondhand smoke from conventional cigarettes (Tucker et al. 

2014; Ambrose et al. 2015; Kong et al. 2015; McDonald 

and Ling 2015; Suris et al. 2015; Sutfin et al. 2015). Other 

reasons youth and young adults reported trying or using 

e-cigarettes included affordability and lower cost than

conventional cigarettes (Tucker et al. 2014; Ambrose et al.

2015); accessibility and convenience (Choi et al. 2012;

Kong et al. 2015); social approval and/or offer from a

family member or friend (Peters et al. 2013; Kong et al.

2015; Suris et al. 2015; Sutfin et al. 2015); perception

that e-cigarettes are “cool,” “modern,” or “high-tech”

(Choi et al. 2012; Kong et al. 2015); avoidance of smelling

cigarette smoke (Peters et al. 2013; Tucker et al. 2014;

Ambrose et al. 2015; Kong et al. 2015; Sutfin et al. 2015);

ease of keeping hidden from parents/teachers (Peters et al.

2013; Kong et al. 2015); and weight control (Tucker et al.

2014). Young adults also perceived that e-cigarettes were

more socially acceptable than smoking conventional cigarettes in public (Trumbo and Harper 2013).

Some youth and young adults also reported using 

e-cigarettes as an aid to reducing and/or quitting their use of 

conventional cigarettes (Li et al. 2013; Schmidt et al. 2014;

Tucker et al. 2014; Suris et al. 2015; Sutfin et al. 2015; Bold

et al. 2016). Data from the 2012 NYTS, however, suggest 

that while e-cigarette use among U.S. youth may be associated with intentions to smoke conventional cigarettes, it is 

not associated with intentions to quit conventional cigarette smoking (Park et al. 2016). This is further reinforced 

by a study of young adults from Switzerland, which found 

that after 15 months of follow-up, e-cigarette use was not 

associated with either cessation or reduction in the use of 

conventional cigarettes (Gmel et al. 2016). There is some 

evidence to suggest that curiosity was a stronger driver of 

an e-cigarette trial among young adults than smoking cessation, and that smoking cessation was a stronger driver 

of such a trial among older adults (Schmidt et al. 2014). 

Other evidence suggests that reasons for use were driven 

by tobacco-use status, with regular adolescent e-cigarette 

users much more likely than adolescents who had used 

e-cigarettes just once to give the reason for use as smoking

cessation, smoking reduction, or avoidance of smoke-free

air regulations (Suris et al. 2015). Nationwide, according

to the 2015 MTF (University of Michigan 2015), “because

they tasted good” was cited as a reason to use e-cigarettes

among 40% of 8th-, 10th-, and 12th-grade users, versus

just 10% who reported they used them in an attempt to

quit smoking conventional cigarettes. In a New Zealand

study, interest in using e-cigarettes to quit using conventional cigarettes was higher among young adults than

older adults (Li et al. 2013). Finally, another study, this

one conducted among high school, middle school, and

college students in Connecticut in 2012–2013, found that

although the students were aware that e-cigarettes could

be used to aid in smoking cessation, they thought that few

smokers had successfully used e-cigarettes to quit smoking

(Camenga et  al. 2015). However, in an article published

by this group (Bold et al. 2016), trying e-cigarettes to

quit smoking was the most robust predictor of continued

e-cigarette use 6 months later, using a multivariable model

that included all reasons simultaneously, though this

reason was only endorsed at baseline by 5.9% of youth. Low

cost was the most robust predictor of more frequent use

6 months later, though only 10% of students endorsed this

reason at baseline (Bold et al. 2016). Therefore, the reasons

to experiment with e-cigarettes are likely different from the

reasons to continue using them, over time.

No randomized controlled trials specific to the efficacy of using e-cigarettes for quitting conventional cigarette smoking for young adults have been conducted to 

date. Although use of e-cigarettes as a potential cessation 

device for conventional cigarette smoking among adults is 

important to examine (e.g., McRobbie et al. 2014; McNeill 

et al. 2015), none of this evidence is included here, as it 

does not directly discuss youth and young adults. Three 

observational studies specific to this issue, however, have 

been conducted among young adults to date. Data from
A Report of the Surgeon General

76 Chapter 2

Table 2.13 Summary of studies on reasons for use and discontinuation of e-cigarettes among youth and young adults

Study Design/population Measures Outcomes/findings

Adkison et 

al. (2013)

• Parallel prospective cohort

• Telephone interview and web-based

surveys

• Probability sampling methods (randomdigit dialing)

• Years sample drawn: 2010–2011 (Wave

8), 2008–2009 (Wave 7; where available)

• Youth: n/a

• Young adults: current smokers,

≥18 years of age; N = 5,939

(Canada, n = 1,581; U.S., n = 1,520;

United Kingdom, n = 1,325;

Australia, n = 1,513)

• Four questions were asked regarding

reasons for use (yes/no):

1. Electronic cigarettes may not be as bad as

cigarettes for your health

2. Easier to cut down on the number of

cigarettes you smoke

3. Can smoke in places where smoking

conventional cigarettes is prohibited

4. Might help you quit

• Not explicitly reported for young adults

Choi et al. 

(2012)

• Focus groups

• Recruitment by (1) online

advertisements, (2) flyers on one

4-year and two 2-year college campuses,

(3) announcements in student life

newsletter at a 2-year college, and

(4) recruitment booth on a 2-year

college campus

• Year sample drawn: 2010

• Youth: n/a

• Young adults: Individuals in

Minneapolis-St. Paul, MN, enrolled in or

who had graduated from

4-year colleges, or those who were

enrolled in or had graduated from

2-year colleges, or those who had not

enrolled in postsecondary education;

N = 66

• Potential as quit aids • Ineffective as quit aids because:

– Contain nicotine

– Potential to be addicted to e-cigarettes

– Eliminate social interaction aspect

• Potential to help quit smoking because:

– Potential for gradual reduction in nicotine
E-Cigarette Use Among Youth and Young Adults

Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 77

Study Design/population Measures Outcomes/findings

Choi and 

Forster 

(2013)

• Population-based prospective cohort

study

• Interview

• Cluster random sampling

• Years sample drawn: 2010–2011

• Youth: n/a

• Young adults: U.S. midwestern adults,

20–28 years of age; n = 2,624 (sample

from Minnesota)

• Indicate your level of agreement:

1. E-cigarettes can help people quit smoking

2. E-cigarettes are less harmful than

cigarettes

3. E-cigarettes are less addictive than

cigarettes

• 44.5% agreed e-cigarettes can help quit smoking;

associated with the following characteristics:

– Not being non-Hispanic White (AOR = 0.60;

CI, 0.44–0.84)

– Enrolled/graduated from 2-year college (AOR = 1.47;

CI, 1.09–1.98)

– Current smoker (AOR = 1.35; CI, 1.05–1.73)

– At least one close friend who smokes (AOR = 1.27;

CI, 1.03–1.57)

• 52.9% agreed e-cigarettes are less harmful than cigarettes;

associated with the following characteristics:

– Not being non-Hispanic White (AOR = 0.73;

CI, 0.53–0.99)

– Male (AOR = 1.39; CI, 1.15–1.67)

– Current smoker (AOR = 1.42; CI, 1.11–1.83)

• 26.4% agreed e-cigarettes are less addictive than cigarettes;

associated with the following characteristics:

– Current smoker (AOR = 1.51; CI, 1.15–1.99)

– Former smoker (AOR = 1.64; CI, 1.19–2.25)

– At least one close friend who smokes (AOR = 1.28;

CI, 1.00–1.63)

Faletau et 

al. (2013)

• Qualitative exploratory

• Structured focus groups and individual

interviews

• Recruited from two low socioeconomic

primary schools in East and South

Auckland, New Zealand

• Year sample drawn: 2011

• Youth: Maori, Tongan, Samoan, Cook

Island, and Niuean children, 6–10 years

of age; N = 20

• Young adults: n/a

• Viewed tobacco cigarette and electronic

cigarette videos

• Stops people from smoking

• People won’t die

• Protects those around e-cigarette users from sickness

Table 2.13 Continued
A Report of the Surgeon General

78 Chapter 2

Study Design/population Measures Outcomes/findings

Li et al. 

(2013)

• Cross-sectional

• Telephone-based survey

• Random-digit-dial sampling

• Years sample drawn: 2011–2012

• Youth: n/a

• Young adults: current smokers and

recent quitters, ≥18 years of age, in New

Zealand; N = 840

• Indicate your level of agreement:

1. E-cigarettes are safer to use than tobacco

cigarettes (n = 317)

2. E-cigarettes can help people quit smoking

tobacco (n = 313)

• OR = 1.81 (.78–4.18) among participants 18–24 years of

age for perceived safety of e-cigarettes compared with

participants ≥45 years of age

• OR = 0.50 (0.21–1.17) among participants 18–24 years of

age for perceived efficacy of e-cigarettes compared with

participants ≥45 years of age

Pepper et 

al. (2013)

• Cross-sectional

• Web-based survey

• Recruited through parents who were

members of an online panel assembled

by random-digit dialing and addressbased sampling.

• Year sample drawn: 2011

• Youth: U.S. males, 11–17 years of age;

N = 228

• Young adults: n/a

• If one of your best friends were to offer you

an e-cigarette, would you try it?

• If one of your best friends were to offer you a

flavored e-cigarette (chocolate, mint, apple,

etc.), would you try it?

• Overall, 18% were willing to try an e-cigarette if offered by

a best friend:

– 13% willing to try a plain e-cigarette

– 5% willing to try flavored e-cigarettes or both kinds

• Willingness to try e-cigarettes by age:

– 11–13: 11%

– 14–16: 15%

– 17–19: 29%

• OR = 3.26 (CI, 1.27–8.35) among those 17–19 years of age

for willingness to try an e-cigarette, compared with those

11–13 years of age

• Willingness to try e-cigarettes by smoking status:

– Nonsmoker: 13%

– Smoker: 74%

• OR = 18.67 (6.22–55.98) among smokers for willingness to

try an e-cigarette, compared with nonsmokers

Peters et 

al. (2013)

• Focus groups

• Recruitment through large, diverse high

school in southwestern United States

• Year sample drawn: 2012

• Youth: U.S. teenage boys; N = 47

• Young adults: n/a

• Why do youth use electronic cigarettes?

• What do your friends think about electronic

cigarettes?

• Why are electronic cigarettes so popular?

• Reported reasons for use among youth:

– Expeditious consumption and concealment: 40%

– High school approval: 26%

– Healthier than cigarettes: 19%

– Odorless: 15%

• Reported perceptions of friends:

– High school approval: 49%

– Healthier than cigarettes: 36%

– Safe high: 15%

• Reported reasons for popularity:

– Accessibility: 43%

– Healthier than cigarettes: 30%

– Aesthetics: 23%

• Don’t know: 4%

Table 2.13 Continued
E-Cigarette Use Among Youth and Young Adults

Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 79

Study Design/population Measures Outcomes/findings

Trumbo 

and 

Harper

(2013)

• Cross-sectional

• Web-based survey

• Recruitment by offer of extra credit to

students in a 100-level course

• Year sample drawn: 2011

• Youth: n/a

• Young adults: freshmen and sophomores

in a 100-level mass media in society

course; n = 244

• Indicate your level of agreement with

relative advantage:

1. I think e-cigarettes are safer in terms of

“secondhand” smoke compared to tobacco

cigarettes

2. I think e-cigarettes are not as harmful to

users as tobacco cigarettes

• Indicate your level of agreement with

compatibility:

1. I think e-cigarette users can easily make

use of existing smoking areas

2. I believe using e-cigarettes would fit in

well with the lifestyle of most smokers

• Indicate your level of agreement with

complexity:

1. I believe it will not be difficult for smokers

to learn how to use e-cigarettes

2. Overall, e-cigarettes are no more

complicated to use than ordinary tobacco

cigarettes

• Indicate your level of agreement with

“trialability”:

1. I think it will be easy for people to

purchase e-cigarettes

2. Smokers could easily give e-cigarettes a

try to see if they like them better than

tobacco

• Mean score (SD) of innovation items: 36.0 (4.7)

Zhu et al. 

(2013)

• Population

• Online-based surveys

• National probability sample

• Year sample drawn: 2012

• Youth: n/a

• Young adults: U.S. adults,

>18 years of age; N = 10,041

• Why did you use e-cigarettes (yes/no)?

1. Safer than cigarettes

2. Cheaper than cigarettes

3. Easy to use when I can’t smoke

4. To try to quit smoking cigarettes

5. Just because

• Not explicitly reported for young adults

Table 2.13 Continued
A Report of the Surgeon General

80 Chapter 2

Study Design/population Measures Outcomes/findings

Choi and 

Forster 

(2014b)

• Population-based prospective cohort

study

• Survey

• Cluster random sampling

• Years sample drawn: 2011–2012

• Youth: n/a

• Young adults: participants in Minnesota

Adolescent Community Cohort;

n = 1,379

• Indicate your level of agreement with the

following:

1. Using e-cigarettes can help people quit

smoking

2. Using e-cigarettes is less harmful to

health of the user than smoking cigarettes

3. E-cigarettes are less addictive than

cigarettes

• 10% agreed that e-cigarettes can help people quit smoking;

associated with e-cigarette experimentation at follow-up

(AOR = 1.98; CI, 1.29–3.04)

• 10.1% agreed that e-cigarettes are less harmful than

cigarettes; associated with e-cigarette experimentation at

follow-up (AOR = 2.34; CI, 1.49–3.69)

• 9.3% agreed that e-cigarettes are less addictive than

cigarettes

Czoli et al. 

(2014)

• Cross-sectional

• Survey

• Recruitment through online panel of

commercial market research company

• Year sample drawn: 2012

• Youth: Canadian youth recruited

from online panel, 16–30 years of age;

n = 1,188

• Young adults: Canadian young adults

recruited from same online panel

• Indicate your agreement with the following

reasons for trying e-cigarettes:

1. In places where you can’t smoke

cigarettes

2. For times when you don’t want to smoke

around others

3. To help you cut back on the amount you

smoke

4. To help you while you are trying to quit

smoking

5. As a long-term replacement for cigarettes

6. As a cheaper alternative to cigarettes

• Reasons for trying e-cigarettes among current cigarette

smokers:

– To help cut back on the amount they smoked (77.7%)

– As a long-term replacement for cigarettes (77.8%)

– For the times when they don’t want to smoke around

others (78.8%)

– To help them while they are trying to quit smoking

(80.4%)

– As a cheaper alternative to cigarettes (80.7%)

– In places where they can’t smoke cigarettes (80.9%)

Li et al. 

(2014)

• Cross-sectional

• Telephone-based survey

• Recruitment by telephone-based

omnibus survey and quitline client

database

• Year sample drawn: 2013

• Youth: n/a

• Young adults: current smokers and

recent quitters, ≥18 years of age, in New

Zealand; N = 267

• Indicate your level of agreement:

1. Electronic cigarettes are for people who

want to stop smoking completely

2. Electronic cigarettes are for people who

want to cut down on their smoking

3. Electronic cigarettes are for people who

want to still smoke in restricted public

places such as inside a cafe, restaurant,

or pub

• OR = 1.99 (CI, 0.99–3.97) among those 18–34 years of

age for agreeing that “electronic cigarettes are for people

who want to stop smoking completely,” compared with

individuals ≥35 years of age

• OR = 0.72 (CI, 0.24–2.21) among those 18–34 years of

age for agreeing that “electronic cigarettes are for people

who want to cut down on their smoking,” compared with

individuals ≥35 years of age

• OR = 0.93 (0.47–1.85) among those 18–34 years of age for

agreeing that “electronic cigarettes are for people who want

to still smoke in restricted public places such as inside a

cafe, restaurant or pub,” compared with individuals ≥35

years of age

Table 2.13 Continued
E-Cigarette Use Among Youth and Young Adults

Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 81

Study Design/population Measures Outcomes/findings

Schmidt et 

al. (2014)

• Cross-sectional

• Telephone-based survey

• Random-digit-dial sampling

• Year sample drawn: 2013

• Youth: n/a

• Young adults: noninstitutionalized

adults in Montana; n = 5,000

• Select all of the reasons you initiated use of

e-cigarettes:

1. To quit smoking cigarettes

2. To reduce cigarette consumption

3. To try something new (curiosity)

4. To not disturb other people with smoke

5. To smoke in a place where cigarette

smoking is prohibited

6. To save money

7. E-cigarettes might be less harmful than

cigarettes

8. E-cigarettes taste better

9. Other

• Among those 18–34 years of age, approximately

50% reported trying e-cigarettes to quit or reduce

cigarette use

• Among those 18–34 years of age, approximately

70% reported trying e-cigarettes to try something

new (curiosity)

Tucker et 

al. (2014)

• Cross-sectional

• Paper-based survey

• Probability-based sampling

• Year sample drawn: not reported

• Youth: n/a

• Young adults: homeless young adults,

17–25 years of age; N = 292 (subset of

lifetime e-cigarette users, n = 83)

• 18-item measure of reasons for using

e-cigarettes, rating each reason on a 4-point

scale (1 = not at all true, 4 = very true)

• Most common reasons for use included:

– Not having to go outside to smoke cigarettes (38%)

– To deal with situations or places where they cannot

smoke (36%)

– To avoid bothering other people with tobacco smoke

(31%)

• Less common to report using e-cigarettes was to quit

smoking (17–18%)

Ambrose 

et al. 

(2015)

• Cross-sectional

• Wave 1 of PATH study

• Household-based, nationally

representative survey

• Youth: 12–17 years of age; n = 13,651

• Young adults: n/a

• Past 30-day e-cigarette users were asked to

report reasons for product use, including “it

comes in flavors I like”

• 81.5% of past-30-day users cited “because they come in

flavors I like” as a reason for using e-cigarettes

• Other common reasons for use were “they might be less

harmful to me than cigarettes” (79.1%); “they might be

less harmful to people around me than cigarettes” (78.1%);

and “I can smoke/use them at times when or in places

where smoking cigarettes isn’t allowed” (58.9%)

Biener et 

al. (2015)

• Cross-sectional

• Population-based mail survey

• Dual-frame sample

• Youth: n/a

• Young adults: 18–25 years of age;

n = 4,740

• Reasons for trying: curiosity, use by friends,

health risks relative to cigarettes, absence of

smell, for use where smoking is prohibited,

and to quit or cut down on smoking

• Reasons for stopping e-cigarette use: health

concerns, negative reactions to taste and

feeling sick, inferiority to other forms of

tobacco, expense, lack of availability, and

social disapproval

• Most common reason cited was curiosity, with never

smokers more likely to cite this (77.3%) than former or

current cigarette smokers (59% and 61%)

Table 2.13 Continued
A Report of the Surgeon General

82 Chapter 2

Study Design/population Measures Outcomes/findings

Camenga 

et al. 

(2015)

• Focus groups

• Purposive sampling

• Years sample drawn:

2012–2013

• Youth: middle and high school students

in Connecticut; n = 68

• Young adults: college students in

Connecticut; n = 59

• Discuss your motivations to use e-cigarettes • Maintain smoking actions while allowing individuals to use

a “healthier” nicotine product

• Maintain tactile sensations to help with conditionedsmoking cues

• College students believed e-cigarettes to be healthier than

cigarettes

Kong et al. 

(2015)

• Cross-sectional

• Focus groups, schoolwide survey

• Recruitment by flyers and active

recruitment sessions

• Years sample drawn: 2012–2013

• Youth: New Haven County, Connecticut,

middle and high school students; focus

group n = 127 (youth and young adults);

survey n = 4,780

• Young adults: New Haven County,

Connecticut, college students; focus

group n = 127 (youth and young adults);

survey n = 625

• Focus group:

– Why do you think people your age would

use e-cigarettes?

• Survey:

– Why did you try an e-cigarette?

– If you tried an e-cigarette but stopped

using it, why did you stop?

• Focus group responses:

– Reasons for use:

| Influence of family and friends

| To be “cool”

| Curiosity

| Readily available

| Flavors

– Comparison to cigarettes:

| Healthier

| Less harsh

| Cheaper

| Smells better

| More convenient

| Can hide it

| Use it indoors

– Reasons for discontinuation:

| Losing interest

| Negative physical effects (e.g., light-headed)

| Bad taste

| High cost

| Less satisfying than cigarettes

• Survey responses:

– Reasons for experimentation (among lifetime e-cigarette

users):

| Curiosity (54.4%)

| Friends’ influence (31.6%)

– Reasons for discontinuation:

| Uncool (16.3%)

| Health risks (12.1%)

Table 2.13 Continued
E-Cigarette Use Among Youth and Young Adults

Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 83

Study Design/population Measures Outcomes/findings

Li et al. 

(2015)

• Cross-sectional

• 2014

• Nationwide, in-home survey in New

Zealand

• Multistage, stratified, clustered, and

random probability sampling method

(oversampling of Maori and Pacific

peoples)

• Participants ≥15 years of age; n = 2,594:

– Youth: 15–17 years of age, 3.8% of

sample

– Young adults: 18–24 years of age,

13.4% of sample

• Why did you try using an electronic

cigarette? (Multiple responses allowed—

wanted to quit smoking cigarettes

completely/wanted to replace smoking

cigarettes some of the time/wanted to smoke

in places where cigarette smoking is not

allowed/cheaper than tobacco cigarettes/

safer than tobacco cigarettes/curiosity/

recommendation/other)

• 57.1% of ever users cited curiosity as a reason for first

trying, followed by 31.3% of ever users who cited wanting

to quit smoking completely

• Current e-cigarette users were more likely than noncurrent

users to report wanting to quit smoking completely as a

reason for using e-cigarettes

McDonald 

and Ling 

(2015)

• Focus groups and semistructured

interviews

• Recruitment from bars through screener

surveys

• Years sample drawn: 2012–2013

• Youth: n/a

• Young adults: young adults in the

boroughs of Manhattan, Brooklyn, and

Queens in New York City, 18–27 years of

age; N = 87

• Bodily sensations

• Use in response to clean air laws

• Vapor described as “harsh” or “burning”

• Discontinued use because believed it would cause one to

smoke more

• Discontinued use due to fear of nicotine hangover

• Use to smoke in places where conventional smoking is not

allowed

Pokhrel et 

al. (2015)

• Cross-sectional

• Web-based survey

• Recruitment by flyers across

three college campuses

• Year sample drawn: 2013

• Youth: n/a

• Young adults: U.S. students from

a 4-year university and two 2-year

community colleges in Oahu, Hawaii;

n = 307

• Fourteen items, scored on a scale of 1 (do not

agree) to 7 (agree), address three main

beliefs. E-cigarettes:

– Are less harmful than cigarettes

– Improve the health of current smokers

– May be used to quit smoking

• Participants generally scored harm-reduction items higher

• Among health benefit items, “e-cigarettes improve

breathing and reduce coughing” received the highest

average score: mean (SD) = 3.9 (1.6)

• Among smoking-cessation items, “e-cigarettes are a good

compromise for people trying to quit smoking” received

the highest average score: mean (SD) = 4.6 (1.8)

• Across all items, “e-cigarettes cut down on the harmful

effects of secondhand smoke” was scored the highest: mean

(SD) = 5.3 (1.7)

• 69% of participants agreed with the above item

Table 2.13 Continued
A Report of the Surgeon General

84 Chapter 2

Study Design/population Measures Outcomes/findings

Suris 

(2015)

• Cross-sectional

• Data drawn from spring 2014 wave of

ado @ internet.ch, a longitudinal study

on Internet use

• Representative sample of students in

French-speaking part of Switzerland

• Sample of 621 students included

never e-cigarette users (n = 353),

experimenters (n = 120), and users

(n = 148); mean age = 16.2 years

• Reason for having used e-cigarettes?

– Curiosity

– To smoke where it is forbidden

– To reduce smoking

– To do like my friends

– To quit smoking

– Other

• Experimenters were significantly more likely to have used

e-cigarettes for curiosity while users were more likely to

use them where it is forbidden to smoke (p<.01)

Sutfin 

(2015)

• Longitudinal cohort study

• Data from the Smokeless Tobacco Use

in College Students Study

• College students from North Carolina

and Virginia

• Reasons for e-cigarette use were

evaluated at Wave 6 of the study, n = 271

• Why did you try e-cigarettes? (check all

that apply):

– “I was curious about the product”

– “It might be better for my health than

smoking cigarettes”

– “My friends use e-cigarettes”

– “I can use it in places where cigarette

smoking is not allowed”

– “To help me quit smoking”

– “To cut down on smoking”

– “It doesn’t smell bad”

• The majority (91.6%) reported curiosity as a reason for

trying e-cigarettes

• More than 70% tried e-cigarettes because their friends

used them

• About 70% tried e-cigarettes because they believed them

to be better for their health than cigarettes

• Fifty percent cited, “It doesn’t smell bad,” and “I can use

it where cigarette smoking is not allowed”

• About 31% said that they used e-cigarettes to cut down

on smoking

• Twenty percent said that they tried e-cigarettes to help

them quit smoking

University 

of 

Michigan 

(2015)

• Cross-sectional

• Data from the Monitoring the Future

Study

• School-based, self-administered, paperand-pencil questionnaire with crosssectional and longitudinal components

• Students from 8th, 10th, and 12th grades

• Weighted sample of students responding

to the “reasons for use of electronic

vaporizer” question: 603 (8th grade), 846

(10th grade), and 1,449 (12th grade)

• “What have been the most important reasons

for your using an electronic vaporizer, such

as an e-cigarette?”

– To help me quit regular cigarettes

– Because regular cigarette use is not

permitted

– To experiment to see what it’s like

– To relax or relieve tension

– To feel good or get high

– Because it looks cool

– To have a good time with my friends

– Because of boredom—nothing else to do

– Because it tastes good

– Because I am “hooked”—I have to have it

• More than half of all students in 8th, 10th, and 12th grades

reported that curiosity to see what they were like was a

primary reason for use

• Forty percent said that they used e-cigarettes because they

tasted good

• About 10% said they used them in an attempt to quit

smoking regular cigarettes

Table 2.13 Continued
E-Cigarette Use Among Youth and Young Adults

Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 85

Study Design/population Measures Outcomes/findings

Berg 

(2016)

• Cross-sectional

• Recruitment through Facebook

targeting of tobacco and marijuana users

and nonusers

• 2014

• Youth: n/a

• Young adults: 18–34 years of age, living

in the United States; N = 1,567

• Reasons for use: For what reasons do you/

might you use e-cigarettes?

• Reasons for discontinued use: Why have you

not used recently?

• Reasons for use among current e-cigarette users:

– ‘‘They might be less harmful than cigarettes’’ (77%)

– ‘‘They do not smell’’ (77%)

– ‘‘They help people quit smoking’’ (66%)

– ‘‘They cost less than other forms of tobacco’’ (62%)

• Reasons for use among nonusers:

– “They might be less harmful than cigarettes” (41%)

– “They don’t smell” (34%)

• Reasons for discontinuation:

– ‘‘Using other tobacco products instead’’ (43%)

– ‘‘They are too expensive’’ (35%)

– ‘‘I just don’t think about it’’ (31%)

Bold 

(2016)

• Longitudinal

• Youth: New Haven County, Connecticut,

middle and high school students

• 2013–2014

• 340 e-cigarette users at baseline

• Reasons for first trying e-cigarettes:

– Curiosity

– It is cool

– Good flavors

– Does not smell bad

– Can hide it from adults

– Low cost

– My friends use it

– My parents/family use it

– Can use it anywhere

– To quit smoking regular cigarettes

– It is healthier than regular cigarettes

• In multivariable model, including all reasons

simultaneously, trying e-cigarettes to quit smoking was

the most robust predictor of current (i.e., past 30 days)

e-cigarette use 6 months later; however, this reason was

endorsed by very few youth (5.9%)

• In multivariable model, including all reasons

simultaneously, trying e-cigarettes because of low cost was

the most robust predictor of more frequent e-cigarette use

(i.e., more days/month) 6 months later; this reason was

endorsed by few youth (10%)

Note: Studies in this table are sorted by year of publication and then alphabetically. AOR = adjusted odds ratio; OR = odds ratio; PATH = Population Assessment of Tobacco 

and Health Study; SD = standard deviation.

Table 2.13 Continued
A Report of the Surgeon General

86 Chapter 2

(Continued from last paragraph on page 75.)

a population-based cohort study of U.S. young adults 

in the Midwest suggest that e-cigarettes are not effective as a technique for quitting the use of conventional 

cigarettes. In that study, 11% of cigarette smokers who 

had used e-cigarettes in the past 30 days at baseline quit 

smoking at the 1-year follow-up, compared with 17% of 

cigarette smokers who had never used e-cigarettes 

(OR = 0.93, p = 0.93) (Choi and Forster 2014a). Another 

cohort study of Swiss young adult men concluded that 

there were no beneficial effects of vaping for conventional 

cigarette smoking cessation or smoking reduction (Gmel 

et al. 2016). In this study, e-cigarette users reported lower 

cigarette smoking cessation rates at follow-up among 

those who were occasional cigarette smokers at baseline 

(OR = 0.43; 95% CI, 0.19–0.96). No differences between 

e-cigarette users and nonusers were noted among those

who were daily cigarette smokers at baseline (OR = 0.42;

95%  CI, 0.15–1.18). No differential changes between

e-cigarette users and nonusers in the number of conventional cigarettes smoked per week were noted at followup, either (Gmel et al. 2016). In a study by Unger and colleagues (2016), which focused on Hispanic young adults

in California, e-cigarette use at baseline (2014) was not

associated with cessation of cigarette smoking (OR = 1.31; 

95% CI, 0.73–2.36) or marijuana use (OR = 1.05; 95% CI, 

0.54–2.01) at follow-up (2015), though e-cigarette use 

at baseline did increase the likelihood of transitioning 

from nonuser to user of cigarettes (OR = 3.32; 95% CI, 

1.55–7.10) and marijuana (OR = 1.97; 95% CI, 1.01–3.86) 

(Unger et al. 2016). Additional research is required to 

determine any potential efficacy of e-cigarette use for conventional cigarette smoking cessation in young adults.

Reason for Discontinuation

In the small number of published studies on reasons 

for discontinuation of e-cigarette use in young users, adolescent and young adult smokers have cited lack of satisfaction and e-cigarettes’ poor taste and cost (Kong et al. 

2015) as reasons for discontinuing. Additional reasons 

have included negative physical effects (e.g., feeling lightheaded) (Kong et al. 2015) and loss of interest. In one study 

of young adults aged 18–35, former and never smokers of 

conventional cigarettes also cited the idea that e-cigarettes 

were “bad for their health” as a reason for discontinuation 

(Biener and Hargraves 2015; Biener et al. 2015).

Evidence Summary

The most recent estimates available show that 

13.5%  of middle school students (2015), 37.7% of high 

school students (2015), and 35.8% of young adults 

(2013–2014) had ever used an e-cigarette (Tables 2.1a, 2.1b, 

and 2.4a). The most recent data also show that past-30-day 

use of e-cigarettes is higher among high school students 

(16% in 2015) and young adults (13.6% in 2013–2014) 

than among middle school students (5.3% in 2015) and 

adults (25  years of age and older) (5.7% in 2013–2014) 

(Tables  2.1b, 2.4a, and 2.4b). Among youth and young 

adults, rates of ever and past-30-day use of e-cigarettes 

have increased greatly since the earliest e-cigarette surveillance efforts began in 2011. The increases among adults 

25 years of age and older, by comparison, have been less 

steep. Among middle school and high school students, both 

ever use and past-30-day use of e-cigarettes more than tripled from 2011 to 2015 (NYTS 2011–2015; Figures 2.1 and 

2.2) (CDC 2013a; Ambrose et al. 2014; Lippert 2015), and 

among young adults (18–24 years of age), the prevalence 

of ever use more than doubled from 2013 to 2014 (Styles 

2013–2014; Figure 2.3).

Among youth, past-30-day exclusive use of 

e-cigarettes among 8th, 10th, and 12 graders (6.8%, 10.4%, 

and 10.4%, respectively) was more common than exclusive

use of conventional cigarettes (1.4%, 2.2%, and 5.3%  in

those grades) or dual use of e-cigarettes and conventional

cigarettes (2.4%, 3.5%, and 5.8% in those grades) (Table 2.5; 

Figure 2.4). However, among young adults 18–24 years of 

age, the patterns were different. In that group, exclusive 

use of conventional cigarettes surpassed exclusive use of 

e-cigarettes and use of both types of products (Figure 2.8).

For example, in 2013–2014, 9.6% of young adults smoked

conventional cigarettes exclusively, 6.1% were current

users of e-cigarettes, and 7.5% currently used both. The

use of e-cigarettes and other tobacco products, such as

combustibles, appeared to co-vary among youth and young

adults (Figures 2.6, 2.7, and 2.8). Although five longitudinal studies suggest that e-cigarette use is related to the

onset of other tobacco product and marijuana use among

youth and young adults (Leventhal et al. 2015; Primack

et  al. 2015; Barrington-Trimis et  al. 2016; Unger et al.

2016; Wills et al. 2016), some studies had limitations in

their ability to distinguish experimental smokers from regular smokers at follow-up (Leventhal et al. 2015; Primack

et al. 2015; Barrington-Trimis et al. 2016; Wills et al. 2016).

Therefore, more studies are needed to elucidate the nature

of any true causal relationship between e-cigarette use and

combustible tobacco products. Investigation of whether

e-cigarette use is related to other types of substance abuse

(e.g., marijuana, alcohol) might help distinguish the extent 

to which e-cigarette use may precede or follow other forms
Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 87

E-Cigarette Use Among Youth and Young Adults

of substance use in the context of the common liability/

vulnerability model (Vanyukov et al. 2012).

Although use of other tobacco products has been the 

strongest correlate of ever and past-30-day e-cigarette use 

among youth and young adults, sociodemographic characteristics have also been associated with the use of these 

products. Across both ever use and past-30-day use measures, e-cigarette use has been more common among high 

school than middle school students, a pattern similar to 

trends seen in other categories of tobacco products (CDC 

2015c). Among middle school students in 2014 and 2015 

(CDC 2016), ever e-cigarette use was highest for Hispanics 

(Table 2.1a); among high school students, ever use was 

highest among Hispanics and Whites (Table 2.1b). No differences between boys and girls were observed among middle 

school students in 2015 (Tables 2.1a, 2.1b). However, in 

2015 male high school students were significantly more 

likely to report past-30-day use than their female counterparts (Table 2.2b) (CDC 2016). For young adults, ever and 

past-30-day use of e-cigarettes were significantly higher 

among males than females (Table 2.4a). Current e-cigarette 

use was significantly lower among Blacks than in other 

racial/ethnic groups (Table 2.4a). Ever and past-30-day 

e-cigarette use was also significantly lower among those 

with a college education. Continued research is warranted 

to monitor patterns of e-cigarette use across population 

groups by gender, age, race/ethnicity, and education, as well 

as by sociodemographic characteristics for which disparities in tobacco use have been noted. Availability of data on 

e-cigarette use among youth and young adults is currently 

limited, including geography (e.g., subnational data at the 

state or local levels), sexual orientation and gender identity (e.g., lesbian, gay, bisexual, transgender), and socioeconomic status (e.g., household income, poverty status) (CDC 

2014a; Johnson et al. 2016).

Research on youth and young adults’ 

e-cigarette-related knowledge, attitudes, and beliefs is 

still developing and remains relatively sparse. Perceived 

harm is the most developed area of research. Most youth 

and young adults believe e-cigarettes are “less harmful” 

than conventional cigarettes (Table 2.11). However, up to 

50% of respondents in some of these studies felt they did 

not know enough about the potential dangers associated 

with e-cigarettes to answer questions about perceived harm 

(Ambrose et al. 2014; Amrock et al. 2015). Although relative harm compared with cigarettes is important to assess, 

equally important is determining young people’s perception of the absolute harm from e-cigarettes. National data 

show that only 23.6% of middle and high school students 

combined believed that e-cigarettes cause “a lot of harm” 

(Table  2.12a), and only 26.8% of young adults believed 

e-cigarettes are “very harmful” (Table 2.12d). However, significant differences emerge in these perceptions of harm 

when examined by whether or not youth and young adults 

use e-cigarettes. Among both middle and high school students and young adults, perceptions of “no harm” were 

much more prevalent among those with prior experience 

with e-cigarettes (Tables  2.12b–2.12d). Current e-cigarette users were two to three times more likely to report 

that e-cigarettes convey “no harm” compared to never 

e-cigarette users, for both age groups (Tables 2.12a and 

2.12d).

The most commonly cited reasons that youth and 

young adults reported using e-cigarettes included curiosity (Schmidt et al. 2014; Biener and Hargraves 2015; 

Biener et al. 2015; Kong et al. 2015; McDonald and Ling 

2015; Suris et al. 2015; Sutfin et al. 2015), flavorings/taste 

(Ambrose et al. 2015; University of Michigan 2015), use as 

a less harmful/less toxic alternative to conventional cigarettes (Peters et al. 2013; Tucker et al. 2014; Ambrose et al. 

2015; Kong et al. 2015; McDonald and Ling 2015; Sutfin 

et al. 2015), and avoidance of indoor smoking restrictions 

or disturbing people with secondhand smoke from conventional cigarettes (Tucker et al. 2014; Ambrose et al. 2015; 

Kong et al. 2015; McDonald and Ling 2015; Suris et al. 2015; 

Sutfin et al. 2015). Using e-cigarettes as an aid to conventional cigarette smoking reduction/cessation (Li et al. 2013; 

Schmidt et al. 2014; Tucker et al. 2014) was not a primary 

motivator among youth and young adults. Youth and young 

adult smokers cited lack of satisfaction, poor taste, and cost 

(Kong et al. 2015) as reasons for discontinuing e-cigarette 

use. Additional research is needed to examine how reasons 

for use, including the appeal of flavored e-cigarettes, are 

causally related to the onset and progression of e-cigarette 

use among youth and young adults. Data from the first 

wave of the PATH study suggest that flavors may play an 

important role in the initiation of e-cigarette use among 

youth (Ambrose et al. 2015), while data from the 2014 

NYTS (Corey et al. 2015) and 2013–2014 NATS (Table 2.9) 

underscore that use of flavored e-cigarettes remains prevalent among youth and young adults who currently use 

e-cigarettes.
A Report of the Surgeon General

88 Chapter 2

Conclusions

1. Among middle and high school students, both ever 

and past-30-day e-cigarette use have more than tripled since 2011. Among young adults 18–24 years 

of age, ever e-cigarette use more than doubled from 

2013 to 2014 following a period of relative stability 

from 2011 to 2013.

2. The most recent data available show that the prevalence of past-30-day use of e-cigarettes is similar 

among high school students (16% in 2015, 13.4% in 

2014) and young adults 18–24 years of age (13.6% in 

2013–2014) compared to middle school students 

(5.3% in 2015, 3.9% in 2014) and adults 25 years of 

age and older (5.7% in 2013–2014).

3. Exclusive, past-30-day use of e-cigarettes among 

8th-, 10th-, and 12th-grade students (6.8%, 10.4%, 

and 10.4%, respectively) exceeded exclusive, 

past-30-day use of conventional cigarettes in 2015 

(1.4%, 2.2%, and 5.3%, respectively). In contrast—

in 2013–2014 among young adults 18–24 years of 

age—exclusive, past-30-day use of conventional cigarettes (9.6%) exceeded exclusive, past-30-day use of 

e-cigarettes (6.1%). For both age groups, dual use of 

these products is common.

4. E-cigarette use is strongly associated with the 

use of other tobacco products among youth and 

young adults, particularly the use of combustible 

tobacco products. For example, in 2015, 58.8% of 

high school students who were current users of 

combustible tobacco products were also current 

users of e-cigarettes.

5. Among youth—older students, Hispanics, and 

Whites are more likely to use e-cigarettes than 

younger students and Blacks. Among young 

adults—males, Hispanics, Whites, and those with 

lower levels of education are more likely to use 

e-cigarettes than females, Blacks, and those with 

higher levels of education.

6. The most commonly cited reasons for using 

e-cigarettes among both youth and young adults are 

curiosity, flavoring/taste, and low perceived harm 

compared to other tobacco products. The use of 

e-cigarettes as an aid to quit conventional cigarettes 

is not reported as a primary reason for use among 

youth and young adults.

7. Flavored e-cigarette use among young adult current 

users (18–24 years of age) exceeds that of older adult 

current users (25 years of age and older). Moreover, 

among youth who have ever tried an e-cigarette, a 

majority used a flavored product the first time they 

tried an e-cigarette.

8. E-cigarette products can be used as a delivery 

system for cannabinoids and potentially for other 

illicit drugs. More specific surveillance measures are 

needed to assess the use of drugs other than nicotine 

in e-cigarettes.
Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 89

E-Cigarette Use Among Youth and Young Adults

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95

Chapter 3

Health Effects of E‐Cigarette Use Among U.S. Youth and 

Young Adults

Introduction 97

Conclusions from Previous Surgeon General’s Reports 97

Health Effects of E‐Cigarette Use 100

Effects of Aerosol Inhalation by the E‐Cigarette User 100

Dose and Effects of Inhaling Aerosolized Nicotine 100

Aerosolized Nicotine and Cardiovascular Function 101

Aerosolized Nicotine and Dependence 102

Effects of Nicotine in Youth Users 104

Nicotine Exposure from Maternal Nicotine Consumption: Prenatal and Postnatal Health Outcomes 108

Summary 113

Effects of the Inhalation of Aerosol Constituents Other than Nicotine 114

Aerosolized Nicotine‐Related Compounds 114

Aerosolized Solvents 115

Aerosolized Flavorants 115

Aerosolized Adulterants 116

Summary 117

Effects of Toxicants Produced During Aerosolization 118

Summary 119

Effects Not Involving Inhalation of Aerosol by the E‐Cigarette User 119

Health Effects Attributable to Explosions and Fires Caused by E‐Cigarettes 119

Health Effects Caused by Ingestion of E‐Cigarette Liquids 119

Secondhand Exposure to the Constituents of E‐Cigarette Aerosol 120

Exposure to Nonusers 120

Movement of E‐Cigarette Aerosol 121

Exposure to E‐Cigarette Aerosol and Considerations of Dose 121

Health Effects of Secondhand Exposure to E‐Cigarette Aerosols 122

Evidence Summary 124

Conclusions 125

References 126

Health Effects of E-Cigarette Use Among U.S. Youth and Young Adults 97

E-Cigarette Use Among Youth and Young Adults

Introduction

This chapter focuses on the short‐term and poten‐ regarding harmful consequences of close contact with 

tial long‐term health effects related to the incidence and malfunctioning e‐cigarette devices and ingestion of the 

continued use of electronic cigarettes (e‐cigarettes) by nicotine‐containing liquids (e‐liquids) are also explored. 

youth and young adults. The sharp increase in the preva‐ This chapter examines available data on e‐cigarettes and 

lence of e‐cigarette use among youth and young adults, youth, reviews established human and animal data on 

especially from 2011 to 2015 (Centers for Disease Control harmful developmental effects of nicotine (prenatal and 

and Prevention [CDC] 2015, 2016), highlights the com‐ adolescent), and reviews data on e‐cigarettes among adults 

pelling need to learn more about this evolving class of when data on youth are not available. Of note, given the 

products. This chapter highlights the scientific litera‐ relatively recent emergence of e‐cigarettes, data are not 

ture that addresses potential adverse health effects caused yet available that address the long‐term health effects of 

by direct exposure to aerosolized nicotine, flavorants, use or exposure over several years compared with nonuse 

chemicals, and other particulates of e‐cigarettes; sec‐ or exposure to air free from secondhand tobacco smoke 

ondhand exposure to e‐cigarette aerosol; and exposure to and aerosol from e‐cigarettes; thus, the discussion is lim‐

the surface‐deposited aerosol contaminants. Literature ited in that regard.

Conclusions from Previous Surgeon General’s Reports

This chapter comprehensively reviews a new and 

emerging body of scientific evidence related to the use 

of e‐cigarettes by youth and young adults. The enormous 

knowledge base on tobacco smoking and human health 

is also relevant to this discussion. That literature, which 

has been accumulating for more than 50 years, provides 

incontrovertible evidence that smoking is a cause of dis‐

ease in almost every organ of the body (U.S. Department 

of Health and Human Services [USDHHS] 2004, 2014). 

Laboratory research has characterized the components 

of tobacco smoke and probed the mechanisms by which 

these constituents cause addiction and injury to cells, tis‐

sues, organs, and the developing fetus.

The evidence on the harmful consequences of nic‐

otine exposure in conventional cigarettes, including 

addiction, and other adverse effects, is particularly rel‐

evant to e‐cigarettes. Nicotine doses from e‐cigarettes 

vary tremendously depending on characteristics of the 

user (experience with smoking conventional cigarettes 

or e‐cigarettes), technical aspects of the e‐cigarette, and 

levels of nicotine in the e‐liquid. Although studies of nico‐

tine doses in youth and young adults are lacking, studies 

of adults have found delivery of nicotine from e‐cigarettes 

in doses ranging from negligible to as large as (Lopez 

et al. 2016; Vansickel and Eissenberg 2013; Spindle et al. 

2015; St. Helen et al. 2016) or larger than (Ramôa et al. 

2016) conventional cigarettes. Similarly, passive exposure 

to secondhand nicotine from e‐cigarettes is just as large 

(Flouris et al. 2013) or lower than (Czogala et al. 2014) 

conventional cigarettes.

The findings of scientific research on smoking 

and involuntary exposure to tobacco smoke have been 

reviewed thoroughly in the 32 reports on smoking and 

health produced by the Surgeon General to date (there is 

one report on smokeless tobacco) (Table 3.1). The land‐

mark first report was published in 1964 (U.S. Department 

of Health, Education, and Welfare [USDHEW] 1964), and 

the 50th‐anniversary report, released in January 2014, 

comprehensively covered multiple aspects of cigarette 

smoking and health and lengthened the list of diseases 

caused by smoking and involuntary exposure to tobacco 

smoke (USDHHS 2014). Other Surgeon General’s reports 

that are particularly relevant to the present report include 

reports on the health consequences of smoking and 

involuntary exposure to tobacco smoke (USDHHS 2004, 

2006), on the mechanisms by which smoking causes dis‐

ease (USDHHS 2010), and on the health consequences 

of smoking on youth and young adults (USDHHS 1994, 

2012). The Surgeon General’s reports on smoking and 

health have provided powerful conclusions on the dangers 

of nicotine. The 1988 report, released by Surgeon General 

C. Everett Koop, was the first to characterize smoking 

as addictive, and it identified nicotine as “...the drug in 

tobacco that causes addiction” (Appendix 3.1)1

1All appendixes and appendix tables that are cross‐referenced in this chapter are available only online at http://www.surgeongeneral.gov/

library/reports/

 (USDHHS 

1988, p. 9).
A Report of the Surgeon General

98 Chapter 3

Table 3.1 Relevant conclusions from previous Surgeon General’s reports on smoking and health

Report Year Conclusions

The Health 

Consequences of 

Smoking: Nicotine 

Addiction (USDHHS 

1988, p. 9)

1988 Major Conclusions

1. Cigarettes and other forms of tobacco are addicting.

2. Nicotine is the drug in tobacco that causes addiction.

3. The pharmacologic and behavioral processes that determine tobacco addiction are similar 

to those that determine addiction to drugs such as heroin and cocaine.

How Tobacco Smoke 

Causes Disease: The 

Biology and Behavioral 

Basis for SmokingAttributable Disease

(USDHHS 2010, p. 183)

2010 Chapter 4. Nicotine Addiction: Past and Present

1. Nicotine is the key chemical compound that causes and sustains the powerful addicting 

effects of commercial tobacco products.

2. The powerful addicting effects of commercial tobacco products are mediated by diverse 

actions of nicotine at multiple types of nicotinic receptors in the brain.

3. Evidence is suggestive that there may be psychosocial, biologic, and genetic determinants 

associated with different trajectories observed among population subgroups as they move 

from experimentation to heavy smoking.

4. Inherited genetic variation in genes such as CYP2A6 contributes to the differing patterns of 

smoking behavior and smoking cessation. 

5. Evidence is consistent that individual differences in smoking histories and severity of 

withdrawal symptoms are related to successful recovery from nicotine addiction.

Preventing Tobacco 

Use Among Youth and 

Young Adults (USDHHS 

2012, pp. 8, 460)

2012 Major Conclusions

1. Cigarette smoking by youth and young adults has immediate adverse health consequences, 

including addiction, and accelerates the development of chronic diseases across the full life 

course.

2. Prevention efforts must focus on both adolescents and young adults because among adults 

who become daily smokers, nearly all first use of cigarettes occurs by 18 years of age 

(88%), with 99% of first use by 26 years of age.

3. Advertising and promotional activities by tobacco companies have been shown to cause the 

onset and continuation of smoking among adolescents and young adults.

4. After years of steady progress, declines in the use of tobacco by youth and young adults 

have slowed for cigarette smoking and stalled for smokeless tobacco use.

5. Coordinated, multicomponent interventions that combine mass media campaigns, 

price increases including those that result from tax increases, school‐based policies and 

programs, and statewide or community‐wide changes in smokefree policies and norms are 

effective in reducing the initiation, prevalence, and intensity of smoking among youth and 

young adults. 

Chapter 4. Social, Environmental, Cognitive, and Genetic Influences on the Use of Tobacco 

Among Youth

1. Given their developmental stage, adolescents and young adults are uniquely susceptible to 

social and environmental influences to use tobacco.

2. Socioeconomic factors and educational attainment influence the development of youth 

smoking behavior. The adolescents most likely to begin to use tobacco and progress to 

regular use are those who have lower academic achievement.

3. The evidence is sufficient to conclude that there is a causal relationship between peer 

group social influences and the initiation and maintenance of smoking behaviors during 

adolescence.

4. Affective processes play an important role in youth smoking behavior, with a strong 

association between youth smoking and negative affect.

5. The evidence is suggestive that tobacco use is a heritable trait, more so for regular use 

than for onset. The expression of genetic risk for smoking among young people may be 

moderated by small‐group and larger social‐environmental factors.
Health Effects of E-Cigarette Use Among U.S. Youth and Young Adults 99

E-Cigarette Use Among Youth and Young Adults

Report Year Conclusions

The Health 

Consequences of 

Smoking—50 Years 

of Progress (USDHHS 

2014, p. 126)

2014 Chapter 5: Nicotine

1. The evidence is sufficient to infer that at high‐enough doses nicotine has acute toxicity.

2. The evidence is sufficient to infer that nicotine activates multiple biological pathways 

through which smoking increases risk for disease.

3. The evidence is sufficient to infer that nicotine exposure during fetal development, 

a critical window for brain development, has lasting adverse consequences for brain 

development.

4. The evidence is sufficient to infer that nicotine adversely affects maternal and fetal health 

during pregnancy, contributing to multiple adverse outcomes such as preterm delivery and 

stillbirth.

5. The evidence is suggestive that nicotine exposure during adolescence, a critical window for 

brain development, may have lasting adverse consequences for brain development.

6. The evidence is inadequate to infer the presence or absence of a causal relationship 

between exposure to nicotine and risk for cancer.

Note: USDHHS = U.S. Department of Health and Human Services.

Table 3.1 Continued

Subsequent reports expanded on the conclusions 

in the 1988 report related to nicotine—reaffirming that 

nicotine causes addiction, describing nicotine’s effects on 

key brain receptors (USDHHS 2010), and emphasizing 

that youth are more sensitive to nicotine than adults 

and can become dependent to nicotine much faster than 

adults (USDHHS 2012). This is of particular concern in 

the context of e‐cigarettes because blood nicotine levels 

in e‐cigarette users have been reported as being compa‐

rable to or higher than levels in smokers of conventional 

cigarettes (Lopez et al. 2016; Spindle et al. 2015), and 

serum cotinine (a nicotine metabolite) levels have been 

reported as being equal to that found in conventional ciga‐

rette users (Etter 2016; Marsot and Simon 2016). Because 

of their sensitivity to nicotine and subsequent addiction, 

about 3  out of 14 young smokers end up smoking into 

adulthood, even if they intend to quit after a few years; 

among youth who continue to smoke as adults, one‐

half will die prematurely from smoking (Peto et al. 1994; 

CDC 1996; Hahn et al. 2002; Doll et al. 2004). Surgeon 

General’s reports have also emphasized the critical role 

of environmental determinants of tobacco use, including 

the causal roles of the tobacco industry’s advertising and 

promotional activities and of the peer social environment 

(USDHHS 2012).

The review documented the broad biological activity of 

nicotine, which can activate multiple biological path‐

ways, and the adverse effects of nicotine exposure during 

pregnancy on fetal development and during adolescence 

on brain development. Of concern with regard to cur‐

rent trends in e‐cigarette use among youth and young 

adults, the evidence suggests that exposure to nicotine 

during this period of life may have lasting deleterious con‐

sequences for brain development, including detrimental 

effects on cognition (USDHHS 2014).

The 2014 Surgeon General’s report included a 

chapter that addressed the numerous adverse conse‐

quences of nicotine other than addiction (USDHHS 2014). 

Finally, the aerosol from e‐cigarettes may include 

other components that have been addressed in previous 

Surgeon General’s reports, such as tobacco‐specific nitro‐

samines (TSNAs), acrolein, and formaldehyde (USDHEW 

1979; USDHHS 2010). Aerosols generated with vapor‐

izers contain up to 31 compounds, including nicotine, 

nicotyrine, formaldehyde, acetaldehyde glycidol, acro‐

lein, acetol, and diacetyl (Sleiman et al. 2016). Glycidol 

is a probable carcinogen not previously identified in the 

vapor, and acrolein is a powerful irritant (Sleiman et al. 

2016). Although these constituents have been identified in 

e‐cigarette aerosol, current evidence is unclear on whether 

typical user dosages achieve levels as high as conventional 

cigarettes, or at harmful or potentially harmful levels. 

More information will be available in the coming years 

as e‐cigarette manufacturers begin reporting harmful or 

potential harmful constituents in compliance with the 

Tobacco Control Act.
A Report of the Surgeon General

100 Chapter 3

Health Effects of E‐Cigarette Use

The potential adverse health effects for youth who 

inhale e‐cigarette aerosol include those on the body from 

acute administration of nicotine, flavorants, chemicals, 

other particulates, and additional effects, such as (1) nico‐

tine addiction; (2) developmental effects on the brain from 

nicotine exposure, which may have implications for cog‐

nition, attention, and mood; (3) e‐cigarette influence ini‐

tiating or supporting the use of conventional cigarettes 

and dual use of conventional cigarettes and e‐cigarettes; 

(4)  e‐cigarette influence on subsequent illicit drug use;

(5) e‐cigarette effects on psychosocial health, particularly 

among youth with one or more comorbid mental health 

disorders; and (6) battery explosion and accidental overdose 

of nicotine.

Effects of Aerosol Inhalation by the 

E‐Cigarette User

Determining the potential health effects of inhaling 

e‐cigarette aerosol is challenging due to the number of pos‐

sible combinations of customizable options (Seidenberg 

et al. 2016), including battery power, nicotine concentra‐

tion, e‐liquids (Goniewicz et al. 2015; Buettner‐Schmidt 

et al. 2016), and use behaviors and puff topography (Dawkins 

et al. 2016; Lopez et al. 2016). The amount of nicotine, fla‐

vorants, and other e‐liquid constituents in e‐cigarettes 

available for consumers to purchase varies widely, and the 

aerosolized constituents delivered vary by the type and 

voltage of the e‐cigarette device being used (Cobb et al. 

2015). Studies of commercial products have shown that 

e‐liquids can contain as little as 0 milligrams/milliliter 

(mg/mL) to as much as 36.6 mg/mL of nicotine (Goniewicz 

et al. 2015); can be mislabeled (Peace et al. 2016); can vary 

by propylene glycol (PG)/vegetable glycerin (VG) ratio; and 

can contain one or more of several thousand available fla‐

vorants (Zhu et al. 2014b). Some liquids intended for use in 

e‐cigarettes contain adulterants not named on ingredient 

lists (Varlet et al. 2015), and under at least some user con‐

ditions, the aerosolization process, which involves heating, 

produces additional toxicants that may present health risks 

(Talih et al. 2015). The sections that follow comprehen‐

sively cover the effects of inhaling aerosolized nicotine and 

then consider what is known about solvents (i.e., PG and 

VG, flavorants, and other chemicals) added to e‐cigarettes, 

adulterants in e‐liquids formed in the nicotine extraction 

process (e.g., N‐nitrosonornicotine), and toxicants formed 

during the heating and aerosolization process (e.g., acro‐

lein and formaldehyde) (Sleiman et al. 2016).

Dose and Effects of Inhaling Aerosolized Nicotine

Nicotine addiction via e‐cigarette use is a primary 

public health concern due to the exponential growth in 

e‐cigarette use among youth. The potential for widespread 

nicotine addiction among youth is high, as are the harmful 

consequences of nicotine on fetal development and the 

developing adolescent brain (USDHHS 2014). Nicotine, a 

psychomotor stimulant drug, is the primary psychoactive 

and addictive constituent in the smoke of conventional 

cigarettes and an important determinant in maintaining 

smoking dependence (e.g., USDHHS 2014). E‐liquids 

typically contain nicotine, although in more widely vari‐

able concentrations than those found in conventional 

cigarettes (Trehy et al. 2011; Cameron et al. 2014; Cheng 

2014; Goniewicz et al. 2015; Marsot and Simon 2016). The 

concentration of liquid nicotine is only one factor that 

influences the amount of aerosolized nicotine available 

for inhalation (Lopez et al. 2016); other factors include 

the power of the device being used (e.g., battery voltage, 

heater resistance) and user behavior (e.g., puff duration, 

interpuff interval) (Shihadeh and Eissenberg 2015; Talih 

et al. 2016; Etter 2016). The interplay of these factors may 

help to explain the variability in plasma nicotine concen‐

tration when adults use e‐cigarettes under controlled con‐

ditions which can be higher (Ramôa et al. 2016), lower 

(Bullen et al. 2010; Vansickel et al. 2010, 2012; Farsalinos 

et al. 2014b; Nides et al. 2014; Oncken et al. 2015; Yan 

and D’Ruiz 2015), or similar to those obtained by smoking 

conventional cigarettes (Vansickel and Eissenberg 2013; 

Spindle et al. 2015; St. Helen et al. 2016; see Figure 3.1). 

Generalization across studies is difficult due to variations 

in devices, e‐liquids, and e‐cigarette use behavior within 

the study sample. As demonstrated in Figure 3.1, in studies 

where a variety of products were used under similar labo‐

ratory conditions (i.e., blood sampling before and imme‐

diately after a 10‐puff episode), there was wide variability 

in nicotine delivery between devices, with “cigalike” prod‐

ucts (cigarette‐like products) delivering less nicotine than 

“tank” products (Farsalinos et al. 2014b; Yan and D’Ruiz 

2015), and low‐resistance, dual‐coil “cartomizer” prod‐

ucts having the capacity to deliver less or more nicotine 

than a conventional cigarette, depending on the concen‐

tration of liquid nicotine (Ramôa et al. 2016).

When the device type and liquid dose were held con‐

stant in a controlled session in one study, plasma nico‐

tine concentrations (in this case in nanograms [ng]/mL) 

varied considerably across participants (0.8 to 8.5 ng/mL) 

(Nides et al. 2014). This variation was likely attributable 

to the manner in which the users puffed when using 
Health Effects of E-Cigarette Use Among U.S. Youth and Young Adults 101

E-Cigarette Use Among Youth and Young Adults

e‐cigarettes, or that person’s “puff topography,” which 

includes the number of puffs, the intake volume and dura‐

tion, the interpuff interval, and the flow rate (Zacny and 

Stitzer 1988; Blank et al. 2009).

Available data suggest that puff durations among 

adult cigarette smokers who are new e‐cigarette users 

are comparable to those observed with conventional cig‐

arettes (at least about 2 seconds [sec]) (Farsalinos et al. 

2013b; Hua et  al. 2013; Norton et  al. 2014). However, 

puff durations during e‐cigarette use among experienced 

e‐cigarette users may be twice as long (~4 sec) (Farsalinos 

et al. 2013b; Hua et al. 2013; Spindle et al. 2015) as puff 

duration during conventional cigarette use. Puff duration 

is directly related to the nicotine content of the e‐cigarette 

aerosol (i.e., the yield or dose) (Talih et  al. 2016), sug‐

gesting that smokers of conventional cigarettes who switch 

to e‐cigarettes may increase the duration of their puffs 

when using the new product in an attempt to extract more 

nicotine. Research also suggests that cigarette smokers 

may learn to alter other aspects of their puffing behavior 

when using an e‐cigarette (Spindle et al. 2015). Relative 

to smokers of conventional cigarettes (Kleykamp et  al. 

2008), experienced e‐cigarette users were found to have 

puff volumes that were significantly higher (101.4 mL vs. 

51.3 mL) and puff flow rates that were significantly lower 

(24.2 mL/sec vs. 37.9 mL/sec) (Spindle et al. 2015). In a 

different study, adult cigarette smokers who had never 

used e‐cigarettes but switched to e‐cigarettes showed sig‐

nificantly increased puff durations and decreased puff flow 

rates within 1 week (Lee et al. 2015). Elsewhere, adult cig‐

arette smokers given an e‐cigarette appeared to show an 

enhanced ability to extract nicotine from their device after 

4 weeks of use (Hajek et al. 2015). Thus, the health effects 

of aerosolized nicotine in e‐cigarette users may depend on 

a variety of factors, including the e‐liquid used, the user’s 

behavior, and the user’s experience with the product.

Aerosolized Nicotine and Cardiovascular Function

Smoking is a major cause of death from cardiovas‐

cular disease (USDHHS 2014), and exposure to nicotine 

has been identified as a potential initiating factor in the 

atherogenic process (Lee et al. 2011; Santanam et al. 2012; 

Benowitz and Burbank 2016). Acute administration of 

nicotine causes a variety of well‐characterized, dose‐ and 

route‐dependent effects in adults, including cardiovascular 

effects, such as increases in heart rate and blood pressure 

(BP) and greater cardiac output, leading to an increase 

in myocardial oxygen demand (Rosenberg et  al. 1980; 

USDHHS 2014). Reports from cell biology and animal 

studies have established biologic plausibility between nic‐

otine alone and negative cardiovascular effects (Hanna 

2006; Santanam et  al. 2012). These studies have shown 

that nicotine induces the production of various inflam‐

matory mediators involved with atherosclerotic patho‐

genesis (Lau and Baldus 2006), and that at the cellular 

level, nicotine induces C‐reactive protein (CRP) expres‐

sion in macrophages that contribute pro‐inflammatory 

and pro‐atherosclerotic effects (Mao et al. 2012).

Long‐term studies on the safety of nicotine‐only 

exposure (e.g., as with using e‐cigarettes rather than 

smoking conventional cigarettes) among youth have not 

been conducted, and little is known about the cardiovas‐

cular effects of e‐cigarette use among adults. However, 

when e‐cigarettes are accompanied by a measurable 

increase in plasma nicotine concentration, it increases 

heart rate (Vansickel et al. 2012; Vansickel and Eissenberg 

2013; Nides et al. 2014; Yan and D’Ruiz 2015), and dia‐

stolic BP rises.

Given the paucity of long‐term data on the impact of 

e‐cigarette smoking in relation to cardiovascular disease, 

other nicotine products offer a useful analogy. A meta‐

analysis reported that replacing the consumption of con‐

ventional cigarettes with nicotine replacement therapy 

(NRT) reduces cardiovascular risk among former smokers 

without significant adverse consequences (compared with 

current smokers) (Greenland et  al. 1998; Moore et  al. 

2009). However, most NRT use is temporary (<26 months), 

and the adverse consequences of longer term NRT therapy 

are unknown.

Elsewhere, investigators examined the relationship 

between the use of Swedish‐type moist snuff (or “snus”), 

which contains high levels of nicotine and low levels of 

TSNAs, and the incidence of acute myocardial infarction 

among men with a mean age of 35 years who had never 

smoked cigarettes. The researchers, who pooled data from 

eight prospective cohort studies, found no support for 

any association between the use of snus and the develop‐

ment of acute myocardial infarction (Hansson et al. 2012), 

regardless of timing, intensity, duration, or period of use 

among the men who were followed for 4–29 years.

In summary, despite overwhelming epidemiologic 

evidence linking the use of conventional cigarettes with 

cardiovascular disease, the precise components of cig‐

arette smoke responsible for this relationship and the 

mechanisms by which they exert their effects have not yet 

been fully explained (Hanna 2006). For e‐cigarettes, bio‐

logical data support a potential association with cardio‐

vascular disease, and short‐term use of these products is 

accompanied by a measurable increase in plasma nicotine 

concentrations in adults as well as increases in heart rate 

and blood pressure. Much more research is needed, but the 

limited data available suggest the typical cardiovascular 

effects exerted by nicotine are also exerted by e‐cigarettes 

(Benowitz and Burbank 2016; Bhatnagar 2016).
A Report of the Surgeon General

102 Chapter 3

Aerosolized Nicotine and Dependence

Although a great deal is known about self‐

administration of nicotine and the development of nicotine 

dependence among adults (USDHHS 2014) and youth (Colby 

et al. 2000; USDHHS 2012; O’Loughlin et al. 2014; Yuan et al. 

2015), more research is needed on nicotine dependence in 

youth and young adults as a result of using e‐cigarettes. 

Nicotine dependence, also referred to as nicotine addic‐

tion (USDHHS 2010) or tobacco use disorder (American 

Psychiatric Association [APA] 2013), is defined as a neu‐

robiological adaptation to repeated drug exposure that is 

manifested behaviorally by highly controlled or compulsive 

use; psychoactive effects such as tolerance, physical depen‐

dence, and pleasant effect; and nicotine‐reinforced behavior, 

including an inability to quit despite harmful effects, a 

desire to quit, and repeated cessation attempts (USDHHS 

1988; APA 2013). In tobacco‐dependent users of conven‐

tional cigarettes, a predictable consequence of short‐term 

abstinence (e.g., for more than a few hours) is the onset 

of withdrawal symptoms indicated by self‐reported behav‐

ioral, cognitive, and physiological symptoms and by clinical 

signs (USDHHS 2010). Subjective withdrawal symptoms 

are manifested by affective disturbance, including irrita‐

bility and anger, anxiety, and depressed mood. The behav‐

ioral symptoms include restlessness, sleep disturbance, and 

increased appetite. Cognitive disturbances usually center 

on difficulty in concentrating (USDHHS 2010).

Early studies of conventional cigarette smokers 

using e‐cigarettes reported poor nicotine delivery with 

little to no increase in blood nicotine levels after puffing 

(Eissenberg 2010; Vansickel et al. 2010). Later studies 

reported that the effect on serum cotinine levels among 

new e‐cigarette users can be similar to that generated by 

conventional cigarettes (Flouris et al. 2013; Lopez et al. 

2016). Studies examining this discrepancy found that 

e‐cigarette users require longer puffs to deliver equivalent 

nicotine doses (Lee et al. 2015), and within a week, inex‐

perienced e‐cigarette users adjust their puffing patterns 

after switching (Hua et al. 2013b; Lee et al. 2015; Talih 

et al. 2015).

In more experienced e‐cigarette users, blood nico‐

tine levels appear to be influenced by puffing patterns, 

such as puff length. Volume and frequency and plasma 

nicotine levels ranging from 2.50 to 13.4 ng/mL have 

been observed after 10 puffs of an e‐cigarette (Dawkins 

and Corcoran 2014). Dawkins and colleagues (2016) used 

24  mg/mL nicotine strength liquid and observed high 

blood nicotine levels that were achieved very quickly, 

matching and even exceeding those reported in conven‐

tional cigarette smokers. St. Helen and colleagues (2016) 

conducted a similar study and reported that e‐cigarettes 

can deliver levels of nicotine that are comparable to or 

higher than conventional cigarettes. Finally, Etter (2016) 

reported cotinine levels among experienced e‐cigarette 

users similar to levels usually observed in conven‐

tional cigarette smokers. Figure 3.1 and Table A3.1‐1 in 

Appendix  3.1 summarize studies on aerosolized nico‐

tine from e‐cigarettes and dependence using dependency 

criteria.

The ability of e‐cigarettes to deliver comparable or 

higher amounts of nicotine compared to conventional 

cigarettes raises concerns about e‐cigarette use gener‐

ating nicotine dependence among young people (Dawkins 

et al. 2016; Etter 2016; St. Helen et al. 2016). The reported 

blood levels of nicotine, or cotinine, in e‐cigarette users 

is likely to cause physiological changes in nicotinic ace‐

tylcholine receptors in the brain that would sustain nico‐

tine addiction (Kandel and Kandel 2014; Yuan et al. 2015). 

This is particularly concerning for adolescents and young 

adults, given that early exposure to nicotine increases the 

severity of future nicotine dependence (St. Helen et al. 

2016; USDHHS 2014).

Symptoms of nicotine dependence can occur soon 

after the initiation of conventional smoking, and even 

before established use, among adolescents and young 

adults (DiFranza et al. 2002; O’Loughlin et al. 2003; 

Dierker et al. 2007; Ramôa et al. 2016). Furthermore, 

some adolescents have reported nicotine dependence 

symptoms while using tobacco as little as 1–3 days per 

month (Rose et al. 2010). Using the National Comorbidity 

Survey‐Adolescent dataset, Dierker and colleagues (2012) 

reported that nicotine dependence in adolescents was 

likely to occur within 1 year of the initiation of weekly or 

daily smoking, regardless of sociodemographic variables. 

Importantly, when smoking onset began at a younger 

age, the transition to weekly and daily smoking was more 

rapid, indicating a youthful neurobiological sensitivity to 

nicotine (Dierker et al. 2012). Zhan and colleagues (2012) 

found that symptoms of nicotine dependence could be 

detected among teenagers before they had smoked even 

100 cigarettes.

Because few validated measures exist for assessing 

dependence on e‐cigarette use, some researchers have 

adapted those originally developed to measure dependence 

in smokers of conventional cigarettes. Among adults, 

scores on these measures have been consistently lower 

in e‐cigarette users than in smokers of conventional ciga‐

rettes (Farsalinos et al. 2013a; Etter and Eissenberg 2015; 

Foulds et al. 2015). Still, scores for e‐cigarette dependence 

among former cigarette smokers were positively associ‐

ated with the nicotine concentration of the e‐cigarette 

liquid and the type of device used (Etter 2015; Etter and 

Eissenberg 2015; Foulds et  al. 2015). Research in this 

area is challenging to interpret because measurement of 

youth e‐cigarette dependence has not been standardized
Health Effects of E-Cigarette Use Among U.S. Youth and Young Adults 103

E-Cigarette Use Among Youth and Young Adults

Figure 3.1 Plasma nicotine concentration from different human laboratory studies and four different products with 

blood sampled before and immediately after a 10‐puff bout with the products

Source: Vansickel et al. (2010); Farsalinos et al. (2014b); Yan and D’Ruiz (2015); and Ramôa et al. (2016).

Notes: Data for conventional cigarettes are from 32 tobacco cigarette smokers using their usual brand of cigarette (Vansickel et al. 2010). 

E‐cigarette A is a cigalike called “blu” loaded with two different concentrations of liquid nicotine (16 or 24 mg/mL, both containing 20% 

propylene glycol and 50% vegetable glycerin). Data are from 23 smokers of tobacco cigarettes with 7 days of experience with the e‐cigarette 

product (Yan and D’Ruiz 2015). E‐cigarette B is a cigalike called “V2cigs”, and E‐cigarette C is a “tank” product called “EVIC” with an “Evod” 

heating element; both were loaded with an 18 mg/mL liquid containing 34% propylene glycol and 66% vegetable glycerin. Data are from 23 

experienced users of e‐cigarettes (Farsalinos et al. 2014b). E‐cigarette D uses a 3.3‐volt “Ego” battery fitted with a 1.5‐Ohm dual coil carto‐

mizer (“Smoktech”) and filled with ~1 mL of a 70% propylene glycol, 30% vegetable glycerin liquid that varied by liquid nicotine concentra‐

tion (0, 8, 18, or 36 mg/mL). Data are from 16 experienced users of e‐cigarettes (Ramôa et al. 2016).
A Report of the Surgeon General

104 Chapter 3

(Continued from last paragraph on page 102.)

and there is a wide variation in device/e‐liquid combina‐

tions, which allow for adjustable nicotine delivery among

study participants. Regardless, among 766 adults, who

were daily users of e‐cigarettes (with nicotine) and who

were either former cigarette smokers (83%) or current

cigarette smokers (17%), 30.7% indicated that they would

likely be unable to stop using e‐cigarettes, 28.2% that they

would find it “very difficult” or “impossible” to stop using

e‐cigarettes, and 27.5% that they were unable to stop

e‐cigarette use (Etter and Eissenberg 2015). However, it

is important to note that e‐cigarettes were less addictive

than conventional cigarettes in this sample (Etter and

Eissenberg 2015).

In summary, the addictive liability of e‐cigarettes 

has the potential to be at least equivalent to that of con‐

ventional cigarettes, given nicotine dose levels produced 

by these products, particularly among experienced users 

operating new‐generation devices (Ramôa et al. 2016). 

More generally, the delivery of nicotine in sufficient doses 

and blood concentration would be expected to produce 

and maintain dependence in e‐cigarette users. Further 

work would be useful to determine the natural course 

and history of e‐cigarette use among smokers of conven‐

tional cigarettes, former smokers, and never smokers and 

to more accurately determine the nicotine addiction lia‐

bility of e‐cigarette use. Unfortunately, these issues have 

not been explored in adolescents, although the prevalence 

of e‐cigarette use has increased considerably in that popu‐

lation since 2011 (see Chapter 2).

Effects of Nicotine in Youth Users

Nicotine is the prime psychoactive substance in con‐

ventional cigarettes (Yuan et al. 2015), and given that the 

developing adolescent brain is immature and vulnerable 

to neurobiological insults (Bernheim et  al. 2013; Lydon 

et al. 2014), it is important to understand how nicotine 

delivered by e‐cigarette use affects adolescent brain devel‐

opment and how responses to nicotine in adolescents 

differ from those seen in adults. Substantial evidence sug‐

gests that nicotine can negatively influence both adoles‐

cent and prenatal brain development (USDHHS 2014). 

For example, Weiss and colleagues (2008) reported a 

strong mechanistic link among early nicotine exposure 

(younger than 16 years of age), common genes related to 

the severity of nicotine addiction (CHRNA5‐A3‐B4 hap‐

lotypes), and adult nicotine addiction in three indepen‐

dent populations of European origins. Although much of 

the literature on nicotine addiction arises from studies 

of nicotine exposure among adults, and with combus‐

tible tobacco products (see Table A3.1‐2 in Appendix 3.1), 

there is a growing body of biological mechanistic litera‐

ture from animal studies that model the effects of nicotine 

in doses equivalent to those for humans (see Table A3.1‐3 

in Appendix 3.1). These animal and human studies, taken 

together with studies of rising e‐cigarette prevalence in 

youth (see Chapter 2), point to an age‐dependent suscep‐

tibility to nicotine as a neurobiological insult.

Limited direct human experimental data exist on 

the effects of nicotine exposure from e‐cigarettes on the 

developing adolescent brain, but experimental laboratory 

data have been found to be relevant in animal models to 

contextualize effects in humans (Stevens and Vaccarino 

2015). Even if the full complexity of human brain develop‐

ment and behavioral function during adolescence cannot 

be completely modeled in other species, the similarities 

across adolescents of different species support the use of 

animal models of adolescence when examining neural and 

environmental contributors to adolescent‐characteristic 

functioning (Spear 2010).

Animal studies provide an effective method to 

examine the persistent effects of prenatal, child, and ado‐

lescent nicotine exposure, in addition to human epide‐

miologic data. When considering an epidemiologic causal 

argument of exposure (risk factor) to health outcome (dis‐

ease), one should note that animal models lend biolog‐

ical plausibility when experimentation with humans is not 

possible (or ethical) (Rothman et al. 2008). Furthermore, 

animal studies offer significant advantages compared to 

human studies—with the ability to control for many con‐

founding factors, to limit nicotine exposure to differing 

levels of physical and neural development—and are piv‐

otal for understanding the neural substrates associated 

with adolescence. The validity of any causal argument 

when examining animal models requires careful consider‐

ation, and yet in combination with epidemiologic data—

such as prevalence, incidence, and strength of association 

between exposure and outcome—a causal argument can 

be constructed with literature from animal models rep‐

resenting biologic plausibility. Using a variety of study 

designs and research paradigms including humans and 

animals, research in this area provides evidence for neu‐

roteratogenic and neurotoxic effects on the developing 

adolescent brain (Lydon et al. 2014; England et al. 2015).

The brain undergoes significant neurobiological 

development during adolescence and young adulthood, 

which are critical periods of sensitivity to neurobiolog‐

ical insults (such as nicotine) and experience‐induced 

plasticity (Spear 2000; Dahl 2004; Gulley and Juraska 

2013). Although maturation occurs in different regions of 

the brain at different rates, a similar progression occurs 

in all areas characterized by a rapid formation of syn‐

aptic connections in early childhood, followed by a loss 

of redundant or unnecessary synapses (called pruning) 

and the formation of myelin. Myelination is the process 

by which a fatty layer, called myelin, accumulates around 
Health Effects of E-Cigarette Use Among U.S. Youth and Young Adults 105

E-Cigarette Use Among Youth and Young Adults

nerve cells (neurons). Because of myelin, nerve cells can 

transmit information faster, allowing for more complex 

brain processes. Pruning allows for more focused con‐

centration, and myelination allows for faster electrical 

and neural signaling; both allow for more efficient cog‐

nitive processing. During adolescence and into young 

adulthood, myelination occurs rapidly in the frontal lobe, 

a place in the brain that controls executive functioning, 

reasoning, decision‐making skills, self‐discipline, and 

impulse control. Plasticity refers to the current under‐

standing that the brain continues to change throughout 

life, not only because of normal, maturational neural 

growth and development but also because of changes in 

environmental neurobiological exposures (such as nico‐

tine), injuries, behaviors, thinking, and emotions (Mills 

and Tamnes 2014).

Across species, and in humans, adolescence is a key 

period of increased plasticity and rapid growth of brain 

circuits that regulate social, emotional, and motivational 

processes and decision making (Spear 2000, 2011; Nelson 

et al. 2005; Ernst and Fudge 2009; Counotte et al. 2011). 

The prefrontal cortex, which is involved in higher level 

regulatory control of complex behaviors (such as plan‐

ning, impulse control, and working memory), continues 

normal structural and functional development into young 

adulthood, to about 25 years of age (Giedd and Rapoport 

2010; Somerville and Casey 2010). Because of the immatu‐

rity and rapid growth of the prefrontal cortex, adolescents 

and young adults normally exhibit moody, risk‐taking, 

and unpredictable impulsive behaviors. The combina‐

tion of delayed maturation of frontal cognitive control 

and increased reactivity of subcortical reward‐related 

and emotion‐processing systems may lead to increased 

risk‐taking behavior and a greater susceptibility to initi‐

ating substance use and the development of dependence 

(Steinberg 2008; Ernst and Fudge 2009; Counotte et al. 

2011; Spear 2011). Thus, myelination is vitally important 

to the healthy functioning of the central nervous system, 

and any exposure that significantly interferes with the 

myelination process can cause mild‐to‐severe cognitive 

and learning problems (Brady et al. 2012).

Brain development in juvenile rodents has been 

reported to display patterns that resemble those of human 

beings, suggesting that the rodent model might be rel‐

evant to studying the neurobiological underpinnings 

of brain maturation in teenagers (Spear 2000). Studies 

across species have revealed unique characteristics of 

adolescent nonhuman brain structure, mechanisms, and 

function that provide biological plausibility to the hypoth‐

esis that human adolescents are particularly vulnerable to 

nicotine uptake (O’Loughlin et al. 2015; Yuan et al. 2015). 

There is evidence for rapid growth of gray matter, fol‐

lowed by activity‐dependent synaptic pruning (the process 

of synapse elimination that occurs between early child‐

hood and the onset of puberty) and increasing myelina‐

tion throughout the brain (Casey et al. 2005; Lenroot and 

Giedd 2006; Giedd and Rapoport 2010; Counotte et  al. 

2011).

Nicotine has more significant and durable damaging 

effects on adolescent brains compared to adult brains, 

the former suffering more harmful effects. Preclinical 

animal studies have shown that in rodent models, nico‐

tinic acetylcholine receptor (nAChR) signaling is still 

actively changing during adolescence, with higher expres‐

sion and functional activity of nAChRs in the forebrain 

of adolescent rodents compared to their adult counter‐

parts (Britton et al. 2007; Kota et al. 2007; Doura et al. 

2008). Furthermore, in rodent models, nicotine actu‐

ally enhances neuronal activity in several reward‐related 

regions and does so more robustly in adolescents than in 

adults (Schochet et al. 2005; Shram et al. 2007; Dao et al. 

2011). This increased sensitivity to nicotine in the reward 

pathways of adolescent rats is associated with enhanced 

behavioral responses, such as strengthening the stimulus‐

response reward for administration of nicotine. In condi‐

tioned place‐preference tests—where reward is measured 

by the amount of time animals spend in an environment 

where they receive nicotine compared to an environment 

where nicotine is not administered—adolescent rodents 

have shown an increased sensitivity to the rewarding 

effects of nicotine at very low doses (0.03 mg/kg) (Vastola 

et  al. 2002; Belluzzi et  al. 2004; Brielmaier et  al. 2007; 

Kota et  al. 2007; Natarajan et  al. 2011) and exhib‐

ited a unique vulnerability to oral self‐administration 

during the early‐adolescent period (Adriani et  al. 2002). 

Adolescent rodents also have shown higher levels of nic‐

otine self‐administration than adults (Levin et  al. 2003; 

Chen et al. 2007; Natividad et al. 2013), decreased sensi‐

tivity to the aversive effects of nicotine (Adriani et al. 2002; 

Shram et al. 2006; Torres et al. 2008), and less prominent 

withdrawal symptoms following chronic nicotine expo‐

sure (O’Dell et  al. 2006). This characteristic in rodent 

models of increased positive and decreased negative short‐

term effects of nicotine during adolescence (versus adult‐

hood) highlights the possibility that human adolescents 

might be particularly vulnerable to developing depen‐

dency to and continuing to use e‐cigarettes. These bio‐

logical mechanisms are of great public health importance 

as exposure to nicotine grows among nonsmoking youth 

through the increasing prevalence of e‐cigarette use.

Beyond their unique vulnerability to nicotine use, 

and thus smoking uptake, human adolescents may be par‐

ticularly vulnerable to the detrimental consequences of 

nicotine exposure, including an increase in drug‐seeking 

behaviors (Kandel and Kandel 2014), deficits in attention 

and cognition, and mood disorders (Yuan et al. 2015). In 
A Report of the Surgeon General

106 Chapter 3

animal models, chronic nicotine exposure during adoles‐

cence has been shown to produce long‐lasting, unique 

effects that are not observed in mature adult animals. 

Moreover, animal models have provided substantial evi‐

dence that the limbic system—which controls cognition, 

emotion, and drug‐reward—is actively maturing during 

adolescence and during this age is vulnerable to long‐

term modification by nicotine.

Reward‐Seeking Behaviors. A very strong argument 

can be made about the association between adolescent expo‐

sure to nicotine by smoking conventional cigarettes and 

the subsequent onset of using other dependence‐producing 

substances. Strong, temporal, and dose‐dependent associa‐

tions have been reported (Isensee et al. 2003; John et al. 

2004b; Bronisch et al. 2008; Kandel and Kandel 2015), and 

a plausible biological mechanism (via rodent and human 

modeling) suggests that long‐term changes in the neural 

reward system take place as a result of adolescent smoking 

(Lewinsohn et al. 1999; Huang et al. 2013; Kandel and 

Kandel 2014). Adolescent smokers of conventional ciga‐

rettes have disproportionately high rates of comorbid sub‐

stance abuse (Kandel et al. 1992; Lai et al. 2000; Hanna et al. 

2001), and longitudinal studies have suggested that early 

adolescent smoking may be a starting point or “gateway” for 

substance abuse later in life (Kandel et al. 1992; Lewinsohn 

et al. 1999; Wagner and Anthony 2002; Brook et al. 2007), 

with this effect more likely for persons with attention 

deficit hyperactivity disorder (ADHD) (Biederman et al. 

2006; Wilens et al. 2008). Although factors such as genetic 

comorbidity, innate propensity for risk taking, and social 

influences may underlie these findings (Lindsay and Rainey 

1997; Smith et al. 2015), both human neuroimaging and 

animal studies suggest a neurobiological mechanism also 

plays a role. In addition, behavioral studies in adolescent 

and young adult smokers have revealed an increased pro‐

pensity for risk taking, both generally and in the presence of 

peers, and neuroimaging studies have shown altered frontal 

neural activation during a risk‐taking task as compared 

with nonsmokers (Lejuez et al. 2005; Cavalca et al. 2013; 

Galvan et al. 2013). Rubinstein and colleagues (2011b) used 

neuroimaging to show decreased brain response to a nat‐

ural reinforcer (pleasurable food cues) in adolescent light 

smokers (1–5 cigarettes per day), with their results high‐

lighting the possibility of neural alterations consistent with 

nicotine dependence and altered brain response to reward 

even in adolescent low‐level smokers.

Nicotine exposure in rodents at an age of physical 

development corresponding to human adolescence has 

been found to increase the reinforcing effects of other 

drugs of abuse, including cocaine, methamphetamine, 

and alcohol, without having a major impact on responding 

for other rewards, thus providing further evidence in sup‐

port of nicotine as an initiation toward other substance 

use and abuse (McQuown et al. 2007; Dao et al. 2011; 

Dickson et al. 2014; Pipkin et al. 2014; Kandel and Kandel 

2014). In several rodent studies, treatment with very low 

doses of nicotine for a few days during early adolescence, 

but not in late adolescence or adulthood, produced lasting 

changes in D2 and D3 dopamine receptors and in the self‐

administration of other abused drugs (McQuown et al. 

2007; Dao et al. 2011; Mojica et al. 2014). Nicotine expo‐

sure in adolescent rats also induced rapid and long‐lasting 

dendritic remodeling in the nucleus accumbens shell, a 

critical component of reward learning and addiction, via 

a D1 dopamine receptor‐mediated mechanism (Ehlinger 

et al. 2016). This persistent form of nicotine‐induced neu‐

roplasticity has the potential to alter synaptic connectivity 

within reward‐processing centers and enhance the addic‐

tive effects of drugs of abuse.

Attention and Cognition. Both cognitive improve‐

ments (Jasinska et  al. 2014) and cognitive deficits (Hall 

et  al. 2014) have been reported after nicotine exposure 

in healthy human adults, while smoking during adoles‐

cence impairs cognition and attention processes. Results 

of a genetically sensitive, longitudinal “concordant” 

and “discordant” twin study from the Netherlands Twin 

Registry indicated a larger increase in attention prob‐

lems from adolescence to adulthood in twins who smoked 

than in their never‐smoking co‐twins (Treur et al. 2015). 

In another study, adolescent smokers were found to have 

chronic impairments in the accuracy of their working 

memory (e.g., in processing information from two sensory 

modalities simultaneously), which were more severe with 

an earlier age of onset of smoking (Jacobsen et al. 2005). 

Functional imaging studies have shown that 24‐hour 

smoking abstinence in adolescent smokers causes acute 

impairments of verbal memory and working memory, 

along with chronic decrements in cognitive performance 

(Jacobsen et al. 2007a). In another study, adolescent users 

of conventional cigarettes showed decreased prefrontal 

cortex activation (versus never smokers) during attention 

tasks, and duration of smoking (in years) was directly cor‐

related with the extent of reduction in prefrontal cortical 

activity (Musso et al. 2007).

Thus, longitudinal and imaging studies in humans 

provide support for the hypothesis that adolescent use of con‐

ventional cigarettes has both acute and long‐term effects on 

attention and memory. Although nicotine exposure cannot 

be cited as the sole cause of cognitive defects (or even one 

of several combined effects in humans), other studies have 

shown that adolescent nicotine exposure in rats induces 

lasting synaptic changes in the prefrontal cortical regions 

critical for normal attention, memory, and cognition that 

likely underlie observed impairments in attentional and 

cognitive function (Bergstrom et  al. 2008). Adolescent 

nicotine exposure in rats has induced impairments in 
Health Effects of E-Cigarette Use Among U.S. Youth and Young Adults 107

E-Cigarette Use Among Youth and Young Adults

stimulus‐response‐discrimination‐learning processes but 

not in abstract rule‐learning processes, which are dependent 

on dissociable cognitive systems, thus showing the selective 

effects of nicotine (Pickens et al. 2013). In addition, adoles‐

cent, but not postadolescent, treatment of rats with nico‐

tine resulted in diminished attention span and enhanced 

impulsivity in adulthood (Counotte et al. 2009, 2011). The 

biological causes of these cognitive disturbances (reduced 

attention span and impulse control) were associated with 

reduced regulation of prefrontal cortex excitatory synapses 

function in metabotropic glutamate receptor 2 (mGluR2) 

(Counotte et al. 2011; Goriounova and Mansvelder 2012). 

In addition, hippocampal function, which is critical for 

memory, was altered in adult mice by nicotine exposure 

during adolescence. Contextual fear conditioning—a 

hippocampus‐dependent task in which animals learn and 

remember to associate a fearful stimulus (e.g., a foot shock) 

with a particular context—was disrupted in adult mice that 

had been treated during adolescence with chronic nicotine 

but not following chronic treatment with nicotine in adult‐

hood (Portugal et al. 2012). Rodent studies have implica‐

tions for human adolescents, suggesting that exposure to 

tobacco during youth may lead to long‐lasting changes in 

behavioral and neuronal plasticity into adulthood.

Mood Disorders. Adolescents with symptoms of 

mental health disorders (e.g., anxiety, aggressive and dis‐

ruptive behaviors, mood disorders) are at increased risk 

for initiation of conventional cigarette use and long‐

term nicotine dependence compared with those without 

such disorders (Gehricke et al. 2007; Morris et al. 2011). 

Although this risk may reflect a common genetic predis‐

position, or the use of nicotine to self‐medicate in the 

hope of improving mental health symptoms, the question 

arises of whether the smoking of conventional cigarettes 

by adolescents contributes to the development of mood 

disorders. A meta‐analysis of existing studies showed con‐

sistent evidence that both tobacco use and dependence 

on tobacco products among adolescents indeed increased 

their risk of anxiety disorders (Moylan et al. 2012). Other 

studies have shown that an early onset of smoking is asso‐

ciated with a shorter time to first onset of an anxiety dis‐

order (Jamal et al. 2011), and there is a positive association 

between adolescent smoking, particularly through a nico‐

tine pathway, and anxiety in early adulthood (Moylan et al. 

2013). Bidirectional relationships between adolescent 

smoking and disruptive disorders (e.g., ADHD; opposi‐

tional defiant disorder [ODD] [Griesler et al. 2011]) as well 

as depression (Tjora et al. 2014) also have been reported, 

while a longitudinal birth cohort found evidence to sup‐

port a causal relationship between teen smoking and onset 

of depression (Boden et al. 2010). Although these findings 

are complex and warrant further study using comparisons 

of genetic polymorphisms associated with smoking or 

twin and sibling discordant/concordant studies (Munafo 

and Araya 2010; Leventhal and Zvolensky 2015), they do 

suggest that nicotine exposure during adolescence could 

contribute to long‐term mental health disorders.

Findings of animal studies support the theory that 

adolescent nicotine exposure results in long‐term alter‐

ations in emotional response, specifically enhanced anx‐

iety and fear (Slawecki et al. 2003; Smith et al. 2006), and 

in persistent alterations in serotonin systems involved in 

mediating mood disorders by reprogramming the future 

response of 5‐HT systems to nicotine (Slotkin and Seidler 

2009). Even a single day of nicotine treatment in adoles‐

cent rats can enhance sensitivity to aversive stimuli later 

in life and result in a depression‐like state in adulthood 

that is normalized by treatment with nicotine or antide‐

pressants (Iniguez et al. 2009).

In summary, given the existing evidence from 

human and animal studies of the detrimental impact of 

nicotine exposure on adolescent brain development, the 

use of e‐cigarettes by youth should be avoided and actively 

discouraged. Both preadolescence and adolescence are 

developmental periods associated with increased vulner‐

ability to nicotine addiction, and exposure to nicotine 

during these periods may lead to long‐lasting changes in 

behavioral and neuronal plasticity. Studies reveal that for 

most tobacco users, initial use begins before 18 years of 

age. Moreover, in some adolescents, symptoms of nico‐

tine dependence can develop after exposure to very low 

levels of nicotine—less than 100 cigarettes. Cross‐species 

studies have identified characteristics of the adolescent 

brain that may render it vulnerable at this age to nicotine 

uptake in the form of equivalent doses via nonsmoking 

administration mechanisms. In addition, animal models 

of nicotine exposure in adolescence reveal neural and 

behavioral alterations consistent with an increased like‐

lihood of future nicotine use, increased activation of 

reward pathways and, unlike in adult animals, decreased 

aversive effects. Regarding e‐cigarettes, data demonstrate 

adolescent use of these devices is associated with use of 

tobacco, alcohol, and other drugs (Dutra and Glantz 2014; 

Kristjansson et al. 2015; Wills et al. 2015a, b; Schneider 

and Diehl 2016). Finally, animal and human studies sug‐

gest a bidirectional relationship between the smoking of 

conventional cigarettes and exposure to nicotine during 

adolescence and factors related to disruptive disorders, 

such as ADHD and ODD that impair academic perfor‐

mance, as well as to depression. Because the adolescent 

brain is still developing, nicotine use during adolescence 

can disrupt the formation of brain circuits that con‐

trol attention, learning, and susceptibility to addiction. 

Further research is warranted to more fully understand 

the effects of e‐cigarette use on youth.
A Report of the Surgeon General

108 Chapter 3

Nicotine Exposure from Maternal Nicotine 

Consumption: Prenatal and Postnatal Health 

Outcomes

Prenatal nicotine exposure through maternal ciga‐

rette use during pregnancy is one of the most widespread 

perinatal insults in the world (Levin and Slotkin 1998; Xiao 

et al. 2008; USDHHS 2014). Despite medical and societal 

sanctions and ongoing public health campaigns, the prev‐

alence of maternal cigarette use during pregnancy in the 

United States was estimated to be 11–15% in 2013 (Tong 

et al. 2013). Smoking rates were even higher among women 

who were poor, young, or less educated, with rates as high 

as 25–30%, indicating that infants born to mothers who are 

poor have disproportionately higher exposure to nicotine 

(Dietz et al. 2011; Hamilton et al. 2012; Tong et al. 2013). 

Despite these adverse consequences, an estimated one‐half 

of pregnant smokers continue to smoke into the third tri‐

mester (Osterman et al. 2013; Tong et al. 2013).

Because adults who use e‐cigarettes can achieve 

plasma nicotine concentrations similar to those found 

among smokers of equivalent amounts of conventional 

cigarettes (Vansickel et  al. 2010; Lopez et  al. 2016; 

St. Helen et al. 2016), it is important that research con‐

tinues in this area. Nicotine has been shown to cross the 

placenta and has been found in placental tissue as early 

as 7 weeks of embryonic gestation, and nicotine concen‐

trations are higher in fetal fluids than in maternal fluids 

(Luck et  al. 1985; Jauniaux et  al. 1999). nAChRs are 

widely distributed in the fetal brain. As has been clearly 

demonstrated in animal models, acetylcholine acts on 

nAChRs to modulate functional connections during crit‐

ical periods of development when regions are most sen‐

sitive to environmental input (Dwyer et al. 2008). When 

nicotine in the maternal bloodstream crosses the pla‐

cental barrier, it binds to these receptors (Pentel et  al. 

2006; Wong et  al. 2015), and in rodents this can result 

in long‐term changes in neural structure and function. 

Results from animal studies show consistent associations 

between prenatal nicotine exposure and upregulation of 

nAChRs associated with disruption of fetal brain cell rep‐

lication and differentiation (Slotkin 1998). Highlighting 

the role of nicotine in the effects of maternal smoking 

during pregnancy, nAChRs have been shown to be present 

in the human embryonic brain from 5 weeks of gesta‐

tion (Hellstrom‐Lindahl et  al. 1998), and their normal 

maturation is altered in a region‐ and receptor subtype‐

dependent fashion by maternal cigarette smoking during 

pregnancy (Falk et al. 2005; Duncan et al. 2008). In those 

brainstem nuclei important for arousal, prenatal nicotine 

exposure decreases [3H]‐nicotine binding (Duncan et al. 

2008) and prevents normal age‐related increases in α4 

and α7 mRNA (Falk et al. 2005).

Prenatal nicotine exposure also has been associated 

with dysregulation of catecholaminergic, serotonergic, 

and other neurotransmitter systems. In addition, animal 

work suggests significant adverse effects of nicotine alone 

at levels commensurate with exposure to secondhand 

smoke (10‐fold below those seen in active smokers), and 

that the non‐nicotine components of tobacco smoke can 

exacerbate nicotine’s teratogenic effects (Slotkin et  al. 

2015). Offermann (2015) concluded that e‐cigarettes 

emit many harmful chemicals into the air and that indi‐

rect exposure to nicotine exceeded exposure‐level stan‐

dards for noncarcinogenic health effects established by 

the California Environmental Protection Agency. No safe 

level of prenatal nicotine exposure has been established 

(England et al. 2015).

Airborne nicotine exposure through secondhand 

aerosol from e‐cigarettes has been observed, as has sali‐

vary cotinine concentrations of nonsmokers in the homes 

of e‐cigarette users (Ballbe et al. 2014; Czogala et al. 

2014). Ballbe and colleagues (2014) reported the geo‐

metric means of airborne nicotine were 0.74 μg/m3 in the 

homes of smokers, 0.13 μg/m3 in the homes of e‐cigarette 

users, and 0.02 μg/m3 in the homes of nonsmoking con‐

trols. While airborne nicotine exposure from combustible 

cigarette smoke was 5.7 (Ballbe et al. 2014) to 10 times 

higher (Czogala et al. 2014) than e‐cigarette aerosol, one 

study reported only a twofold increase in salivary cotinine 

(0.38 ng/ml in the homes of smokers versus 0.19 ng/ml in 

the homes of e‐cigarette users) (Ballbe et al. 2014), and 

another study found that exposure to cigarette smoke and 

exposure to e‐cigarette aerosol had similar effects on the 

serum cotinine levels of bystanders (Flouris et al. 2013). 

Thus, the passive exposure to nicotine from e‐cigarette 

smoking has been reported to be just as large (Flouris 

et al. 2013; Grana et al. 2013) or lower than (Czogala et al. 

2014) conventional cigarettes, but exposure to nicotine 

from e‐cigarette smoking is not negligible and is higher 

than in nonsmoking environments. This evidence sug‐

gests the importance of avoiding secondhand exposure 

of e‐cigarette vapor and secondhand smoke during preg‐

nancy (Flouris et al. 2013; Grana et al. 2013; Czogala et al. 

2014).

Of the components of tobacco smoke, nicotine 

has been cited as the most important toxicant in terms 

of interfering with fetal development. Because of the 

health risks to the developing fetus associated with nico‐

tine exposure during pregnancy, the U.S. Food and Drug 

Administration (FDA) (2015) recommends that pregnant 

women seek medical approval before using NRT, and the 

American College of Obstetricians and Gynecologists

(2011) recommends consideration of NRT only if a woman 

fails behavioral interventions to quit smoking conven‐

tional cigarettes and has discussed the potential harms 
Health Effects of E-Cigarette Use Among U.S. Youth and Young Adults 109

E-Cigarette Use Among Youth and Young Adults

and benefits of NRT with her physician. NRT is most often 

used during pregnancy as a last resort to avoid exposing 

the fetus to the other toxic ingredients found in con‐

ventional tobacco smoke (Fiore et al. 2008). A Cochrane 

Database systematic review concluded that both the effec‐

tiveness and safety of NRT during pregnancy are unclear 

(Coleman et al. 2012). Table A3.1‐4 in Appendix 3.1 pres‐

ents a summary of studies in humans on the effects of 

tobacco exposure on fetal brain development.

Even with a firm understanding of the negative 

health consequences of nicotine on the developing fetus 

(Fiore et  al. 2008; USDHHS 2014; Ekblad et  al. 2015), 

little is known about the prevalence of e‐cigarette use 

among pregnant women or the direct harmful effects 

on their fetus by other toxicants delivered by the aerosol 

from e‐cigarettes (England et al. 2015; Suter et al. 2015). 

In one of the few studies identified, a survey of 316 preg‐

nant women in a Maryland clinic found that the majority 

had heard of e‐cigarettes, 13% had ever used them, and 

0.6% were current daily users (Mark et al. 2015). These 

findings are of concern because the dose of nicotine 

delivered by e‐cigarettes can be as high or higher than 

that delivered by conventional cigarettes. Therefore, 

plasma nicotine concentrations delivered while using 

e‐cigarettes have the potential to harm the developing 

fetus. Furthermore, in 2013 in the United States, there 

were 26.5 births for every 1,000 adolescent females 

(15–19 years of age), or 273,105 babies born to females 

in this age group (Hamilton et al. 2013). Currently, the 

rate of e‐cigarette use among pregnant adolescents is 

unknown, but the effects of nicotine and the potential for 

harm by other e‐cigarette toxicants indicate that the use 

of e‐cigarettes is a fetal risk factor among pregnant ado‐

lescent girls.

As outlined below, the specific effects of nicotine 

on prenatal development and postnatal outcomes include 

sudden infant death syndrome (SIDS) and may include 

altered development of the corpus callosum, deficits in 

auditory processing, and alterations in appetitive behavior, 

attention, and cognition.

SIDS. SIDS is the sudden and unexplained death of 

an infant younger than 1 year of age (Krous 2014). Maternal 

smoking and infant exposure to secondhand smoke have 

been causally associated with SIDS, with 20–29% of deaths 

from SIDS attributable to maternal smoking of conven‐

tional cigarettes during pregnancy (Dietz et  al. 2010; 

Zhang and Wang 2013; USDHHS 2014). Prenatal exposure 

to cigarettes and to smokeless tobacco have been associ‐

ated with increased risk for apnea events, which have been 

linked to increased risk for SIDS (Gunnerbeck et al. 2011; 

Zhang and Wang 2013; Inamdar et al. 2015).

Although the mechanistic pathways underlying 

SIDS remain largely unknown, nicotine has effects on 

pathways that could be related to SIDS and is related 

to known risk factors, particularly lung and respira‐

tory development (England et al. 2015; Holbrook 2016; 

Spindel and McEvoy 2016). Evidence from animal models 

supports the hypothesis that prenatal nicotine exposure 

alters both fetal autonomic function and arousal, which 

could increase the risk of SIDS (Slotkin 1998; Task Force 

on Sudden Infant Death Syndrome and Moon 2011). In 

humans, a dose–response relationship between cotinine 

(the major nicotine metabolite) and altered arousal pat‐

terns has been shown in preterm infants (Richardson 

et  al. 2009), and this relationship is suggestive of nico‐

tine’s role in arousal deficits that could be linked to SIDS. 

There is widespread distribution of nAChRs in the brain‐

stem nuclei in both humans and animals that control car‐

diopulmonary integration and arousal in the newborn 

(Dwyer et  al. 2008). In some animal studies, prenatal 

exposure to nicotine has increased mortality in newborns 

that were exposed to reduced oxygen (Slotkin et al. 1995; 

Fewell and Smith 1998). Prenatal exposure to nicotine 

is also associated with altered serotonin signaling in the 

brainstem in the rat model, leading to an exaggerated tri‐

geminocardiac reflex and resulting in bradycardia, hypo‐

tension, and apnea (Gorini et al. 2013).

Altered Development of the Corpus Callosum. The 

corpus callosum, the largest white matter structure in 

the brain, facilitates communication between the left and 

right cerebral hemispheres. Several human studies have 

revealed alterations in the structure of the corpus callosum 

in offspring following their exposure to maternal cigarette 

use during pregnancy (Jacobsen et al. 2007b; Paus et al. 

2008). In animal models, prenatal exposure to nicotine 

has been shown to result in widespread alterations in gene 

expression in the brains of adolescent offspring (Cao et al. 

2011, 2013; Wei et al. 2011). In particular, the expression 

of a number of genes involved in myelination—the forma‐

tion of white matter via the addition of protective myelin 

sheaths to axons—is altered in a sex‐dependent manner, 

with upregulation in males and downregulation in females 

(Cao et al. 2013). Such changes in the expression profiles 

of myelin‐related genes may influence the structure and 

function of white matter, and both hypermyelination and 

hypomyelination have been associated with cognitive defi‐

cits (Quaranta et al. 2002; Sokolov 2007).

Deficits in Auditory Processing. A number of 

human studies, using a variety of methods, have inves‐

tigated the effects of maternal cigarette smoking during 

pregnancy on auditory processing from the fetal period 

through childhood (Jacobson and Morehouse 1984; 

Kristjansson et  al. 1989; McCartney et  al. 1994; Franco 

et al. 1999; Leech et al. 1999; Cowperthwaite et al. 2007). 

Deficits in auditory processing in fetuses are of concern 

because they affect later language development (Kisilevsky 
A Report of the Surgeon General

110 Chapter 3

and Davies 2007; Kisilevsky et al. 2014). Various studies in 

infants have investigated the brain’s physiological activity 

response to auditory stimuli (the cochlea translates sound 

into nerve impulses to be sent to the brain), neuroelectric 

activity of the auditory nerve, and cochlear response (Key 

et al. 2007; Korres et al. 2007; Kable et al. 2009; Peck et al. 

2010; Katbamna et al. 2013). Key and colleagues (2007) 

reported prenatal exposure to cigarette use (compared 

with nonexposed infants) to be associated with alterations 

in hemispheric asymmetry and suboptimal brain activity 

related to speech processing in otherwise healthy new‐

borns at least 2 days of age. Korres and associates (2007) 

found altered cochlear responses to auditory stimuli 

in newborns that were exposed to maternal cigarette 

smoking (n = 200) compared with those that were unex‐

posed (n = 200), regardless of degree of cigarette exposure. 

Similar findings were reported by Durante and colleagues 

(2011) in two case‐control studies.

Two additional studies investigated effects of 

maternal cigarette use during pregnancy on auditory 

brainstem responses in newborns (≤2 days old) (Peck et al. 

2010) and infants (6 months old) (Kable et al. 2009). Both 

studies found greater neuroelectric response to sound 

stimuli, a phenomenon that may disrupt an infant’s ability 

to encode auditory information, potentially leading to def‐

icits in language development. Furthermore, both studies 

demonstrated dose–response relationships between 

altered auditory processing and maternal cotinine levels. 

Finally, in a study of a small sample of newborns that 

sought to understand the direct biological pathway, 

maternal smoking during pregnancy produced changes in 

newborn cochlear and auditory brainstem functions and 

changes in placental gene expression in genes that appear 

to modulate the motility of cochlear hair cells (Katbamna 

et al. 2013). Thus, all three studies indicate effects based 

on consumption of conventional cigarettes, and they high‐

light the possibility of a mediating role of maternal nico‐

tine use in altered infant auditory processing, although 

further work must rule out confounding effects and effect 

modification by other constituents (e.g., arsenic, benzene, 

and cadmium).

A study using functional magnetic resonance 

imaging (fMRI) in older offspring exposed to tobacco 

in utero assessed response to auditory and visual atten‐

tion tasks in adolescent smokers (Jacobsen et al. 2007a). 

Teens whose mothers smoked during pregnancy exhibited 

decreased accuracy in the tasks, with greater activation 

of both the temporal lobe and the occipital lobe, regions 

of the brain that are critical for auditory and visual pro‐

cessing. Additive effects of maternal cigarette use during 

pregnancy and of adolescent smoking on activation of the 

temporal and occipital lobes also emerged, indicative of 

reduced coordination among brain regions during audi‐

tory attention tasks.

Animal studies have shown that nAChRs play a 

critical developmental role in establishing synaptic con‐

nections between sensory thalamic afferents and those 

cortical targets that are necessary for normal sensory 

processing (Table A3.1‐5 in Appendix 3.1). Brief nicotine 

exposure during this critical postnatal period of sensory 

cortex development disrupts glutamate transmission 

(Aramakis et al. 2000) and eliminates nAChR regulation of 

signal processing in the adult auditory cortex, inhibiting 

normal auditory learning (Liang et  al. 2006). Animals 

that are prenatally exposed to nicotine also exhibit defi‐

cits in cognitive processing in response to an auditory cue, 

which appears to be mediated by a loss of function of the 

nAChR β2 subunit (Liang et al. 2006; Horst et al. 2012).

Appetitive and Consummatory Behaviors. Clinical 

studies and animal studies have linked prenatal exposure 

to nicotine to subsequent appetitive behaviors (an active 

searching process that is performed consciously) and con‐

summatory behaviors (such as ingestion of food or drugs) 

in offspring. Associations have been demonstrated in 

humans between maternal cigarette use during pregnancy 

and risk to the child of smoking uptake/nicotine depen‐

dence, drug abuse, and obesity; parallel relationships have 

been shown in animal models between prenatal exposure 

to nicotine and similar appetitive behaviors of offspring.

Parental use of tobacco is one of many well‐known 

risk factors for offspring initiation of tobacco, progres‐

sion to heavy use, and nicotine dependence. Tobacco use 

by parents influences their children through social, envi‐

ronmental, cognitive, and genetic mechanisms (USDHHS 

2012). As a subset of these influences, mothers’ use of 

tobacco during pregnancy has been studied as an inde‐

pendent risk factor and has been associated with offspring 

susceptibility, initiation, regular use, and dependence 

(Kandel et al. 1994; Griesler et al. 1998; Kandel and Udry 

1999; Buka et  al. 2003; Lieb et  al. 2003; Oncken et  al. 

2004; Al Mamun et  al. 2006; O’Callaghan et  al. 2009; 

Tehranifar et  al. 2009; Agrawal et  al. 2010; Rydell et  al. 

2012; Weden and Miles 2012; Stroud et al. 2014; Shenassa 

et al. 2015). Wakschlag and colleagues (2010, 2011) sug‐

gest that maternal smoking during pregnancy has a ter‐

atologic effect with abnormalities stemming from the in 

utero environment which disrupt neural (Kandel et  al. 

1994; Jacobsen et  al. 2006) and dopamine systems that 

promote sensitivity to nicotine dependence (Kandel et al. 

1994; Selya et al. 2013). For example, nicotinic receptors 

of laboratory animals exposed to nicotine in utero are 

upregulated, suggesting a latent vulnerability to nicotine 

dependence among animals exposed to nicotine in utero 

(Slotkin et al. 2006, 2015).
Health Effects of E-Cigarette Use Among U.S. Youth and Young Adults 111

E-Cigarette Use Among Youth and Young Adults

At issue with all human studies investigating 

maternal use of tobacco during pregnancy and offspring 

use of tobacco is isolating the independent effect on the 

fetus in relation to the other social, environmental, and 

cognitive factors that also predict offspring tobacco use. 

After controlling for maternal smoking during the off‐

spring’s childhood, several studies have reported that 

maternal smoking during pregnancy is associated with 

higher nicotine dependence in offspring (Kardia et  al. 

2003; Lieb et al. 2003; Selya et al. 2013; Shenassa et al. 

2015), increased or earlier smoking initiation, and heavier 

smoking among adolescent girls and adult offspring 

(Kandel et al. 1994; Cornelius et al. 2005). However, the 

association was attenuated and nonsignificant among sev‐

eral studies that controlled for a variety of environmental, 

social, and cognitive confounders between maternal cig‐

arette use during pregnancy and initiation of offspring 

smoking (but not nicotine dependence) (Cornelius et al. 

2005; Roberts et al. 2005; Munafo et al. 2006; Kandel et al. 

2007; D’Onofrio et al. 2012; Rydell et al. 2014; Taylor et al. 

2014), leaving speculation for the independent effect. In 

summary, evidence from animal models offers a biologic 

mechanism for, and human evidence is suggestive of, an 

association between maternal tobacco use during preg‐

nancy with offspring smoking and nicotine dependence, 

but is insufficient to infer causation. Further research and 

longitudinal studies that examine these outcomes while 

assessing the full spectrum of environmental, social, and 

cognitive mediating pathways are needed to disentangle 

these issues.

A smaller set of literature has documented associa‐

tions between maternal cigarette smoking during preg‐

nancy and use of other substances by the child (Fergusson 

et al. 1998; Weissman et al. 1999; Porath and Fried 2005; 

Nomura et al. 2011). In utero exposure to nicotine also 

affects behavioral responses for drug rewards in both ado‐

lescent and adult experimental animals. Prenatal expo‐

sure to nicotine increases the preference of adolescents 

for a saccharin solution containing nicotine compared 

with saccharin alone (Klein et al. 2003), and it results in 

self‐administration of nicotine either during acquisition 

of the task (Chistyakov et al. 2010) or after forced absti‐

nence (Levin et al. 2006). Prenatal exposure to nicotine 

also increases subsequent oral intake of alcohol (Chang 

et al. 2013), and intravenous self‐administration of both 

cocaine and methamphetamine is enhanced in a dose‐

dependent manner in adolescent rats (Franke et al. 2008) 

and adult rats (Lacy et al. 2014).

 In contrast, in a study that used a discordant sib‐

ling pair design to reduce confounding by genetic and 

environmental factors, initial associations between pre‐

natal smoking and alcohol use disorder were attenuated 

and were no longer statistically significant (D’Onofrio 

et  al. 2012). In a large longitudinal study that spanned 

40 years, Shenassa and colleagues (2015) found evidence 

to support effects on nicotine dependence among chil‐

dren of mothers who smoked during pregnancy, but no 

effects on their progression to marijuana dependence 

were observed. A possible explanation for these discordant 

findings is suggested by a study that found significant 

effects from prenatal smoking of conventional cigarettes 

on drug use among adolescents, but showed that these 

effects were restricted to a genetic subpopulation of car‐

riers of a specific α6 nAChR gene (rs2304297) polymor‐

phism (Lotfipour et al. 2010). In sum, a number of studies 

have documented associations between cigarette use by 

the mother during pregnancy and smoking initiation, 

heavy use, and nicotine dependence among her children, 

although control of confounding reduces this associa‐

tion. In addition, the literature is sparse and inconsistent 

regarding a connection between maternal cigarette use 

during pregnancy and the use of nontobacco substances 

by the child.

A large body of literature has demonstrated effects 

of maternal cigarette use during pregnancy on weight 

levels and obesity in childhood. For example, three meta‐

analytic reviews found a 47–64% increased risk of obe‐

sity in children following exposure to maternal cigarette 

smoking during pregnancy (Oken et al. 2008; Ino 2010; 

Weng et  al. 2012; Behl et  al. 2013). Additional system‐

atic reviews (Bruin et al. 2010) and other studies (Harrod 

et al. 2015; La Merrill et al. 2015; Mourtakos et al. 2015; 

Bao et  al. 2016) have all concluded that prenatal expo‐

sure to nicotine likely acts as a developmental obesogen 

in humans. However, unmeasured residual confounding 

or confounding by familial factors, which have not been 

fully explored, could attenuate the observed associations 

(Gilman et al. 2008; Iliadou et al. 2010). Animal studies 

support the epidemiologic literature suggesting a poten‐

tially causal relationship here by defining biologic path‐

ways (Wong et al. 2015). Fetal and neonatal exposure to 

nicotine in rodents has resulted in neurochemical, neu‐

robehavioral, and metabolic changes in the children that 

are consistent with obesity and type 2 diabetes (Williams 

and Kanagasabai 1984; Newman et al. 1999; Grove et al. 

2001; Chen and Kelly 2005; Gao et  al. 2005; Holloway 

et al. 2005).

In humans, studies involving structural MRI and 

fMRI have shown alterations in the size and sensitivity of 

brain reward centers in the teenage offspring of maternal 

smokers. Several of these studies revealed a thinning of 

the orbitofrontal cortex among persons who were prena‐

tally exposed to maternal cigarette smoking, a thinning 

that was associated with drug use and experimentation 

during adolescence (Toro et  al. 2008; Lotfipour et  al. 

2009); decreased amygdalar volume, which is associated 
A Report of the Surgeon General

112 Chapter 3

with increased fat intake (Haghighi et  al. 2013); and 

altered response to reward anticipation in the ventral stri‐

atum, an area associated with risk taking and drug use 

(Muller et al. 2013). In addition, highlighting the role of 

altered nicotinic pathways in the disruption of neural cir‐

cuits from prenatal tobacco exposure, changes in striatal 

volume, and a propensity for drug use in adolescent off‐

spring have been linked to interactions between prenatal 

exposure to cigarette smoking and a polymorphism in 

the gene encoding the α6 nAChR (Lotfipour et al. 2010). 

Structural alterations in the orbital frontal cortex have 

also been shown to result from interactions between 

maternal cigarette smoking during pregnancy and poly‐

morphisms of brain‐derived neurotrophic factor, a growth 

factor that regulates growth and differentiation of new 

neurons and supports existing neurons (Lotfipour et  al. 

2009). Although these clinical findings are specific to con‐

ventional cigarettes, they converge with results of animal 

studies of the effects of prenatal nicotine on brain reward 

centers and thus highlight the potential pernicious effects 

of e‐cigarettes in pregnant women.

Animal studies have shown that the dopamine 

system, which is critically involved in satisfaction‐seeking 

or appetitive behaviors, is modulated by nAChRs from the 

fetal period to adulthood (Azam et al. 2007). Prenatal nico‐

tine exposure alters dopamine’s content, turnover, release, 

and receptor expression in forebrain regions, which are 

important for motor and cognitive functions (Navarro 

et al. 1988; Richardson and Tizabi 1994; Muneoka et al. 

1999; Zhu et al. 2012) and for assigning motivational value 

to natural and drug rewards (Kohlmeier 2015; McNair and 

Kohlmeier 2015). Prenatal exposure to nicotine also mod‐

ifies the structure of dendritic targets of dopamine inner‐

vations in the nucleus accumbens (a critical component 

of reward learning and addiction) (Mychasiuk et al. 2013) 

and alters neuronal signaling that affects dopamine func‐

tion (Chang et al. 2013; Morgan et al. 2013).

Prenatal exposure to nicotine has been shown in 

a variety of animal studies to induce complex effects on 

behavioral response to natural rewards. Although adoles‐

cent offspring of nicotine‐exposed mothers show an ini‐

tial decrease in motivation to work for sucrose reward 

(Franke et al. 2008), they exhibit enhanced sensitivity to 

the rewarding effects as the task becomes harder (Lacy 

et  al. 2012). Prenatal exposure to nicotine also results 

in enhanced intake of fatty foods, with no change in the 

intake of normal chow (Chang et al. 2013).

Attention and Cognition. Numerous human 

studies have investigated the effects of maternal cigarette 

use during pregnancy on disruptive behavior and atten‐

tion deficits in the child. The 2014 Surgeon General’s 

report included results of a systematic review of effects 

of maternal cigarette use during pregnancy on disrup‐

tive‐behavior disorders—including ADHD, conduct dis‐

order, and ODD—in offspring (USDHHS 2014). The 

evidence for effects of maternal cigarette use during 

pregnancy on disruptive‐behavior disorders, and ADHD 

in particular, was suggestive but not sufficient to infer 

a causal relationship. Several systematic reviews using 

meta‐analyses have found evidence for associations 

between exposure to maternal cigarette use during preg‐

nancy and ADHD in offspring, including dose–response 

relationships between number of cigarettes smoked per 

day and ADHD symptoms (Linnet et  al. 2003; Langley 

et  al. 2005; Latimer et  al. 2012; Massey et  al. 2016). 

However, similar to effects on nicotine dependence and 

obesity in offspring, the possibility of unmeasured con‐

founding remains (D’Onofrio et  al. 2008; Thapar et  al. 

2009; Langley et  al. 2012). Evidence for associations 

with maternal cigarette use during pregnancy is perhaps 

more consistent for offspring conduct disorders than it 

is for ADHD. In particular, although some studies that 

used a gene–environment interaction design or a pro‐

pensity score‐matching approach to exposure to control 

for confounding, they found no effect of maternal cig‐

arette smoking during pregnancy on conduct disorders

(D’Onofrio et al. 2008; Gilman et al. 2008; Boutwell and 

Beaver 2010; Lavigne et al. 2011). However, several other 

studies—including a meta‐analytic review across three 

studies using “genetically sensitive”2

2Genetically sensitive designs typically include monozygotic and dizygotic twins and a broader inclusion of sibling pairs, mother–child 

pairs, and grandparent–grandchild pairs. Genetically sensitive multigroup designs allow for simultaneous testing of additive and nonadditive genetic, common, and specific environmental effects, including cultural transmission and twin-specific environmental influences.

research designs—

have suggested a direct causal relationship between 

maternal smoking during pregnancy and conduct disor‐

ders in offspring (McCrory and Layte 2012; Gaysina et al. 

2013; Kuja‐Halkola et  al. 2014; Estabrook et  al. 2015; 

Paus and Pausova 2015).

To explore the potential role of nicotine exposure in 

these associations, a small number of studies have included 

a prospective measure of confirmed tobacco exposure, 

maternal cotinine levels, in addition to maternal report 

of smoking, to study relationships with disruptive behav‐

iors among offspring (Wakschlag et al. 2011; O’Brien et al. 

2013; Massey et al. 2016). Wakschlag and colleagues (2011) 

found associations between maternal cigarette smoking 

and aggression and noncompliance among offspring. 

Studies have also shown alterations in the structure and 
Health Effects of E-Cigarette Use Among U.S. Youth and Young Adults 113

E-Cigarette Use Among Youth and Young Adults

function of the orbital frontal cortex, a  region impor‐

tant for emotional regulation and cognition, in relation 

to maternal cigarette smoking during pregnancy (Toro 

et al. 2008; Bennett et al. 2009). Consistent with animal 

models of altered dopamine regulation, two studies have 

shown interactions of maternal cigarette smoking during 

pregnancy with dopamine regulation genotype (DAT1) in 

influencing disruptive‐behavior phenotypes in offspring 

(Wakschlag et  al. 2011; O’Brien et  al. 2013). In another 

study, Wakschlag and colleagues (2010) demonstrated a 

sex‐dependent interaction of maternal smoking during 

pregnancy with monoamine oxidase A (MAOA) geno‐

type, which is associated with the development of anti‐

social behavior. In this study, maternal smoking during 

pregnancy further increased the risk for conduct disorder. 

In sum, although issues of confounding remain, much 

evidence from human studies is suggestive of a causal 

association between maternal cigarette smoking during 

pregnancy and disruptive behaviors among offspring. 

This was confirmed by the 2014 Surgeon General’s report 

on tobacco (USDHHS 2014). Since then, newer studies, 

controlling for personal and genetic confounders, have 

reported significant associations as well as nonsignificant, 

attenuated associations. Biologic evidence of nicotine‐

induced alterations in dopamine regulation also provides 

a possible mechanism for the role of nicotine in these 

outcomes.

Animal studies have shown that cholinergic modu‐

lation of prefrontal cortex function, via nAChRs, is essen‐

tial for attention and cognition (Poorthuis and Mansvelder 

2013; Proulx et  al. 2014). Prenatal exposure to nicotine 

alters the morphology and nAChR functional response of 

prefrontal cortical neurons (Mychasiuk et al. 2013; Bailey 

et al. 2014). When tested as adolescents, animals that were 

exposed prenatally to nicotine show some behaviors char‐

acteristic of ADHD. For example, exposed offspring were 

found in two studies to show less impulse control and/or 

slower learning acquisition on two cognitive tests that tax 

attentional processes (Sorenson et  al. 1991; Schneider 

et al. 2012). In addition, some studies have found hyper‐

activity in exposed offspring (Pauly et al. 2004; Schneider 

et al. 2012; Zhu et al. 2012), which was found in another 

study to be transmitted via maternal lineage from one 

generation to the next and to be ameliorated by methyl‐

phenidate treatment across all generations, showcasing 

the long‐term impact of prenatal nicotine exposure (Zhu 

et al. 2014a). This transgenerational transmission of pre‐

natal nicotine‐induced hyperactivity must reflect long‐

term changes to the epigenome (Leslie 2013). Finally, 

emerging animal studies suggest that prenatal exposure 

to nicotine affects the proliferation and maturation of 

progenitor cells to glutamatergic neurons during neu‐

rodevelopment in the medial prefrontal cortex, resulting 

in behavioral impairments in attentional function and 

behavioral flexibility in adulthood (Aoyama et  al. 2016; 

Poon and Leibowitz 2016; Powell et al. 2016).

Summary

Because of the rising prevalence of e‐cigarette use, 

there is potential for widespread nicotine exposure to 

youth and young adults, resulting in nicotine addiction 

and related harmful consequences associated with expo‐

sure to nicotine. During pregnancy, there is neural sensi‐

tivity to the number and volume of substances, including 

nicotine, transported through the placenta. From pre‐

natal development through adolescence and early adult‐

hood, exposure to nicotine poses a serious threat, because 

these are critical times for brain development and brain 

plasticity. Furthermore, youth and young adults are more 

vulnerable than adults to the long‐term consequences 

of nicotine exposure, including susceptibility to nicotine 

addiction and potentially reduced impulse control, deficits 

in attention and cognition, and mood disorders. An addi‐

tional public health concern is exposure to e‐cigarettes 

among persons who have never used conventional tobacco 

products. If the prevalence of e‐cigarette use continues to 

rise among those who do not use conventional tobacco 

products, the harmful consequences of exposure to nico‐

tine will rise accordingly.

The 2014 Surgeon General’s report (USDHHS 2014) 

states there is sufficient evidence to infer that: (a) nicotine 

activates multiple biological pathways through which 

smoking increases risk for disease; (b) nicotine expo‐

sure during fetal development, a critical window for brain 

development, has lasting adverse consequences for brain 

development; (c) nicotine adversely affects maternal and 

fetal health during pregnancy, contributing to multiple 

adverse outcomes such as preterm delivery and stillbirth; 

and (d) nicotine exposure during adolescence, a critical 

window for brain development, may have lasting adverse 

consequences for brain development and cognition. The 

literature presented in this section attempts to differen‐

tiate the risks to fetal and child health associated with nic‐

otine in tobacco versus nicotine alone or in e‐cigarettes. 

Evidence is sufficient to conclude tobacco use increases 

the risk of SIDS (USDHHS 2014), but further research 

is necessary with regard to nicotine alone or nicotine in 

e‐cigarettes. The review finds evidence that tobacco is 

associated with structural brain changes and alterations 

in cognition, attention, and appetitive behaviors in human 

offspring. Less well known is the role that nicotine plays 

in mediating these associations, although animal models 

provide support for a role for nicotine in these outcomes. 

nAChRs, the chief receptor targets for nicotine, are widely 

expressed in the fetal brain, and their normal functioning 
A Report of the Surgeon General

114 Chapter 3

is negatively affected by smoking and, in animals, by pre‐

natal exposure to nicotine through experimental treat‐

ment. Furthermore, both human genetic studies and 

animal studies implicate a neurotoxic effect of fetal nic‐

otine exposure. Pregnant women and women intending 

to become pregnant should be cautioned against using 

e‐cigarettes to avoid unnecessary nicotine exposure to 

their baby.

Effects of the Inhalation of Aerosol 

Constituents Other than Nicotine

The scientific literature on the health effects of expo‐

sure to constituents other than nicotine in the e‐cigarette 

aerosol is still developing. One study found that after 

5 minutes of ad lib e‐cigarette use, healthy adult cigarette 

smokers showed an increase in airway resistance, but 

no effect on other spirometry parameters such as forced 

vital capacity (FVC), forced expiratory volume in 1 second 

FEV1, and ratios of these values (FEV1/FVC) (Vardavas 

et al. 2012).

A noninvasive marker of airway inflammation is 

the fraction of exhaled nitric oxide (FeNO) (Taylor et al. 

2006; Munakata 2012). NO is a gaseous molecule that pro‐

duces vasodilation and bronchodilation (decreasing resis‐

tance in the respiratory airway and increasing airflow to 

the lungs). FeNO is reduced by acute and chronic ciga‐

rette smoking (resulting in poorer vasodilation and bron‐

chodilation) and is increased among smokers following 

cessation (see Vleeming et al. 2002 for a review). Studies 

examining current adult cigarette smokers revealed a 

reduction in FeNO after use of an e‐cigarette with and 

without nicotine (Vardavas et al. 2012; Marini et al. 2014; 

Ferrari et al. 2015). One study found that these reductions 

did not differ significantly between e‐cigarettes containing 

nicotine and those without nicotine (Marini et al. 2014), 

suggesting non‐nicotine factors mediated the effect.

However, a study of occasional smokers (<10 cig‐

arettes per week), but non‐e‐cigarette users, found an 

increase in FeNO after use of an e‐cigarette containing 

nicotine (Schober et  al. 2014). Furthermore, this study 

found no statistical difference in FeNO after use of an 

e‐cigarette not containing nicotine. This variation in 

findings suggests the impact of e‐cigarette use on FeNO 

may vary based on smoking history, nicotine content of 

e‐liquid, or other environmental or biological factors.

Limited studies have examined chronic exposure 

on the potential inhalation toxicity of PG and VG. Prior 

to e‐cigarettes, consumer products containing these 

chemicals were almost exclusively liquids or creams, or 

the substance was contained in a matrix. Animal models 

have shown few toxicological effects resulting from nose‐

only exposure to VG aerosol, with the exception of min‐

imal or mild squamous metaplasia in rats exposed to the 

highest concentration (0.662 mg glycerol) for 13 weeks 

(Anderson et  al. 1950; Renne et  al. 1992). Other inhala‐

tion studies testing PG in rats and monkeys did not observe 

treatment‐related effects on respiratory physiology, clin‐

ical chemistry, hematology, gross pathology, or respiratory 

tract histology (Robertson et  al. 1947). However, neither 

of these studies examined potential inhalation toxicity of 

PG and VG in humans using e‐cigarette devices. In sum‐

mary, other than nicotine, very little is known from human 

studies about the long‐term health effects of inhaling PG 

and VG from e‐cigarette aerosol, although adverse effects 

have been detected in animal models. Further investigation 

would improve our understanding of the effects of nicotine‐

related compounds, aerosolized solvents (PG and VG), aero‐

solized flavorants, aerosolized adulterants in e‐liquids, and 

toxicants produced during the aerosolization process—or a 

combination of these chemicals.

Aerosolized Nicotine‐Related Compounds

The nicotine used in e‐liquids is extracted from 

tobacco. The extraction process may produce some poten‐

tially harmful tobacco‐specific impurities, including 

minor alkaloids like nornicotine, anatabine, anabasine, 

myosmine, cotinine, nicotine‐N‐oxides (cis and trans iso‐

mers), β‐nicotyrine, and β‐nornicotyrine (Etter et al. 2013; 

Farsalinos et al. 2015a; Lisko et al. 2015; Oh and Shin 2015). 

The correlation between nicotine and the concentrations of 

minor alkaloids is much stronger in conventional tobacco 

products (Jacob et al. 1999) than in e‐cigarettes (Lisko et al. 

2015). While the cause of these differing concentrations of 

minor alkaloids is unknown, Lisko and colleagues (2015) 

speculated potential reasons may derive from the e‐liquid 

extraction process (i.e.,  purification and manufacturing) 

used to obtain nicotine from tobacco, as well as poor quality 

control of e‐liquid products.

The American E‐Liquid Manufacturing Standards 

Association (2014), an industry group with no regula‐

tory authority, has called for the use of U.S. Pharmacopeia 

(USP)‐grade nicotine in its e‐cigarette products. USP 

specifications for nicotine allow for a maximum of 

0.5% (5 mg/g) of a single impurity and 1% (10 mg/g) of 

total impurities (U.S. Pharmacopeia n.d.). Although the 

health implications of nicotine‐related impurities are not 

known, toxicology studies are needed to demonstrate the 

effects of high levels of these products.
Health Effects of E-Cigarette Use Among U.S. Youth and Young Adults 115

E-Cigarette Use Among Youth and Young Adults

Aerosolized Solvents

Although e‐cigarettes produce PG aerosols at levels 

known to cause eye and respiratory irritation to both 

users and nonusers (Offermann 2015), only mild effects 

(e.g., upper respiratory irritation) have been described 

in humans exposed to PG mist for 1 minute (Wieslander 

et al. 2001), and little is known about long‐term effects. 

Inhaling PG can increase the risk of developing asthma 

(Choi et al. 2010). Animal studies of PG and VG aerosol‐

izing agents not produced by e‐cigarettes concluded that 

these substances are relatively safe when inhaled by ani‐

mals for up to 28 days (Werley et al. 2011) or 18 months 

(Robertson et al. 1947).

Particles emitted from e‐cigarettes are assumed 

to be formed from supersaturated PG (i.e., concentra‐

tion beyond the point of saturation) in e‐liquids (Schripp 

et al. 2013). Several studies designed to characterize the 

aerosol generated by e‐cigarettes examined the chemical 

composition of the particles and their concentrations as 

measured by their number and distribution by size (Trehy 

et al. 2011; Ingebrethsen et al. 2012; Schripp et al. 2013; 

Zhang et al. 2013; Fuoco et al. 2014; Ruprecht et al. 2014; 

Saffari et  al. 2014 ; Mikheev et al. 2016). E‐cigarettes 

are recognized as a new source of submicron‐sized par‐

ticles, leading to possible high exposure to these parti‐

cles in users. Concentrations in the range of 109 particles 

× cm‐3 were measured in the mainstream of e‐cigarette 

and colleagues (2013) found that under the conditions 

of a single‐puff experiment, an e‐cigarette generated an 

aerosol having particle sizes in the range of 100–600 nm 

(nanometers), similar to that of conventional cigarettes. 

Mikheev and colleagues (2016) reported that the size dis‐

tribution of e‐cigarette aerosol differs from that of com‐

bustible tobacco smoke and that e‐cigarettes normally 

exhibit a bimodal particle size distribution: nanoparti‐

cles (11–25 nm count median diameter) and submicron 

particles (96–175 nm count median diameter). Each 

mode has comparable number concentrations 

aerosols (Fuoco et al. 2014). An in vitro study by Zhang 

(107–108

particles/cm3). Goel and colleagues (2015) detected radi‐

cals in aerosols from all e‐cigarettes and e‐liquids tested 

(2.5−10.3 x1013 radicals per puff at 3.3 V [voltage]), from 

e‐liquid solvents PG and VG, and from “dry puffing” (over‐

heating of e‐liquid) (Farsalinos et al. 2015c).

Because the aerosols deriving from e‐liquids are 

mainly made of droplets that are expected to dissolve as 

they reach the lung’s epithelium, not only the number but 

also the volume (size) of particles needs to be considered. 

Manigrasso and colleagues (2015) found that e‐cigarettes 

are a source of extremely high doses of particles in the 

human respiratory system. On average, 6.25 ×1010 par‐

ticles were deposited in the respiratory tree after a single 

2‐second puff, an estimated 30% of the daily doses of par‐

ticles for a nonsmoking person. After 10 puffs, the relevant 

mean‐layer thickness of the e‐liquid on the lung epithe‐

lium was comparable to the thickness of surfactant layer 

covering the alveolar and bronchial regions, suggesting 

a higher susceptibility to irritant endpoints (Manigrasso 

et al. 2015). These results demonstrate that e‐cigarettes 

produce submicron‐sized particles and highly oxidizing 

free radicals that may present a potential toxicologic risk 

to e‐cigarette users.

Aerosolized Flavorants

Little is known about the flavorants used in 

e‐cigarettes, and more than 7,700 unique flavors are on 

the market (Zhu et al. 2014b). Flavored e‐cigarette prod‐

ucts are popular with adult users, and sweet and candy‐

like flavors may make these products attractive to children 

and adolescents (Villanti et  al. 2013; Farley et  al. 2014; 

King et al. 2014). Many of the chemicals used in e‐liquid 

flavorings are “generally recognized as safe” for ingesting 

(e.g., in food). However, these substances have not been 

tested adequately for safety when heated at various tem‐

peratures when inhaled in aerosolized form (Barrington‐

Trimis et al. 2014). The Flavor and Extract Manufacturers 

Association of the United States (2015), in an official state‐

ment, notes that ingredients in flavors are evaluated for 

exposure through ingestion only; thus, any results cannot 

be extrapolated to use through inhalation. Further, fla‐

voring compounds often remain undeclared on e‐cigarette 

and e‐liquid packaging (Tierney et al. 2016).

CDC tested 36 e‐cigarette products for 10 flavor 

compounds commonly used as additives in tobacco prod‐

ucts (Lisko et al. 2015). Measurable levels of eucalyptol and 

pulegone were found in the menthol‐flavored varieties for 

all manufacturers. Menthol concentrations ranged from 

3,700 to 12,000 μg/g in flavored e‐liquids, levels similar 

to those found in the filler of conventional cigarettes. 

Interestingly, menthol was found at low concentrations in 

40% of the tobacco‐flavored nonmenthol products tested. 

Other flavor compounds found were camphor, methyl, 

salicylate, pulegone, cinnamaldehyde (CAD), and eugenol 

(Lisko et al. 2015).

Tierney and colleagues (2016) analyzed 30 e‐cigarette 

products on the U.S. market and found 13 products con‐

tained more than 1% flavor chemicals by weight. Among 

the chemicals identified were aldehydes (e.g., benzalde‐

hyde and vanillin), which are categorized as primary irri‐

tants of the respiratory tract (Roberts et al. 2015). Tierney 

and colleagues (2016) also found that tobacco‐flavored 

e‐liquids were derived from confection‐flavored chemicals 

(e.g., bubble gum and cotton candy flavoring) rather than 

tobacco extract.
A Report of the Surgeon General

116 Chapter 3

Some chemicals in e‐cigarettes, although approved 

for ingestion, have established adverse health effects when 

inhaled. In vitro studies of cytotoxicity suggest that dif‐

ferent flavored e‐cigarette products may vary in their 

potential to adversely affect health. Bahl and colleagues 

(2012) reported cytotoxic effects of the solutions used in 

e‐cigarettes that were not attributable to the nicotine but 

to the concentration of chemicals employed as flavors. 

These effects were most pronounced on mouse neural 

stem cells and human embryonic stem cells compared to 

human pulmonary fibroblast (Bahl et al. 2012).

Similar findings were reported by Behar and col‐

leagues (2014) who found a greater cytotoxic effect 

of flavored e‐liquid solutions on human embryonic 

stem cells compared to human pulmonary fibroblast. 

Further, two  cinnamon‐related chemicals, CAD and 

2‐methoxycinnamaldehyde, were particularly cytotoxic at 

doses found in the refill liquids (Behar et al. 2014). CAD, 

which is derived from the essential oil of cinnamon bark, is 

a highly bioactive compound (Jayaprakasha and Rao 2011). 

It has been used as an anticancer agent (Nagle et al. 2012), 

an insecticide (Cheng et al. 2009), and a bactericide (Nostro 

et al. 2012), and it is employed commercially as an additive 

in many foods and fragrances (Cocchiara et al. 2005).

Farsalinos and colleagues (2014a) analyzed 

159 e‐liquids obtained from a variety of manufacturers and 

retailers in Europe and the United States for the presence 

of two flavorings: diacetyl (DA) and acetyl propionyl (AP). 

The study revealed that these substances were present in 

the majority of the samples tested, with a significant pro‐

portion containing both chemicals. Furthermore, Allen and 

colleagues (2016) detected DA above the laboratory limit 

of detection in 39 of 51 flavors tested. DA, also known as 

2, 3‐butanedione, is a member of a general class of organic 

compounds referred to as diketones, α‐diketones, or 

α‐dicarbonyls. It provides a characteristic buttery flavor, 

is naturally found in various foods, and is used as a syn‐

thetic flavoring agent in food products such as butter, car‐

amel, cocoa, coffee, dairy products, and alcoholic beverages. 

Although it is generally recognized as safe when ingested, 

it has been associated with a decline in respiratory func‐

tion in persons exposed to it through inhalation (Egilman 

et al. 2011; Clark and Winter 2015). Inhaling DA and arti‐

ficial butter‐flavored powders and aerosols can cause fixed 

obstructive lung disease in exposed workers (Chaisson et al. 

2010). In addition, it has been implicated in the develop‐

ment of bronchiolitis obliterans, an irreversible respiratory 

disease also called “popcorn lung disease” (Harber et  al. 

2006). AP, also called 2, 3‐pentanedione, is a α‐diketone 

that is chemically and structurally similar to DA. Although 

it has become a popular replacement for DA, acute inhala‐

tion exposure to AP has been shown to cause airway epithe‐

lial damage similar to DA (Hubbs et al. 2012).

The analysis by Farsalinos and colleagues (2014a) 

found that 74.2% of the sample contained one or both 

of these chemicals, with 69.2% of the sample containing 

DA. Both DA and AP were found in 28.3% of the sample 

e‐liquids. These chemicals were detected even in samples 

coming from manufacturers that stated these flavorings 

were not present in their products. However, exposure 

to DA and AP was 100 and 10 times lower, respectively, 

than exposure to these chemicals from cigarette smoking. 

Few studies have examined safe levels of DA and AP via 

tobacco product; however, 47.3% of DA‐ and 41.5%  of 

AP‐containing samples exposed consumers to levels higher 

than the safety limits outlined by the National Institute 

for Occupational Safety (NIOSH) for occupational expo‐

sure. This exposure threshold outlined by NIOSH is not 

intended to suggest exposure at or below that limit should 

be considered sufficiently safe (Hubbs et al. 2015).

Aerosolized Adulterants

TSNAs, potent carcinogens identified in tobacco 

and tobacco smoke, include N‐nitrosonornicotine (NNN), 

4‐(methylnitrosamino)‐1‐(3‐pyridyl)‐1‐butanone (NNK), 

N‐nitrosoanabasine (NAB), and N‐nitrosoanatabine 

(NAT) (Hecht 1998, 1999; USDHHS 2010, 2014). NNN 

and NNK are classified by the International Agency for 

Research on Cancer (IARC) as Group 1 human carcino‐

gens (IARC 2004). Their presence in e‐liquids is mostly 

attributable to the processes used in extracting nicotine 

from tobacco leaves or the addition of tobacco flavorings 

(Kim and Shin 2013; Cheng 2014). These compounds are 

formed from their alkaloid precursors and from nitrite or 

nitrate, predominantly during tobacco curing, fermen‐

tation, and aging. NNN, NAB, and NAT are formed pri‐

marily from their corresponding secondary amines (nor‐

nicotine, anatabine, and anabasine) in the early stages of 

tobacco curing and processing, while the majority of NNK 

is formed from the tertiary amine nicotine at the later 

stages of tobacco curing and fermentation (Hecht 1998). 

Nitrosation reactions of corresponding amines can occur 

in e‐liquids, especially during inadequate storage or man‐

ufacturing processes; inadequate storage is believed to 

increase the levels of NNN as a consequence of the nitro‐

sation of nornicotine converted from nicotine in liquids 

(Kim and Shin 2013).

Some studies have identified traces of TSNAs in 

e‐liquids, but at levels far below those seen in combustible 

tobacco (Trehy et al. 2011; Farsalinos et al. 2015a). Further, 

Goniewicz and colleagues (2014b) found that the aerosol of 

some e‐cigarettes contains traces of the carcinogenic nitro‐

samines NNN and NNK, but neither was detected in aerosol 

from the Nicorette inhalator (an NRT product).
Health Effects of E-Cigarette Use Among U.S. Youth and Young Adults 117

E-Cigarette Use Among Youth and Young Adults

Several studies have reported the presence of other 

hazardous compounds in e‐liquids or in the aerosol pro‐

duced by e‐cigarettes (Exponent Inc. 2009; Hadwiger et al. 

2010; Lim and Shin 2013; Uchiyama et al. 2013; Williams 

et  al. 2013; Bekki et  al. 2014; Goniewicz et  al. 2014a,b; 

Kosmider et al. 2014; Jensen et al. 2015; Kavvalakis et al. 

2015; Laugesen 2015; Oh and Shin 2015; Varlet et al. 2015; 

Khlystov and Samburova 2016). For example, an FDA study 

detected the presence of amino‐tadalafil and rimonabant in 

e‐liquids (Hadwiger et al. 2010); amino‐tadalafil is a struc‐

tural analogue of tadalafil, the active pharmaceutical ingre‐

dient in Cialis, a prescription drug approved in the United 

States for treatment of erectile dysfunction. Rimonabant 

(trade name Zimulti) was approved in Europe for the treat‐

ment of obesity, but its marketing authorization was with‐

drawn by the European Medicines Agency in 2009. FDA 

approval of this drug has been withheld because of unre‐

solved issues involving rimonabant therapy and increased 

frequencies of psychiatric adverse events, including suicide 

and an ill‐defined constellation of neurologic symptoms 

and seizures (FDA 2007). The presence of unapproved active 

pharmaceutical ingredients suggests that some e‐cigarettes 

may expose users to pharmacologically active substances 

with undocumented and unknown effects.

Oh and Shin (2015) conducted a study to identify 

and quantify the presence of diethyl phthalate (DEP) and 

diethylhexyl phthalate (DEHP) in e‐liquids. DEP is used 

as a solvent to bind cosmetics and fragrances and in var‐

ious industrial applications, including plasticizers, deter‐

gent bases, and aerosol sprays. DEHP is used widely as a 

plasticizer in the manufacture of articles made of poly‐

vinylchloride. DEP and DEHP were detected in 47.6% and 

79.1% of e‐liquids, respectively, with concentration 

ranges of 0.01–1745.20 mg/L and 0.06–81.89 mg/L (Oh 

and Shin 2015). Both DEP and DEHP have estrogenic 

and antiandrogenic activity that cause premature breast 

development in girls. DEHP is classified by IARC as a pos‐

sible carcinogen in humans (IARC 2000). Although the 

amounts of the two phthalates detected in this study were 

lower than the safety levels, the source of these toxicants 

is unknown, perhaps coming from packaging materials 

and the production procedure.

Carbonyls are present in e‐cigarettes, and levels 

increase with device voltage (Kosmider et  al. 2014; 

Jensen et al. 2015). Long‐term exposure to carbonyl 

compounds, such as formaldehyde, acetaldehyde, and 

acrolein, increases the risk of cancer. IARC and the U.S. 

Environmental Protection Agency (EPA) have classified 

formaldehyde as “carcinogenic to humans” (USDHHS 

1999; IARC 2009). EPA has set the acceptable daily intake 

(ADI) of formaldehyde as 0.2 mg/kg (kilograms) body 

weight and has warned of the potential adverse health 

effects of exceeding ADI. Acetaldehyde is also toxic, an 

irritant, and a probable carcinogen (USDHHS 1999). 

Acrolein is toxic through all routes of administration and 

may cause respiratory and ocular irritation (Faroon et al. 

2008; Bein and Leikauf 2011). Acrolein in cigarette smoke 

has been linked to several pulmonary diseases, including 

increased risk of lung cancer (Feng et al. 2006), as well 

as asthma and chronic obstructive pulmonary disease 

(Bein and Leikauf 2011). One study found an association 

between acrolein exposure and risk of cardiovascular dis‐

ease (DeJarnett et al. 2014).

Lim and Shin (2013) detected formaldehyde and 

acetaldehyde in 225 replacement liquids for e‐cigarettes 

purchased in Korea, with ranges of 0.02–10.09 mg/L (mean 

2.16 mg/L) and 0.10–15.63 mg/L (mean = 4.98 mg/L). 

Although the amounts of formaldehyde and acetalde‐

hyde detected in replacement liquids for e‐cigarettes are 

relatively low compared to conventional cigarettes, they 

should be controlled to the lowest possible concentrations 

in raw materials, as they may be formed when e‐liquids 

are heated. Furthermore, as larger capacity batteries 

and heating mechanisms are developed (Farsalinos et al. 

2014b; Sleiman et al. 2016), users will be exposed to higher 

concentrations of formaldehyde, acetaldehyde, acro‐

lein, and other carbonyls (Kosmider et al. 2014). Jensen 

and colleagues (2015) reported formaldehyde concentra‐

tions higher than conventional cigarettes in high‐voltage 

e‐cigarettes. Havel and colleagues (2016) reported acetal‐

dehyde, acrolein, and formaldehyde generation increased 

markedly at voltages at or above 5 volts. Geiss and col‐

leagues (2016) reported that formaldehyde exceeded safety 

levels at the lowest wattage (5 watts), which is the wattage 

applied in most second generation e‐cigarettes.

Summary

Although some typical constituents of the e‐cigarette 

aerosol have been identified, the potential short‐ and long‐

term health consequences of inhalation of the heated and 

aerosolized constituents of the e‐liquids, including solvents, 

flavorants, and toxicants, still require further investigation 

to quantify health effects. Commercial and custom‐mixed 

e‐liquids are produced with undisclosed manufacturing 

procedures, packaging materials, and purity standards for 

their constituents, increasing the risks of potential health 

consequences. E‐cigarettes are a source of extremely high 

doses of fine particles (e.g., aerosol) in the human respira‐

tory system. Fine particles are emitted when the solvents 

PG and VG are aerosolized, and mild respiratory effects have 

been documented, but adequate assessments are lacking. 

An additional concern is the aerosolization and inhalation 

of flavor additives in e‐liquids. While some of the chemicals 

used may be generally recognized as safe for use in foods, 

they have not been thoroughly tested for their potential 
A Report of the Surgeon General

118 Chapter 3

sensitizing, toxic, or irritating characteristics when inhaled. 

Further, given the extent of possible variations in the ratio 

of flavor additives, with up to 7,700 unique e‐liquid vari‐

eties available (Zhu et al. 2014b), these chemicals may be 

toxic in the concentrations present in manufactured or 

do‐it‐yourself e‐liquids. Finally, other hazardous com‐

pounds and carcinogens have been detected in e‐liquids, or 

in the heated aerosol produced by e‐cigarettes, including 

formaldehyde, acetaldehyde, and acrolein.

Effects of Toxicants Produced 

During Aerosolization

A primary reason for investigating the health effects 

of heated and aerosolized e‐liquids is that, under such con‐

ditions, chemical reactions may result in the formation of 

new compounds (Sleiman et al. 2016). In some devices, 

the temperature in the center of a heating coil can exceed 

350°C, causing changes in the chemical components of 

the e‐liquid. When carbonyl compounds are present in the 

refill liquids, heating can enhance their concentrations in 

the aerosol (Talih et al. 2015). Carbonyl compounds result 

from dehydration and fragmentation of VG and PG, which 

can be oxidized to formaldehyde and acetaldehyde during 

heating. Hutzler and colleagues (2014) applied headspace 

gas chromatography‐mass spectrometry to enable incuba‐

tion of liquids at various temperatures. At 150°C, the levels 

of acetaldehyde and formaldehyde were found to be up to 

10‐fold higher than they were at ambient temperatures for 

samples in which PG was a main component. The gen‐

eration of carbonyl compounds seems to increase when 

liquids touch the heating element inside an e‐cigarette, 

which is indicated by a color change around the wire, as 

has been reported in some devices (Uchiyama et al. 2013). 

Evidence suggests when e‐liquid touches the heating ele‐

ment (heated nichrome wire), it is oxidized to formalde‐

hyde, acetaldehyde, acrolein, glyoxal, and methylglyoxal 

in the presence of oxygen (Bekki et al. 2014; Goniewicz 

et al. 2014b; Kosmider et al. 2014).

Several studies have reported that short‐chain alde‐

hydes, such as formaldehyde, acetaldehyde, or acrolein, are 

produced during heating. Uchiyama and colleagues (2013) 

measured carbonyl compounds in e‐cigarette aerosols 

generated according to the Canadian “intense regimen” 

(55mL puff volume, 2‐second puff duration, 30  seconds 

between puffs, and a total of 10 puffs). Thirteen brands of 

e‐cigarettes were assessed, and investigators detected sev‐

eral carbonyl compounds, such as formaldehyde, acetal‐

dehyde, acetone, acrolein, propanol, crotonaldehyde, and 

butanol. They also detected two other harmful carbonyl 

compounds that had not been detected in the mainstream 

smoke from conventional cigarettes: glyoxal and methyl‐

glyoxal. Jensen and colleagues (2015) observed that form‐

aldehyde‐containing hemiacetals can be formed during 

the aerosolization process. These molecules are known to 

release formaldehyde and are used as industrial biocides, 

but it is not currently known how formaldehyde‐releasing 

agents affect the respiratory tract.

The amount of carbonyl compounds in e‐cigarette 

aerosols varies substantially, not only among different 

brands but also among different samples of the same prod‐

ucts (Ohta et al. 2011; Bekki et al. 2014; Kosmider et al. 

2014; Jensen et al. 2015), from 100‐fold less than tobacco 

to nearly equivalent values. Notably, the amount of voltage 

the battery puts out affects the concentration of the car‐

bonyl compounds in the emission. Some e‐cigarettes allow 

users to increase aerosol production and nicotine delivery 

by raising the battery’s output voltage. In addition, some 

users elect to directly drip e‐liquid onto an exposed heater 

coil, reportedly for greater aerosol production and “throat 

hit.” Talih and colleagues (2015) showed that use of such 

direct‐drip atomizers may involve greater exposure to 

toxic carbonyls, including formaldehyde, because of the 

potentially higher temperatures reached by the coil. The 

adverse effects of acrolein (2‐propenal), an unsaturated 

aldehyde, depend on dose and cell type and are influenced 

by experimental conditions (Bein and Leikauf 2011). In 

vitro studies found that acrolein inhibits DNA repair and 

forms acrolein‐deoxyguanosine DNA adducts that are 

mutagenic (Wang et  al. 2009, 2012; Tang et  al. 2011). 

Despite the known DNA‐damaging effects of acrolein, its 

mutagenicity in mammalian cells remains uncertain, and 

according to an evaluation by the IARC, there is inade‐

quate evidence for carcinogenicity in humans or animals 

(IARC 1995). Because of its extreme toxicity, acrolein has 

been difficult to characterize in standard animal carcino‐

genicity tests. Animal experiments showed that acrolein 

can have a range of adverse effects, including a role in car‐

cinogenesis (Cohen et al. 1992); excessive mucus produc‐

tion and macrophage and neutrophil accumulation with 

consequent production of proinflammatory cytokines and 

proteases (Moretto et  al. 2012); damage to neurons and 

myelin disruption (Shi et al. 2011); and it may play a role 

in the progression of atherosclerosis and cardiovascular 

disease (Park and Taniguchi 2008; DeJarnett et al. 2014).

Other volatile organic compounds (VOCs) found 

in e‐cigarette aerosol include a variety of chemicals 

(e.g., aliphatic and aromatic hydrocarbons), some of 

which may have short‐ or long‐term adverse health 

effects. Benzene (classified as group 1 by IARC) and other 

solvents (toluene, xylenes, and styrene) could be present 

in e‐cigarettes because of their use in the extraction of 

nicotine from tobacco leaves. Goniewicz and colleagues 

(2014b) detected both toluene and m‐ and p‐xylene in 
Health Effects of E-Cigarette Use Among U.S. Youth and Young Adults 119

E-Cigarette Use Among Youth and Young Adults

e‐cigarette aerosols. A wide variety of other VOCs in 

e‐cigarette liquids produce aromas and flavor through 

heating (Tierney et al. 2016).

Heavy metals such as tin, lead, and nickel were dis‐

covered by Williams and colleagues (2013) in a brand of 

e‐liquids and the resulting aerosols. Those researchers 

analyzed the contents of e‐cigarette cartomizers (a poly‐

fill wrapped heating coil capable of longer puff durations 

than an atomizer) and the aerosols by using light and elec‐

tron microscopy, x‐ray microanalysis, particle counting, 

and inductively coupled plasma optical emission spec‐

trometry. The aerosol contained particles >1 μm that were 

composed of tin, silver, iron, nickel, aluminum, and sili‐

cate, and nanoparticles (<100 nm) of tin, chromium, and 

nickel. Small particles composed of various elements (tin, 

other metals, semimetals, and silicates) passed through 

the cartomizer fibers and were present in aerosols. 

These particles likely originated from parts of the device 

(i.e., atomizer/cartomizer) (Williams et al. 2013).

Concentrations of 9 of the 11 elements in e‐cigarette 

aerosol identified by Williams and colleagues (2013) 

were higher than or equal to concentrations in conven‐

tional cigarette smoke. Many of the metals identified in 

e‐cigarette aerosol, such as lead and cadmium (Farsalinos 

et al. 2015b), are known to cause respiratory distress and 

disease (Zalups and Ahmad 2003). These metals are pro‐

duced by the aerosolization of e‐liquids (Farsalinos et al. 

2015b) and by flaws in e‐cigarette heating mechanisms 

and poor quality control (Williams et al. 2013; Farsalinos 

et al. 2015b; Mikheev et al. 2016). While these initial anal‐

yses indicate potential exposures, additional measures are 

needed because of challenges in measuring trace levels of 

metals.

Summary

E‐liquids produce chemical reactions that may result 

in the formation of new, harmful compounds. Carcinogens 

(e.g., formaldehyde, acetaldehyde, and acrolein) and toxic 

heavy metals (e.g., lead and cadmium) have been found 

in e‐cigarette aerosols in laboratory tests conducted at 

temperatures within the range of most e‐cigarette prod‐

ucts. These chemicals and metals have been detected in 

e‐liquids and e‐cigarette aerosols, signifying the need for 

further study on the potential short‐ and long‐term health 

ramifications.

A limitation to understanding the health impact 

of chemical reactions is the heterogeneity of e‐cigarette 

devices (e.g., voltage), e‐liquids (e.g., quality, content), 

and use behaviors (e.g., puff duration), as emissions 

may be altered by any combination of these mechanical 

and behavioral differences. Further, it is difficult to fully 

contextualize the carcinogenic emissions of e‐cigarette 

aerosol given the diversity of products currently available, 

as well as those that may become available as the devices 

continue to evolve (Farsalinos et al. 2014b).

Effects Not Involving Inhalation of 

Aerosol by the E‐Cigarette User

Health effects not attributable to direct inhalation 

of e‐cigarette aerosol include explosion or fire associ‐

ated with malfunctioned devices, poisoning through con‐

tact exposure or intentional or unintentional ingestion 

of e‐liquid, and exposure to secondhand aerosol or its 

condensate.

Health Effects Attributable to Explosions and 

Fires Caused by E‐Cigarettes

Most reports of explosions and fires caused by 

e‐cigarettes have appeared in print and online media and 

on televised programs. From August 2009 to March 2014, a 

search of U.S. media by the U.S. Fire Administration (2014) 

found 25 reports of e‐cigarette explosions or fires. These 

data suggest that the number of such events is small when 

compared with the number of e‐cigarette users. Of the 

25 incidents found in the search, 2 caused serious harm, 

and there were no deaths attributable to explosions. In most 

cases, the resulting fires did not spread far from the site of 

the explosion. However, in one case an entire bedroom was 

lost to fire (U.S. Fire Administration 2014). As for explo‐

sions, several have occurred during an e‐cigarette’s use, 

causing severe facial damage or injuries to bodies and hands 

(Brennan 2015; Corona and Marcus 2015; Duranty 2015; 

Fox 5 Digital Team 2015; Goff and Schwartz 2015; Jablow 

and Sexton 2015; Shastry and Langdorf 2016), but most 

occurred while the device’s batteries were being charged. 

Overcharging lithium batteries can lead to thermal run‐

away, causing the e‐cigarette battery or container to be 

propelled, often with portions catching fire (U.S. Fire 

Administration 2014; Bohr et al. in press).

Health Effects Caused by Ingestion of E‐Cigarette 

Liquids

The liquids in both e‐cigarettes and the con‐

tainers used to refill them can cause nicotine poisoning. 

Consequences of nicotine intoxication in the e‐liquid 

include nausea, vomiting, headaches, dizziness, and diar‐

rhea at low doses; seizures; tachycardia; abdominal pain; 

confusion; and even death (Cervellin et  al. 2013). The 

amount of nicotine needed to cause death in humans is 

uncertain and, according to a reevaluation, may be higher 

than previously thought (Mayer 2014). The total amount 
A Report of the Surgeon General

120 Chapter 3

of nicotine in refill liquids varies and can be as high as 

1,000 mg/10 mL in do‐it‐yourself bottles (Davis et  al. 

2015), which could be lethal if consumed (Mayer 2014).

The increase in poisonings prompted enactment of 

the Child Nicotine Poisoning Prevention Act of 2015 (2016) 

in January 2016. This law requires any container of liquid 

nicotine sold, manufactured, distributed, or imported 

into the United States be placed in special packaging 

that is difficult to open by children under 5 years of age. 

Although labels may indicate the concentrations of nico‐

tine, such labels can be incomplete, confusing, or inaccu‐

rate (Trtchounian and Talbot 2011; Cameron et al. 2014), 

and some bottles have not been labeled at all (Davis et al. 

2015). Of most concern, some bottles of e‐cigarette refill 

liquids labeled “no nicotine” have been found to contain 

significant amounts of that substance (e.g., 25.6 mg/mL; 

Trehy et al. 2011). Regardless, many e‐cigarette users may 

not be aware of the toxic effects of nicotine and may not 

know that refill liquids should be kept away from toddlers 

and children. These liquids are often sold in colorful bot‐

tles with flavors that are attractive to children (Bahl et al. 

2012). The liquids usually come in small dropper bottles 

that can be mistaken for bottles containing food dye or eye 

drops. Finally, many refill liquids are made in local “vape 

shops,” which have only recently come under FDA regu‐

lation (Federal Register 2016), with no uniform training 

process for mixers, a lack of standards and protections, 

and unknown concentrations of nicotine.

The rapid growth in popularity of e‐cigarettes and 

the ease with which refill liquids can be purchased have 

made e‐cigarettes an increasingly common item in many 

households, thereby elevating the possibility of accidental 

nicotine poisoning. Instances of related case reports, often 

involving children or infants, are increasing. For example, 

an 18‐month‐old girl was treated at an emergency room 

for hypertension and tachycardia after drinking about 

2 mL of refill liquid from a bottle on a nightstand (Shawn 

and Nelson 2013). Unintentional exposure to nicotine 

can occur through ingestion, absorption through the 

skin, inhalation, or dropping refill liquids into one’s eyes 

(Cantrell 2014).

Figure 3.2 shows data from 2011 to 2016 on expo‐

sures to e‐cigarettes or liquid nicotine (i.e., any con‐

tact with e‐cigarettes or liquid nicotine, not necessarily 

resulting in any health effects) (American Association of 

Poison Control Centers 2016). These data show a dramatic 

increase in exposures through 2014 with a slight reduc‐

tion of exposures in 2015. Fifty‐one percent of the calls to 

poison control centers regarding exposures to e‐cigarettes 

involved children 5 years of age or younger (CDC 2014). 

Increased e‐cigarette exposures have also been reported by 

state and local poison centers (Banerji et al. 2014; Cantrell 

2014; Guttenburg et al. 2014; Lee et al. 2014; California 

Department of Public Health 2015).

Secondhand Exposure to the 

Constituents of E‐Cigarette Aerosol 

Exposure to secondhand smoke from combustible 

tobacco products is a known cause of morbidity and mor‐

tality (USDHHS 2006). Secondhand smoke, a mixture of 

the sidestream smoke from a smoldering cigarette and the 

mainstream smoke exhaled by a smoker, is known to con‐

taminate both indoor and outdoor environments. In addi‐

tion, when the constituents of smoke deposit on surfaces, 

nonsmokers can be exposed to them via touch, ingestion, 

or inhalation. These deposited constituents of combustible 

smoke are known as “thirdhand smoke” (Matt et al. 2011; 

Protano and Vitali 2011). E‐cigarettes represent another 

potential source of exposure to toxicants for nonusers, via 

secondhand or thirdhand exposure to aerosol.

Exposure to Nonusers

In contrast to combustible tobacco products, 

e‐cigarettes do not produce sidestream emissions; aerosol 

is produced during activation of the device. Some of this 

aerosol is subsequently exhaled into the environment 

where nonusers may be exposed through inhalation, inges‐

tion, or dermal contact. As previously described in this 

chapter, constituents of the emissions may include nico‐

tine, carbonyl compounds, VOCs, polyaromatic hydro‐

carbons, TSNAs, heavy metals, and glycols. It is not clear 

how much of inhaled e‐cigarette aerosol is exhaled into 

the environment where nonusers can be exposed. Some 

studies have used machines to produce e‐cigarette aero‐

sols and measured the pollutants emitted (McAuley et al. 

2012; Czogala et al. 2014; Geiss et al. 2015); others have 

involved the use by one or more persons of an e‐cigarette 

and measured the change in pollutants in either a room 

or a test chamber after use (Schripp et al. 2013; Schober 

et al. 2014). One study measured airborne nicotine in the 

homes of e‐cigarette users (Ballbe et al. 2014). The concen‐

tration of e‐cigarette aerosol in a given microenvironment 

depends primarily on the strength of the source or the 

number of e‐cigarettes used and the emission rate of the 

aerosol for that device. E‐cigarettes, however, are heteroge‐

neous in their design and in the liquids used, and the spe‐

cific product combination significantly affects the second‐

hand emissions (Kosmider et al. 2014; Geiss et al. 2015). 

The number of puffs and depth of inhalation may be partic‐

ularly relevant to the amount exhaled by the user and may 

also affect e‐cigarette emissions (Talih et al. 2016).
Health Effects of E-Cigarette Use Among U.S. Youth and Young Adults 121

E-Cigarette Use Among Youth and Young Adults

Figure 3.2 Data showing exponential increase in the number of cases of human exposure to e‐cigarette products and 

liquid nicotine between 2011 and 2016

Source: American Association of Poison Control Centers (2016).

Note: These numbers reflect the closed human exposures to e‐cigarettes and liquid nicotine reported to poison centers as of July 31, 

2016. The numbers may change as cases are closed and additional information is received.

Movement of E‐Cigarette Aerosol

Similar to the case with secondhand tobacco smoke, 

e‐cigarette aerosol is an inherently dynamic mixture that 

changes over time in terms of constituents and concen‐

trations. Czogala and colleagues (2014) demonstrated a 

significant signal from a laser photometer indicating the 

presence of ambient aerosol in a room after e‐cigarette 

use. However, this aerosol disappeared in just seconds 

to a few minutes as it either evaporated to the gas phase 

or deposited on surfaces in the room. In contrast, in the 

same study, secondhand cigarette smoke exhibited a par‐

ticulate phase that stayed suspended in the room at high 

concentrations for more than 30 minutes. For the VOCs 

in e‐cigarette aerosol, such as formaldehyde, acrolein, and 

acetaldehyde, the source strength and ventilation rate will 

largely determine their concentration in indoor air. Semi‐

VOCs, such as nicotine and TSNAs, are also largely affected 

by sorption on and subsequent desorption from surfaces 

and dust in a room (Singer et al. 2002, 2003; Goniewicz 

and Lee 2015). The extent of this type of thirdhand con‐

tamination from e‐cigarettes in real‐world settings has 

not been established but would be of particular concern 

for children living in homes of e‐cigarette users, as they 

spend more time indoors, are in proximity to and engage 

in greater activity in areas where dust collects and may be 

resuspended (e.g., carpets on the floor), and insert non‐

food items in their mouths more frequently (EPA 2008; 

Matt et al. 2011).

Exposure to E‐Cigarette Aerosol and 

Considerations of Dose

A large body of studies has measured exposure to 

secondhand and thirdhand smoke from conventional 

cigarettes using personal or area air monitoring, sur‐

face testing, and dust testing. Studies of the exposure 

of e‐cigarette aerosol to nonusers, however, are limited. 

Schripp and colleagues (2013) observed small increases of 

fine and ultrafine particles and some VOCs, including PG, 
A Report of the Surgeon General

122 Chapter 3

flavoring substances, and nicotine, indicating passive inha‐

lation of e‐cigarette aerosols by nonusers in the presence 

of e‐cigarette users. Those authors demonstrated that the 

distribution in the sizes of the aerosol’s component par‐

ticles changes in the lungs and results in the exhalation of 

smaller particles, likely caused by the evaporation of the 

liquid particles in the lungs and in the environment after 

exhalation. Schober and colleagues (2014) found substan‐

tially higher amounts of PG, VG, particulate matter (PM), 

and nicotine in a 45‐m3 chamber during e‐cigarette use 

sessions with volunteers compared to controlled sessions. 

They also found a 20% increase in the level of polycyclic 

aromatic hydrocarbons (PAHs) and a 2.4‐fold increase in 

aluminum concentrations.

Williams and colleagues (2013) demonstrated con‐

tamination by metal and silicate particles in e‐liquid 

and its aerosol using scanning electron microscopy. In 

a different study measuring machine‐generated second‐

hand e‐cigarette aerosol in an emission chamber, Geiss 

and colleagues (2015) found significant levels of PG, VG, 

and nicotine in the chamber’s air. Carbonyl compounds 

of concern (e.g., formaldehyde, acetaldehyde, acrolein, 

and acetone) were below the limits of detection in this 

study. O’Connell and colleagues (2015), who assessed 

secondhand e‐cigarette emissions in a small meeting 

room (12.8  m2) with three e‐cigarette users during a 

165‐minute session, found a significant increase in PG but 

did not see the expected increase in VG or nicotine. This 

study reported no increase in PAHs, trace metals, TSNAs, 

or acrolein, but did find an increase in total VOCs, formal‐

dehyde, and acetaldehyde. However, the compounds were 

found at levels below guidelines for the quality of indoor 

air from the World Health Organization or European 

Union. Ruprecht and colleagues (2014) found signifi‐

cantly lower concentrations and counts for particles from 

an e‐cigarette used in a 50‐m3 room compared with con‐

ventional cigarettes. Interestingly, they also found that 

nicotine‐free e‐cigarettes produced higher particle levels 

than e‐cigarettes containing nicotine. Saffari and col‐

leagues (2014) found that total particulate exposure was 

10‐fold lower in e‐cigarettes than it was in conventional 

cigarettes. Emissions of heavy metals from e‐cigarettes 

were also dramatically less, with the exception of nickel, 

zinc sulfide, and silver, which showed higher emission 

rates from e‐cigarettes. PAH levels were not elevated by 

e‐cigarette use in this study.

Concentrations of PM, especially PM2.5, which is 

fine PM, and nicotine are the two most common markers 

used to measure exposure to secondhand smoke (Avila‐

Tang et al. 2010; Apelberg et al. 2013). Indirect measures 

of the mass concentration of PM from secondhand smoke 

using real‐time particle monitors are well validated in 

terms of the accuracy of these measurements in relation 

to other constituents of secondhand smoke and to health 

effects (Hyland et  al. 2008; Apelberg et  al. 2013). These 

same types of particle monitors are often used in studies 

of e‐cigarette aerosol to compare PM levels from conven‐

tional cigarettes with those from e‐cigarettes, though PM 

findings may not directly relate to the short‐ and long‐

term health effects of each product (Czogala et al. 2014; 

Schober et al. 2014).

Caution is warranted when interpreting the results 

of PM measurements comparing e‐cigarettes with conven‐

tional cigarettes. The aerosols produced are fundamentally 

different, with the former resulting from aerosolization of 

liquid and the latter resulting from combustion of organic 

matter. The true PM2.5 mass concentration of e‐cigarette 

aerosol from commonly used light‐scattering instruments 

(Czogala et al. 2014) cannot be determined without cali‐

brating the device to a reference standard for the aerosol 

in question. Even this calibration would be questionable 

given the highly volatile nature of e‐cigarette aerosol, 

making it difficult to capture and accurately determine 

the mass. Real‐time PM2.5 measurements such as this are 

useful, however, to determine the presence of an aerosol 

and to see the relative changes in this aerosol over time 

and under various conditions, such as changing source 

strength. Figure 3.3 shows the significant increase in 

aerosol concentration from e‐cigarettes after about 1 hour 

and the subsequent rapid decline, presumably from initial 

aerosolization and deposition of this aerosol. There may 

still be significant amounts of this e‐cigarette aerosol in 

the environment, but the particle monitor can no longer 

measure it, as it is either in the aerosol phase or deposited 

on surfaces. For these reasons, it is important not to rely 

solely on PM mass concentrations for determining expo‐

sure to e‐cigarette aerosol and for making comparisons 

with conventional cigarettes. Measurement of the indi‐

vidual toxicants of concern in the aerosol phase and on 

surfaces is warranted.

Health Effects of Secondhand Exposure to 

E‐Cigarette Aerosols

Flouris and colleagues (2012, 2013) conducted two 

clinical studies of the health effects of secondhand exposure 

to e‐cigarette aerosol. The researchers found no short‐term 

change in markers of complete blood count after 1 hour 

of exposure to e‐cigarette aerosol in a group of 15  non‐

smokers (Flouris et al. 2012). Similarly, the same exposure 

caused no significant change in short‐term lung function, 

although the results were of borderline statistical signifi‐

cance (Flouris et  al. 2013). However, these studies dem‐

onstrated that passive exposure to e‐cigarettes causes an 

increase in serum cotinine that is similar to that from pas‐

sive exposure to cigarette smoke, suggesting the need to 
Health Effects of E-Cigarette Use Among U.S. Youth and Young Adults 123

E-Cigarette Use Among Youth and Young Adults

examine the impact of passive aerosolized nicotine inha‐

lation on long‐term lung function. Furthermore, limited 

effects would likely occur in the short exposure observed 

through the methodologies used by Flouris and colleagues 

(2012, 2013), as these studies did not account for prolonged 

and persistent passive exposure to e‐cigarette aerosols.

Figure 3.3 Changes in aerosol particle PM2.5 concentrations during experiment of e‐cigarette use and tobacco 

cigarette smoking in an exposure chamber

Source: Czogala et al. (2014).

Note: PM = particulate matter.

Several researchers have modeled the health risks 

of passive exposure to e‐cigarettes (Colard et al. 2015) on 

the basis of the limited exposure data available and have 

come to various conclusions. Offermann (2015) concluded 

that, for indirect exposure, two chemicals—nicotine and 

PG—exceeded California EPA exposure level standards for 

noncarcinogenic health effects. Burstyn (2014), who com‐

pared e‐cigarette aerosol exposure to workplace exposure 

standards, concluded that only PG and VG warrant atten‐

tion in e‐cigarette users while, for bystanders, none of the 

constituents of e‐cigarette aerosol pose apparent concern. It 

is important to note that standards for workplace exposure 

are typically not appropriate to apply to the population as a 

whole, as they are intended for a healthy working popula‐

tion during a typical work day, not accounting for the risks 

to children, pregnant women, or those with preexisting 

health conditions. Further, standards for workplace expo‐

sure are very different in concentration and duration than 

what is to be expected from e‐cigarette use.

An additional consideration for regulating e‐cigarettes 

in indoor environments is the potential for allergic reactions 

in nonusers. Dermal and oral PG exposures are known causes 

of dermatitis and allergic sensitization (Warshaw et al. 2009; 

Al Jasser et  al. 2011). Several e‐liquids contain flavorants 

derived from nuts and in fact have labels cautioning persons 

who have nut allergies not to use these products. Research 

has not evaluated whether nonusers can have allergic reac‐

tions from these potential allergens in e‐cigarette aerosol, 

but this is a risk that should be explored as 8% of U.S. chil‐

dren have food allergies (Gupta et al. 2011).
A Report of the Surgeon General

124 Chapter 3

Evidence Summary

E‐cigarette use among youth and young adults in the 

United States has increased considerably in recent years (see 

Chapter 2). There is little doubt that the use of e‐cigarettes 

by youth and young adults represents self‐administration 

of the drug nicotine, and this self‐administration of nic‐

otine puts youth at risk for addiction and many related 

harmful consequences. Animal research indicates adoles‐

cent brains are particularly sensitive to nicotine’s effects, 

such that subsequent self‐administration is more likely, 

and that same literature indicates that this age group is 

at risk for a constellation of nicotine‐induced neural and 

behavioral alterations. Studies of the effects of maternal 

smoking of conventional cigarettes during pregnancy, 

coupled with preclinical literature examining the effects 

of maternal self‐administration of nicotine during preg‐

nancy, suggest that e‐cigarette use by mothers during 

pregnancy presents a wide variety of risks to fetal, infant, 

and child brain development.

Users of e‐cigarettes risk respiratory exposure to a 

variety of aerosolized chemicals, including solvents and fla‐

vorants added intentionally to e‐liquids, adulterants added 

unintentionally, and other toxicants produced during the 

heating/aerosolization process. The health impacts of fre‐

quent exposure to the toxicants in e‐cigarette aerosol 

are not well understood, though several are known car‐

cinogens. As highlighted previously in this chapter, the 

detection and level of these carcinogens depend on several 

factors, including the concentration of the e‐liquid and the 

strength of the heating device. Although e‐cigarettes have 

been used as a cessation device, the evidence supporting the 

effectiveness of e‐cigarettes as an aid for quitting conven‐

tional cigarettes remains extremely weak for adults (Bullen 

et  al. 2013; Caponnetto et  al. 2013; Grana et  al. 2014; 

Kalkhoran and Glantz 2016) and untested and nonexistent 

among youth.

Further research is warranted to focus on the 

characteristics of e‐cigarette devices, the constituents 

of e‐liquids, and the user behaviors that can influence 

the yield of nicotine and other toxicants (Shihadeh and 

Eissenberg 2015). This close focus includes providing 

details of devices (e.g., voltage of the power supply, heating 

element resistance) and components of e‐liquids (e.g., pro‐

pylene glycol, vegetable glycerin, other additives), and 

measuring user puff topography. Standardization of pro‐

cedures for producing and delivering the aerosol is likely a 

necessary component of at least some in vivo and in vitro 

work. Preclinical work examining the effects of e‐cigarette 

aerosols is a clear research need and, again, the standard‐

ization of procedures for production and delivery of the 

aerosol is necessary. To enhance relevance, the parameters 

of aerosol production should span the range of those seen 

with humans (Shihadeh and Eissenberg 2011).

The huge variety of products of different origin and 

design, the rapid emergence of new products, and the 

varied ways in which consumers use these products make 

the development of standard measurement conditions 

challenging (Famele et al. 2015). Accordingly, research is 

needed to understand how different design features relate 

to potential toxicity—for example, if the compounds in 

e‐cigarettes are affected by heating, changes in chemical 

composition, or pH; if these compounds are absorbed into 

the bloodstream; and how additives to the e‐liquid affect 

the bioavailability of these compounds, among other con‐

siderations. Research is also needed to understand whether 

potential health risks may be ameliorated by changes in 

product engineering.
Health Effects of E-Cigarette Use Among U.S. Youth and Young Adults 125

E-Cigarette Use Among Youth and Young Adults

Conclusions

1. Nicotine exposure during adolescence can cause addic‐

tion and can harm the developing adolescent brain.

2. Nicotine can cross the placenta and has known effects 

on fetal and postnatal development. Therefore, nico‐

tine delivered by e‐cigarettes during pregnancy can

result in multiple adverse consequences, including

sudden infant death syndrome, and could result in

altered corpus callosum, deficits in auditory pro‐

cessing, and obesity.

3. E‐cigarettes can expose users to several chemicals,

including nicotine, carbonyl compounds, and vol‐

atile organic compounds, known to have adverse

health effects. The health effects and potentially 

harmful doses of heated and aerosolized constituents 

of e‐cigarette liquids, including solvents, flavorants, 

and toxicants, are not completely understood.

4. E‐cigarette aerosol is not harmless “water vapor,”

although it generally contains fewer toxicants than

combustible tobacco products.

5. Ingestion of e‐cigarette liquids containing nicotine

can cause acute toxicity and possibly death if the

contents of refill cartridges or bottles containing

nicotine are consumed.
A Report of the Surgeon General

126 Chapter 3

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147

Chapter 4 

Activities of the E-Cigarette Companies

Introduction 149

Manufacturing and Price 149

Overview of the E-Cigarette Market in the United States 149

Distribution and Purchase Channels 149

Product Evolution 151

Evolution of Market Share in the E-Cigarette Market 152

E-Cigarette Sales in Tracked Retail Outlets 152

Production of E-Liquids 154

Impact of E-Cigarette Price on Sales and Use of These Products 155

Trends in E-Cigarette Prices over Time 155

Impact of E-Cigarette Prices on E-Cigarette Sales 156

Marketing and Promotion of E-Cigarettes 157

Marketing Expenditures 157

Magazine and Print Advertising 158

Television Advertising to Youth and Young Adults 159

Sponsorships 159

Digital Landscape for E-Cigarettes 163

E-Cigarettes in the Retail Environment 167

Conventional Tobacco Retailers (Convenience Stores, Pharmacies, Tobacco Shops) 167

“Vape Shops” 168

Exposure and Receptivity to Advertising for E-Cigarettes 169

Exposure 169

Receptivity to Advertising 169

Effect of E-Cigarette Advertising on Behavior 170

Associations with E-Cigarette Use and Intentions to Use 170

Associations with Knowledge, Risk Perceptions, and Other Attitudes 171

Evidence Summary 172

Conclusions 172

References 173

Activities of the E-Cigarette Companies 149

E-Cigarette Use Among Youth and Young Adults

Introduction

This chapter focuses on the companies that 

are active in the production, distribution, or marketing 

of e-cigarettes in the United States and examines the 

potential influence of these companies on the use of 

e-cigarettes, particularly among youth and young adults. 

The e-cigarette marketplace is complicated by the fact that 

some brands and devices are owned by tobacco companies, 

while others are independently owned. This chapter will 

refer to the e-cigarette companies as a whole but, when 

necessary, will distinguish between the e-cigarette brands 

that are owned by tobacco companies and others that are 

independently owned. The chapter covers manufacturing 

and price, marketing and promotional activities, the retail 

environments for e-cigarette products, exposure to marketing and receptivity to such activity, and the effects of 

e-cigarette marketing activities on consumer behavior.

Manufacturing and Price

As discussed in Chapter 1, although the concept 

of e-cigarettes was initially introduced in the 1960s, the 

first-generation version of e-cigarettes was not developed and commercialized until the mid-2000s (Grana 

and Ling 2014). In the short period since the first appearance of e-cigarettes, the exponential growth in awareness 

and use of these products (Centers for Disease Control 

and Prevention [CDC] 2015), the rapid product development (Zhu et al. 2014), and the rapid evolution of both 

the e-cigarette market and the industry itself (Huang 

and Chaloupka in press) have been unprecedented. 

E-cigarettes were recently named a “disruptive innovation” that may change the existing tobacco market and 

displace conventional (combustible) cigarettes in a foreseeable timeframe (Spielman and Azer 2013).

Consumer demand for a less harmful alternative to 

conventional cigarettes and the implementation of macro 

policies, such as those that restrict cigarette use or mandate clean indoor air, may influence the use of e-cigarettes 

(Pepper et al. 2014b; Rose et al. 2014). However, e-cigarette 

companies may play a critical role in shaping the market, 

affecting everything from the development and innovation 

of new products and brands to the manufacture, distribution, marketing, promotion, and pricing of the product—

activities that parallel those in the cigarette industry.

This section describes and summarizes both the 

rapidly changing e-cigarette market and the activities 

of e-cigarette companies in the United States, providing 

a broad overview of the major players. These participants 

include the major tobacco companies and other manufacturers. The chapter also addresses how the companies 

influence the e-cigarette market in the United States, 

focusing on the impact of product development and innovation, distribution channels, product availability, and 

pricing strategies, as well as the role of e-cigarette trade 

organizations and partnerships.

Overview of the E-Cigarette Market 

in the United States

For 2014, the value of the e-cigarette market in the 

United States was estimated at $2.5 billion: 40% ($1.0 billion) was for cigarette-like e-cigarettes (cigalikes), and 

60% ($1.5 billion) was for tank-style e-cigarettes, mods, 

and other types of “vaporizers” (Wells Fargo Securities 

2015a) (Table 4.1). The market was projected to grow 

to $3.5 billion, a rise of 40%, in 2015 (Rose et al. 2014) 

(Table 4.2). Total sales of e-cigarettes in convenience, food, 

drug, and big-box stores (such as Walmart), which are 

tracked by commercial market research companies (such 

as Nielsen), were estimated to be $900 million in 2014. 

There was an additional estimated $500 million in online 

sales, and $1.1 billion in sales in “vape shops” and other 

channels, which are not currently tracked by commercial market research companies (Table 4.1) (Wells Fargo 

Securities 2015b).

Distribution and Purchase Channels

E-cigarettes entered the U.S. market around 

2006–2007, and since that time the distribution and purchase channels for these products have evolved greatly. 

Initially they were sold exclusively by Internet retailers, 

but then selling activity expanded to shopping mall kiosks 

and conventional retail outlets and, more recently, to 

“vape shops” and some pharmacies (Rose et al. 2014; Lee 

and Kim 2015). 

Some companies operating in the U.S. market have 

their own manufacturing facilities in this country, but 

companies generally import parts or even complete products from abroad, almost exclusively from China (Barboza 

2014). Manufacturers and importers distribute their products via a wide number of channels, such as the companies’ 
A Report of the Surgeon General

150 Chapter 4

own e-commerce websites and/or retail outlets. In 2010, 

the most popular channels for selling e-cigarettes and 

their accessories directly to consumers were websites and 

third parties, such as retail outlets (Linarch Information 

Solutions 2012). Many e-cigarette manufacturers and 

importers, including the big-brand companies and those 

supplying products to “vape shops,” rely on distributors 

and retailers to deliver the products to the consumer 

(Linarch Information Solutions 2012).

Table 4.1 Estimated e-cigarette market size in 2014 ($ billion)

Convenience, food, drug, 

and big-box stores Online

Other channels (“vape shops” and 

other untracked retail channels) Total

E-cigarettes 0.6 0.2 0.2 1.0

Vapors/tanks/mods 0.3 0.3 0.9 1.5

Total 0.9 0.5 1.1 2.5

Source: Wells Fargo Securities (2015a).

Table 4.2 Estimated e-cigarette market size in 2015 ($ billion)

Convenience, food, drug, 

and big-box stores Online

Other channels (“vape shops” and 

other untracked retail channels) Total

E-cigarettes 0.7 0.4 0.4 1.5

Vapors/tanks/mods 0.4 0.4 1.2 2.0

Total 1.1 0.8 1.6 3.5

Source: Wells Fargo Securities (2015a).

The emergence of e-cigarette devices and products 

resulted from the endeavors of a few entrepreneurs and 

widespread Internet and television advertising (Grana et al. 

2013; Rose et al. 2014). It is noteworthy that the product 

class took hold when e-commerce was rapidly expanding 

in the United States, and major social media platforms—

such as Facebook (founded in 2004), YouTube (2005), and 

Twitter (2006)—were emerging. In such an environment, 

information about a new product like e-cigarettes could be 

rapidly disseminated across geographic boundaries, and 

new products and technologies could be speedily adopted. 

This process is partly reflected by the Google search 

volume of queries related to e-cigarettes; the volume of 

queries surpassed those for nicotine replacement therapy 

products and snus by 2008 (Ayers et al. 2011).

Manufacturers noticed the fast rise in consumer 

interest in e-cigarettes, so they quickly pushed to expand 

the sale of their products to brick-and-mortar retail stores. 

Sales of cigalikes and related products were first observed 

in Nielsen’s store-scanner database in 2007, and between 

2009 and 2012, retail sales of e-cigarettes expanded to all 

major markets in the United States (Huang and Chaloupka 

in press). This growth coincided with a surge in marketing expenditures by the e-cigarette companies across 

all media platforms (Kim et al. 2014; Kornfield et al. 

2015). The products sold in these conventional channels 

were predominantly disposable and rechargeable cigalikes 

(Giovenco et al. 2015; Huang and Chaloupka in press), but 

retail stores started to carry tank-style e-cigarette devices 

as well (CSP Daily News 2014; Giovenco et al. 2015).

Today, e-cigarette brands, such as MarkTen (manufactured by Altria) and VUSE (manufactured by Reynolds 

American Inc.), are available in more than 70,000 retail 

stores across the country, and their availability is expanding 

rapidly (Wells Fargo Securities 2014b). E-cigarettes were 

more likely to be available in retail locations in neighborhoods with a higher median household income and 

a lower percentage of African American and Hispanic residents; these sales patterns are consistent with patterns 

of use of these products observed among youth, young 

adults, and adults more generally (see Chapter 2). Notably, 

the price of conventional cigarettes and the existence of 

comprehensive smokefree laws were inversely associated 

with the availability of e-cigarettes (Rose et al. 2014).

Through growth in their sales, tank-style e-cigarettes 

(also known as mods) and advanced personal vaporizers 

(APVs) have begun to play an increasingly important role 

in the e-cigarette market (Wells Fargo Securities 2015a). 

“Vape shops,” which provide a range of e-cigarette devices 

and products, have emerged as the primary retail channel 

for consumers seeking such products (Lee and Kim 2015). 

Unlike conventional retail outlets, “vape shops” sell a wide 

range of more complex and powerful tank-style e-cigarettes 
Activities of the E-Cigarette Companies 151

E-Cigarette Use Among Youth and Young Adults

and many different types of liquids for e-cigarette devices 

(e-liquids or e-juices) (Sussman et al. 2016).

The rise of “vape shops” can be attributed to a number 

of factors. First, in the past, most of these establishments 

offered a wide range of e-cigarettes and e-liquids, allowed 

users to sample different types of flavored e-liquids at 

no cost, and permitted the trial use of various types of 

e-cigarettes. Most of these establishments sell products 

made by independent companies, as opposed to products 

manufactured by the major conventional tobacco companies (Kamerow 2014; Sussman et al. 2016). As a result, 

“vape shops” can serve as an information hub where consumers can easily obtain knowledge about (and gain 

experience with) a wide range of e-cigarettes and related 

products (Sussman et al. 2016). However, the information 

provided may be misleading or misinterpreted (Cheney 

et al. 2016). Second, unlike traditional retail outlets, “vape 

shops” are usually equipped to provide consumers with 

individualized information about how e-cigarette products can be used to best satisfy the user’s preferences; 

this capability may be important as e-cigarette products 

become more diversified and sophisticated. Because of 

the diversity of these products, some of these establishments provided free samples of different flavored e-liquids 

and allowed trial use of different e-cigarettes before actual 

purchase in an attempt to compete with traditional retail 

outlets. Under the deeming rule published in May 2016, 

free samples of e-liquids containing nicotine were banned 

(Federal Register 2016). Third, “vape shops” serve as a 

place for e-cigarette users to socialize.

Some “vape shops” also host various events, 

including competitions (also known as cloud chasing), 

that build loyal customer bases by creating a sense of community and camaraderie among customers (Sussman et al. 

2014; Cheney et al. 2015; Lee and Kim 2015). Additionally, 

a 2015 study of “vape shop” owners found that customers 

view the owners as important sources of health information, which could include information related to cessation (Cheney et al. 2016). However, the owners reported 

(a) obtaining their information from YouTube or industry 

sources but finding the research hard to understand and 

(b) looking for government sources but not finding them. 

Estimates of the number of “vape shops” in the 

United States have varied greatly due to the lack of a clear 

definition of what constitutes such an establishment. 

The low end of these estimates puts the number around 

3,500 (Klein 2013; Lee and Kim 2015), while intermediate estimates indicate that there are about 6,000–15,000 

“vape shops” in this country (Bour 2015; Wells Fargo 

Securities 2015b). One high estimate is that in 2014 there 

were as many as 35,000 such shops in the United States 

(Kamerow 2014).

Product Evolution

E-cigarette products have evolved and diversified 

rapidly since they entered the U.S. market (see Chapter 1). 

Detailed information about different types of e-cigarette 

products has been presented elsewhere (Grana et  al. 

2014). Over time, with consolidation of e-cigarette companies and technological improvements, the manufacturing process has become more standardized, enabling 

the production of e-cigarette products with a more effective and more consistent dose and delivery of nicotine and 

flavorings, and a more consistent generation of aerosol 

(Goniewicz et  al. 2013a,b; Farsalinos and Polosa 2014; 

Saitta et al. 2014).

Many e-cigarette manufacturers make multiple 

types of e-cigarette products. For example, the NJOY brand 

has not only disposable and rechargeable cigalikes but also 

tank-style e-cigarette devices, which are larger than cigalikes and include options for refills and batteries. In addition, NJOY sells a variety of flavored e-liquids, although 

in California, flavors appealing to minors (e.g., strawberry 

and cookies and cream) are prohibited (State of California 

v. Sottera, Inc. 2010). Within each product type, there 

are many different brands, albeit the brands are often 

very similar. For example, NJOY, blu, Logic, Mistic, and 

many other brands of rechargeable e-cigarettes differ very 

little from each other with regard to the flavors and types 

of products offered (e.g., cigalike, tank style) (Zhu et al. 

2014). A study examining the growth of brands and flavors 

between 2012 and 2014 found that older brands were more 

likely to involve cigalikes, while newer brands were more 

likely to offer tank-style devices and mods (Zhu et al. 2014).

As tank systems and mods become more popular, the 

distinction between a closed system and an open system 

becomes more important. In a closed system, components 

cannot be customized. In this case, the e-liquid is “locked 

in”; the amounts of e-liquid, level of nicotine, and flavors 

are dictated by the manufacturer. Because users cannot mix 

their own e-liquids or refill the cartridges or tanks, there 

is less risk of spillage, nicotine overdose, and accidental 

ingestion. In addition, users cannot change the power 

source, adjust the voltage, or customize the atomizers. 

Many brands offer only closed-system devices (e.g., Vype, 

Vapestick, and FIN). Most cigalikes are closed systems, sold 

primarily online or in conventional retail outlets, and are 

favored by the larger e-cigarette companies, likely because 

of the high profit margins from the e-liquid refill cartridges 

and the nature of the distribution paths.

Open systems, in contrast, allow for personalization and customization: Users can mix their own e-liquid, 

choosing different e-liquid bases, flavors, and nicotine 

concentration levels. Users can also adjust the voltage, 

customize the atomizers, and/or modify the aesthetics and 
A Report of the Surgeon General

152 Chapter 4

shapes/sizes of their devices (Popken 2014; Richtel 2014c; 

Lee and Kim 2015). Tanks and mods/APVs are open systems 

sold primarily in “vape shops” or online. While research 

has demonstrated that more-experienced e-cigarette users 

prefer open system mods (Farsalinos et al. 2014), one analyst has suggested that closed systems may better facilitate 

consistent and enforceable product and manufacturing 

standards (Wells Fargo Securities 2014a).

Beyond the increased variety over time of products, 

their components, and related products (including accessories such as carriers, lanyards, stickers, and sleeves), 

the products continue to appeal to consumers through 

the incorporation of increasingly complex technologies—

including location tracking; Bluetooth connectivity; 

social networking functions and integration with users’ 

social media accounts; and entertainment functions, such 

as playing music and videos (Bauld et al. 2014; Brown and 

Cheng 2014; Honig 2014).

The terminology for e-cigarettes has also expanded. 

Terms such as e-cigars, e-hookahs, vaping pens, hookah 

pens, and personal vaporizers are used interchangeably (or preferentially) by some users (Richtel 2014b). 

In addition, the spectrum of use has broadened, as some 

e-cigarettes that involve open systems are also used for the 

aerosolization of marijuana and cannabis oil (Bryan 2014; 

Morean et al. 2015) and could be adapted for other illicit 

substances (see Chapter 2).

Worldwide, more than 95% of e-cigarettes sold are 

thought to have been manufactured in China (Jourdan 

2014), most in one city—Shenzhen (Barboza 2014). A few 

large manufacturers (e.g., Joyetech, Kimree, and First 

Union) dominate the market (see Appendix 4.1 for descriptions of the major e-cigarette manufacturers).1

1All appendixes and appendix tables that are cross-referenced in this chapter are available only online at http://www.surgeongeneral.gov/

library/reports/.

 Most of 

these manufacturers provide supplies to many different 

e-cigarette companies, including American companies 

marketing conventional cigarettes, as well as independent 

e-cigarette companies. Some companies (e.g., Gamucci) 

have an exclusive manufacturer in Shenzhen.

Some e-cigarette companies have begun to locate 

their manufacturing base in the United States. Reynolds 

American, for example, has a factory in Tobaccoville, 

North Carolina, to manufacture its VUSE brand and 

strongly emphasizes this location as part of its marketing 

strategy (CSP Daily News 2015). White Cloud, another 

U.S.-based company, moved its cartridge-filling production from China to Tarpon Springs, Florida, in May 2014 

(McConnell 2014), and the U.S.-based brand Mistic has 

announced plans to move its manufacturing from China 

to Greenville, North Carolina (Bettis 2014).

Evolution of Market Share in the E-Cigarette 

Market

Although the e-cigarette market in the United States 

has changed significantly since its emergence, these 

changes have not been studied extensively. This section 

documents market share by brand for e-cigarette sales 

in retail outlets tracked by Nielsen, using data from the 

forthcoming study by Huang and Chaloupka (in press) 

and supplemented with data from industry reports issued 

by a number of investment banks. These data, available 

in Appendix 4.5, clearly show the dynamic changes in the 

e-cigarette market, and these changes are important to 

understand in terms of access to and marketing of these 

products to youth and young adults.

E-Cigarette Sales in Tracked Retail Outlets

Total sales of e-cigarettes in tracked retail channels 

have surged exponentially since 2010, increasing from 

only a few million dollars per quarter in 2010 to more 

than $170 million in the last quarter of 2014 (Figure 4.1). 

Although Reynolds American’s VUSE brand did not 

enter the market until late 2013, its sales climbed rapidly in 2014 because of heavy promotion and price discounts. At the end of 2014, VUSE had become the market 

leader with the highest quarterly sales at $56 million. Blu 

(owned by Lorillard and thus now by Imperial Tobacco) 

was the market leader for most of 2013 and 2014, with an 

average $60 million in quarterly sales. During this time 

the number of its distribution points rose from 60,000 to 

more than 150,000 because of its acquisition by Lorillard 

and subsequent marketing and promotion efforts.

After doubling every year between 2010 and 2013 

(Figure 4.2) in the tracked retail channels, rates of 

increase in the sales of e-cigarettes decelerated significantly, with total sales actually declining in the second 

quarter of 2014. The deceleration may reflect, in part, the 

shift away from cigalikes to tank-style devices, mods, and 

other e-cigarette products among users; the sales of these 

devices are not tracked as well, which makes it difficult to 

know the true trends in sales (see Tables 4.1 and 4.2).

Figure 4.2 presents sales data by product type. Sales 

of disposable e-cigarettes trended upward from 2010 

to 2013, increasing from a minimal amount in 2010 to 

almost $100 million in the second quarter of 2013, but 

2014 showed a substantial decline, with the value only 

about $50 million for the final quarter of that year. The 

figure shows a clear pattern of seasonality in sales for 

disposables: sales usually rose in the first quarter of the
Activities of the E-Cigarette Companies 153

E-Cigarette Use Among Youth and Young Adults

Figure 4.1 E-cigarette sales in tracked channels by brand, 2010–2014

Source: Huang and Chaloupka (in press).

Note: Data points for this figure are shown in Table A4.4-1 in Appendix 4.4.
A Report of the Surgeon General

154 Chapter 4

year—potentially reflecting the effect of New Year’s resolutions among smokers who seek to use rechargeable 

e-cigarettes as a way to quit conventional cigarettes—

but had subsequently declined during the rest of the year. 

Sales of e-liquid refills increased steadily over the 4-year 

period between 2010 and 2014 and reached $80 million in 

the final quarter of 2014, representing approximately half 

of the total e-cigarette sales in the tracked retail channels.

Figure 4.2 E-cigarette sales in tracked channels by product type, 2010–2014

Source: Huang and Chaloupka (in press).

In 2014, more than 85% of e-cigarette sales occurred 

in the tracked retail and online channels, including certain convenience stores and food, drug, and big-box stores 

(Wells Fargo Securities 2015a; see Table  4.1). It  was 

estimated that 20% of all e-cigarette sales (including 

e-cigarettes and tanks/mods) in 2014 occurred online, 

while 44% of all e-cigarette sales occurred in “vape 

shops” and other untracked retail channels (Wells Fargo 

Securities 2015a; see Table 4.1).

Another important trend in e-cigarette sales is the 

growth of flavored products. Although some brands, such 

as NJOY, initially did not sell flavored e-cigarette products, 

most companies now offer some form of flavored varieties. 

Giovenco and colleagues (2015) found that sales of menthol-flavored e-cigarettes in traditional U.S. retail channels (e.g., convenience stores, grocery stores, pharmacies, 

and mass merchandisers) more than doubled between 

2012 and 2013, increasing from $96.4 million in 2012 to 

$215.7 million in 2013. Sales of fruit-flavored e-cigarettes 

more than tripled during the same period, from $4.9 million to $16.7 million.

Sales of different types and brands of e-cigarettes 

likely differ by demographic group. For example, anecdotal evidence suggests that youth and young adults prefer 

pen-style devices, those that come in various shapes and 

styles, and devices that may be used interchangeably with 

e-hookahs (Richtel 2014b). Research also suggests that 

users may eventually graduate to more complex systems; 

more specifically, experienced users may be more likely to 

use tanks and mods (Farsalinos et al. 2014). Unfortunately, 

sales data by demographics are very limited, and studies 

have not yet examined how sales of e-cigarette products 

differ by demographic classification.

Production of E-Liquids

E-liquids used in closed-system devices usually are 

produced in the United States and then shipped to China 

to be included in the assembly process. For example, 

MarkTen, blu, and NJOY manufacture their own e-liquids 

in the United States, which then are sent to China before 

the final product is assembled there.

In the United States, one of the biggest players in 

the premixed e-liquid market for refillable e-cigarettes is 

Johnson Creek Vapor Company (2011), which claims to 

be the world’s leading manufacturer of e-liquid and the 

first company to produce and manufacture e-liquid in the 

United States. Johnson Creek has not disclosed the suppliers of its nicotine solution.
Activities of the E-Cigarette Companies 155

E-Cigarette Use Among Youth and Young Adults

Impact of E-Cigarette Price on Sales 

and Use of These Products

This section summarizes the limited evidence on 

the impact of e-cigarette prices on the sales and consumption of these products. The sizable body of research examining the effects of taxes and prices on the sale and use 

of conventional cigarettes (Chaloupka and Tauras 2011; 

International Agency for Research on Cancer 2011) leads 

to the conclusion that price increases resulting from 

higher excise taxes are effective tools for reducing cigarette consumption, especially among youth.

Trends in E-Cigarette Prices over Time

A study by Huang and Chaloupka (in press) documented and analyzed the relationship between real price 

and sales volume for both disposable and rechargeable 

e-cigarettes by using Nielsen data, which reflected the 

e-cigarette (predominantly cigalikes) sales and prices in 

retail stores tracked by Nielsen.

Figure 4.3 presents U.S. data on real price (determined by adjusting the prices to the value of the U.S. dollar 

in the fourth quarter of 2014) and sales volume for disposable e-cigarettes between 2010 and 2014 based on data from 

Huang and Chaloupka (in press). The average price for a 

single disposable e-cigarette declined from approximately 

$17 in the first quarter of 2010 to less than $9 in 2014. 

In terms of volume, the estimate for disposables increased 

from far below 100,000 in the first quarter of 2010 to 

almost 11 million in the first quarter of 2014, before dropping to about 6.3 million in the final quarter of 2014. This 

graph reveals an association between real price and the 

sales volume for disposable e-cigarettes from 2010 to the 

second quarter of 2013: As real price declined over time, 

sales volume increased. Looking back, the rapid decline in 

the price of disposable e-cigarettes between 2007 and 2011 

(Huang and Chaloupka in press) may have occurred because 

of improvements in product technology and industry promotion, which significantly cut the costs of producing such 

products (Bhatnagar et al. 2014; Wells Fargo Securities 

2015c). The rather modest declines in prices since 2011 

may reflect the fact that further technological improvements became less feasible (Wells Fargo Securities 2015c).

Figure 4.3 Sales volume and price of disposable e-cigarettes, U.S. market, 2010–2014

Source: Huang and Chaloupka (in press).

In terms of volume, the substantial decrease in 2014 

may be partly attributable to consumers shifting away 

from cigalikes to tanks, mods, and other more powerful 

devices, for which sales were not tracked well.

An inverse relationship is also evident between 

real price and sales volume for rechargeable e-cigarettes. 

Figure 4.4 demonstrates that when the real price went 

down, the sales volume increased, particularly after 

2012. Between 2010 and 2014, the average unit price for 

rechargeables decreased markedly, dropping from $37 

in the first quarter of 2010 to $12 at the end of 2014. 

However, there were more price fluctuations than were 

found for disposable e-cigarettes (Figure 4.3). The price 

fluctuations for rechargeables were likely because of the 
A Report of the Surgeon General

156 Chapter 4

change in product mix and the influx of various new types 

and brands of these devices during this period (Bhatnagar 

et al. 2014; Wells Fargo Securities 2015c). Sales volume 

increased dramatically between 2010 and 2014, rising 

from a minimal amount at the beginning of 2010 to about 

3 million units in the last quarter of 2014.

Figure 4.4 Sales volume and price of rechargeable e-cigarettes, U.S. market, 2010–2014

Source: Huang and Chaloupka (in press).

Impact of E-Cigarette Prices on E-Cigarette Sales

In one of the first studies to explore the effects of 

e-cigarette prices on the sales of these products, Huang 

and colleagues (2014b) estimated, from Nielsen data, 

both the own-price elasticity and the cross-price elasticity 

of demand for e-cigarettes (disposable or rechargeable) 

and studied the impact of conventional cigarette prices 

and smokefree policies on e-cigarette sales. Own-price 

elasticity is a measure showing how much demand for a 

product will change given a change in its price, while crossprice elasticity is a measure showing how much demand 

for a product will change given a change in another product’s price. Using data from Nielsen’s commercial retail 

store scanning service, this study employed fixed-effects 

models to estimate elasticity of demand and associations between e-cigarette sales and either the prices of 

conventional cigarettes or smokefree policies from 2009 

to 2012. Results demonstrated (a) that e-cigarette sales 

were quite responsive to own-price changes (estimated 

own-price elasticities for disposable e-cigarettes centered 

around −1.2 [a  10%  increase in price would decrease 

sales by 12%], while those for rechargeable e-cigarettes 

were approximately −1.9 [a 10% increase in price would 

decrease sales by 19%]) and (b) that disposable e-cigarettes 

appeared to be emerging as substitutes for rechargeables (a 10%  increase in rechargeable e-cigarette prices 

increased sales of disposable e-cigarettes by about 5%). 

This study concluded that policies increasing the retail 

prices of e-cigarettes—such as imposing taxes or limiting rebates, coupons, and discounts—could potentially 

lead to significant reductions in e-cigarette sales and that 

variations in tax policy by product type could lead to substitution between product categories. It is important to 

note that “vape shops” were not included in these data, as 

Nielsen collects data only from convenience, food, drug, 

and big-box stores.

Although these results provide evidence that 

changing the price of e-cigarettes affects the number 

sold, the potential effects of the price of conventional 

cigarettes on the purchase of e-cigarettes are less clear. 

Huang and colleagues (2014b) found no consistent or 

statistically significant relationship between the price of 

conventional cigarettes and the sale of e-cigarettes. In 

contrast, Grace and colleagues (2015), who measured the 

cross-price elasticity of e-cigarettes and conventional cigarettes using simulated demand for the latter in a sample 

of New Zealand smokers, found that the cross-price elasticity of e-cigarettes was significantly positive, suggesting 

that e-cigarettes may be partially substitutable for conventional cigarettes. Thus, the use of e-cigarettes may 

increase as the price of conventional cigarettes increases.
Activities of the E-Cigarette Companies 157

E-Cigarette Use Among Youth and Young Adults

Other evidence suggests that the potential impact 

of price changes on the use of e-cigarettes may differ by 

demographic characteristics. Relationships between the 

smoking of conventional cigarettes and socioeconomic 

status (SES) are well documented in the literature, and 

additional evidence has demonstrated that youth and 

young adults, and those with low SES, tend to exhibit 

higher sensitivity to changes in the price of conventional 

cigarettes (International Agency for Research on Cancer 

2011; U.S. Department of Health and Human Services 

[USDHHS] 2012). Therefore, youth and young adults, as 

well as low-SES persons, may be more price-sensitive in 

the purchase of e-cigarette products, and thus they may 

be more likely to stop using e-cigarettes as their price 

increases. These potential connections between the price 

of e-cigarettes and their use should be examined carefully 

as more data become available. 

Marketing and Promotion of E-Cigarettes

Marketing is an important tool for industries to use 

in influencing consumer preferences, and the potential 

for marketing to influence smoking behaviors has been 

a source of public health concern for many years (DiFranza 

et al. 1991; USDHHS 2000, 2012; National Cancer Institute 

[NCI] 2008). Research has demonstrated a causal relationship between tobacco marketing and smoking, with the 

majority of research focusing on the impact of tobacco 

marketing on the initiation of smoking by youth (Biener 

and Siegel 2000; USDHHS 2012). For adolescents, studies 

have found cross-sectional and longitudinal associations 

between the intensity of cigarette marketing and initiation 

of smoking, brand awareness, brand preferences, attitudes 

toward smoking, susceptibility to smoking, and smoking 

behaviors (O’Connell et al. 1981; Chapman and Fitzgerald 

1982; McNeill et al. 1985; Charlton 1986; Potts et al. 1986; 

Aitken et al. 1987; Goldstein et al. 1987; Aitken and Eadie 

1990; Botvin et al. 1991; DiFranza et al. 1991; Klitzner et al. 

1991; Pierce et al. 1991; Botvin et al. 1993; Hastings et al. 

1994; Pierce et al. 1994; Coeytaux et al. 1995; Evans et al. 

1995; Pierce and Gilpin 1995; Richards et  al. 1995; Slade 

et al. 1995; Unger et al. 1995; Pollay et al. 1996; Schooler 

et al. 1996; Gilpin and Pierce 1997; Lam et al. 1998; Feighery 

et al. 2006). A review of these and other studies led the 2012 

Surgeon General’s report to conclude that exposure to advertising causes the initiation of smoking (USDHHS 2012).

In general, product marketing is designed to 

inform people about the products being offered (and thus 

develop brand “awareness”) and to persuade people to 

buy particular brands (i.e., develop brand “preference”). 

Branding is particularly important for products considered to be “commodities,” such as conventional cigarettes and e-cigarettes, where the offerings are similar 

and branding differentiates the products (Rossiter and 

Bellman 2005; NCI 2008). Marketing is particularly critical for e-cigarettes, as new products must be introduced 

to potential users (Sethuraman et al. 2011).

Like marketers of conventional cigarettes, marketers of e-cigarettes use a number of channels and tactics 

to advertise and promote their products. These channels have included extensive marketing on the Internet 

and advertising in mainstream media, including popular 

magazines, retailer point-of-sale ads, product placement 

on popular media, and even television commercials—

an advertising option unavailable to cigarette manufacturers because of regulatory policies (Legacy for Health 

2014; Ganz et al. 2015). E-cigarette brands also use websites to interact directly with their customers through 

direct-to-consumer marketing (e.g., direct mail and direct 

e-mail) and social media channels, such as Facebook, 

Twitter, and Instagram (Huang et al. 2014a; Richardson 

et al. 2014; Ganz et al. 2015).

Marketing Expenditures

E-cigarette manufacturers currently are not 

required to report marketing expenditures to any regulatory agency (Boxer et al. 2013; Federal Register 2015). 

Using proprietary data from Kantar Media, however, 

Kornfield and colleagues (2015) tracked marketing expenditures (television, print, radio, and Internet) back to 2008 

for approximately 130 e-cigarette brands (note that many 

e-cigarette products are not branded, and thus these data 

are not complete). Kornfield and colleagues (2015) found 

minimal spending through 2010, followed by an acceleration in spending from $12 million in 2011 to $125 million in 2014 (Figure 4.5). Not shown in the figure is that 

in 2012, more than 60% of advertising expenditures were 

for blu (then owned by Lorillard, now Imperial Tobacco), 

which was the market leader (Kornfield et al. 2015). The 

trajectory for spending was consistent with the pattern for 

product sales, particularly for the most dominant brands 

(Figures 4.1 and 4.5).

Annual marketing expenditures for conventional 

cigarettes ($9.2 billion in 2012) dwarf the $125 million in 

2014 for e-cigarettes (Federal Trade Commission 2015a,b; 
A Report of the Surgeon General

158 Chapter 4

Kornfield et al. 2015). However, the available data about 

e-cigarette marketing also underestimate total marketing expenditures. Not included are expenditures for 

retail marketing, social media, and sponsored events, all 

of which are essential components of the industry’s integrated marketing strategy. In the absence of regulation, 

television advertising for e-cigarettes will continue, as 

the two largest tobacco companies moved promotions of 

MarkTen (Altria) and VUSE (Reynolds American) from test 

markets to national distribution in 2014 (Kornfield et al. 

2015; Truth Initiative 2015; Cantrell et al. 2016).

Tobacco marketing and surveillance systems—

including the Trinkets & Trash archive maintained by 

the Rutgers University School of Public Health and the 

Stanford Research into the Impact of Tobacco Advertising 

(SRITA) research group—collect examples of e-cigarette 

advertising and promotions and make these available to 

users through image-rich websites (see Trinkets & Trash 

[http://www.trinketsandtrash.org] and Stanford Research 

into the Impact of Tobacco Advertising [http://tobacco.

stanford.edu/tobacco_main/index.php]).

Magazine and Print Advertising

Print has been the dominant channel for tracked 

expenditures of traditional e-cigarette advertising, representing 84% of annual expenditures in 2014 (Kornfield 

et al. 2015; Figure 4.5). A study by Richardson and colleagues (2014) collected U.S. advertisements for all 

noncombustible tobacco products (i.e., e-cigarettes, snus, 

dissolvables, and chew/dip/snuff) for a 3-month period in 

2012 through Mintel, which tracks direct mail and opt-in 

e-mail ads, and Competitrack, which monitors 21  other 

media sources. Metadata for identified ads showed advertising for e-cigarettes in print, television, radio, online, 

direct mail, and e-mail. The three most common media 

were print, television, and e-mail, and spending was 

highest for print ads (Richardson et al. 2014). An analysis of industry marketing data by the American Legacy 

Foundation (now called Truth Initiative) reported that 

47% of U.S. teens (12–17 years of age) and 82% of young 

adults (18–21 years of age) were exposed to magazine 

advertising for e-cigarettes in 2014; popular venues 

Figure 4.5 Quarterly promotional spending for e-cigarettes, 2010–2014

Source: Data for 2010–2013 (Q2) from Kornfield and colleagues (2015, p. 110) and adapted with permission from BMJ Publishing 

Group Limited. Data for 2013 (Q3)–2014 from Kantar Media (unpublished data).
Activities of the E-Cigarette Companies 159

E-Cigarette Use Among Youth and Young Adults

included tabloids, entertainment weeklies, and men’s lifestyle magazines (Truth Initiative 2015).

Research indicates that e-cigarette advertising 

in magazines with high teen readership is on the rise 

(U.S. Congress 2014). From 2012 to 2013, the number 

of e-cigarette advertisements in magazines with high 

youth readership was four times the number in magazines 

with high adult readership (U.S. Congress 2014). Recent 

studies using data from Kantar Media and GfK MRI (the 

latter measures media audiences and consumer insights; 

see http://www.mri.gfk.com) on e-cigarette advertisements show that blu led all e-cigarette brands in magazine 

advertising and that respondents had the highest recall of 

blu advertisements (Legacy for Health 2014).

A content analysis by Banerjee and colleagues (2015) 

of print magazine tobacco ads for 2012–2013, using data 

collected from Kantar Media, identified 171 e-cigarette 

ads over this period, 27 of which were unique. Ads were 

found in 24 magazines, 11 of which had been identified in 

prior studies as having youth and young adult readerships 

greater than 2 million per year or for which the teen portion of the audience was more than 10%. By number, ads for 

e-cigarettes were second only to those for conventional cigarettes and higher than the numbers for moist snuff, cigars, 

and snus. Eighty-five percent of the content in e-cigarette 

ads focused more on a theme of logos (i.e., logic or facts to 

support a position) than on a theme of emotional appeal.

In examining persuasive themes, the study found 

that ads used several approaches, including highlighting 

the conventional advantages of the product—such as 

a  focus on customer satisfaction—and emphasizing the 

quality of the product or price (85.2%) (Banerjee et al. 

2015). The ads also used the comparative approach, such as 

portraying the product as being different from other products, being smokefree, or being exempt from use in areas 

where conventional cigarettes are prohibited. Figure 4.6 

shows examples of the claims in e-cigarette marketing. 

In terms of images, 100% of the ads included the brand 

name and an image of the product. In addition, ads were 

most frequently full-page advertisements (89.9%), usually placed the product in a way that drew attention to it 

(92.6%), and most often used six or more colors (85.2%), 

which the authors noted increases the attention-grabbing 

ability of the ads (Banerjee et al. 2015).

A different content analysis of magazine ads for 

e-cigarettes, this one for a 3-month period in 2012 

(Richardson et al. 2014), found health-related themes and 

non-health-related attributes—such as romantic, sexual, 

or sociability content, with the highlighting of taste as the 

most frequent selling proposition (see Figure 4.6, parts 

B–D for examples). All ads in this analysis were found 

to contain links to a product’s website. When examined 

by readership, e-cigarette ads were found to have run in 

magazines with mostly White-male readers and, to a lesser 

extent, magazines targeting White women. The analysis 

noted that ads were targeted to a magazine’s readership, 

with different ads shown in the White, male-oriented 

Rolling Stone publication as compared with the femaledominated Us Weekly.

Television Advertising to Youth and Young Adults

The increasing frequency and reach of advertising 

on television raises concerns about the potential impact of 

promoting nicotine products and renormalizing smoking 

through that medium, particularly for youth (Hodge Jr 

2013; Duke et al. 2014; Grana and Ling 2014). At least 

40 unique advertisements for e-cigarettes appeared on U.S. 

television in 2013 and early 2014 (Farrelly et al. 2015). For 

example, e-cigarette ads were featured in the Super Bowl 

broadcast, which reached an estimated audience of more 

than 100 million persons in 2012 (Deans 2012). The Truth 

Initiative (formerly the American Legacy Foundation) 

found that in 2014, television advertising reached similar proportions of youth (62% of 12- to 17-year-olds) and 

young adults (64% of 18- to 24-year-olds) (Truth Initiative 

2015). Using proprietary data from Nielsen, Duke and 

colleagues (2014) estimated that 50% of U.S. youth 

were exposed to e-cigarette ads on television in 2013 

and that 80% of this advertising was for blu (Lorillard, 

now Reynolds American). On average, those exposed 

saw 21  ads between October 2012 and September 2013. 

Between 2011 and 2013, exposure to e-cigarette advertising on television increased dramatically, by 321% for 

young adults (18–24 years of age) and 256% for adolescents (12–17 years of age) (Duke et al. 2014).

The same study (Duke et al. 2014) found that 

more than 75% of the exposure of youth to e-cigarette 

ads occurred on cable networks. The study found television ads for several different brands—including blu, FIN, 

Starfire, and NJOY—during a 9-month period in 2013. 

The most widely aired ad was for blu, featuring a celebrity and closing with the tagline “we’re all adults here. It’s 

time to take back your freedom” (Duke et al. 2014, p. 6).

Sponsorships

After the Master Settlement Agreement in 1998, 

sponsorship of events with a significant youth audience, such as concerts and athletic events, was banned 

for conventional cigarettes. However, e-cigarettes do not 

fall under these parameters, and recalling the early marketing of conventional cigarettes, e-cigarette brands have 

used sponsorships to increase the awareness and appeal 

of their label and product. For example, in 2011 blu sponsored a NASCAR driver and had its own car in some races 

(PRNewswire 2011). Additionally, blu has handed out free
A Report of the Surgeon General

160 Chapter 4

Figure 4.6 E-cigarette marketing claims

A. Freedom

Source: Esquire (2014).

B. Health

Source: Stanford Research into the Impact of 

Tobacco Advertising (n.d.b.).

C. Romance, sexuality, or sociability

Source: (Left) Maxim (2012), (middle) Men’s Journal (2014), and (right) Sports Illustrated (2014).
Activities of the E-Cigarette Companies 161

E-Cigarette Use Among Youth and Young Adults

Figure 4.6 Continued

D. Taste

Source: Soap Opera Digest (2013).

E. Smoking cessation

Source: Rolling Stone (2013).

F. Use in smokefree environments

Source: Rolling Stone (2012).

G. Product engineering

Source: Rolling Stone (2015).
A Report of the Surgeon General

162 Chapter 4

Figure 4.6 Continued

H. Cleaner than cigarettes

Source: Car and Driver (2014).

I. Save money

Source: FIN Electronic Cigarettes (n.d.).

J. Circumvent smokefree policies

Source: Spin (2012).
Activities of the E-Cigarette Companies 163

E-Cigarette Use Among Youth and Young Adults

samples during large events and has even sponsored events 

at music festivals (PRNewswire 2013; blu eCigs 2014). 

Further, conservative estimates indicate that in 2012 and 

2013, free samples were provided by six companies at 

348  events, most of these events having high participation by youth (Durbin et al. 2014). Under the deeming rule 

published in May 2016 (currently under litigation), free 

samples were banned (Federal Register 2016).

Digital Landscape for E-Cigarettes

The Internet has been widely used to promote cigarettes, cigars, and smokeless products (Ribisl 2003; 

Freeman and Chapman 2007; USDHHS 2012). This 

medium—through websites, message forums, and social 

media—has been heavily used to sell and glamorize 

e-cigarettes and their use. Nearly all teens 13–17 years 

of age (92%) use the Internet daily, and 73% of teens 

access the Internet via smartphones (Lenhart 2015). In 

2015, a study conducted by the Truth Initiative indicated 

that 40% of youth (13–17 years of age) and 57% of young 

adults (18–21 years of age) had seen e-cigarette advertising online (Truth Initiative 2015).

Price promotions are not just involved in sales at 

brick-and-mortar stores; they are also offered by online 

stores and through social media. Grana and Ling (2014) 

found that 80% of websites indicated a sale price or discount, while Huang and colleagues (2014a) found that 

34% of commercial tweets mentioned the words “price” or 

“discount.” Both Facebook and Twitter provide opportunities for brands and companies to offer online coupons and 

discounts (Discount Coupons for blu n.d.; Vapor4Life n.d.). 

In a study of online e-cigarette retailers, 28% of the websites offered a promotion, such as a discount, other free 

items, or a loyalty program (Williams et al. in press). 

Without age restrictions or age verification, youth can 

access these websites easily and thus obtain the discount 

or coupon (Williams et al. in press). However, under the 

deeming rule, websites cannot sell e-cigarettes to youth 

under the age of 18, so access will likely be curtailed as 

a result (Federal Register 2016). The following sections 

review three basic categories of online e-cigarette content: 

websites that sell e-cigarettes, manufacturer-sponsored 

brand name websites, and e-cigarette promotions on 

social media websites (including Facebook, Twitter, and 

YouTube).

Websites Selling E-Cigarettes

Tobacco industry analysts estimate that online sales 

accounted for approximately 30% of e-cigarette sales 

volume in the first quarter of 2015 (Wells Fargo Securities 

2015a). Some Internet vendors sell their own brands 

exclusively (e.g., Mistic, Green Smoke), while a large 

number are online stores that sell many brands and varieties of products (Zhu et al. 2014; Williams et al. in press). 

Although the marketers of e-cigarettes have made 

claims that differ from those made for conventional cigarettes (such as use for smoking cessation, which is illegal 

without being an approved cessation drug or device), 

a content analysis of e-cigarette marketing (Grana and 

Ling 2014) and the observations of tobacco marketing surveillance systems point to several similarities, including 

the use of young, attractive models; lifestyle claims; and 

celebrities. Other claims made in e-cigarette advertising 

have been used in the past by conventional cigarette 

brands (such as having fewer carcinogens, lower risk of 

tobacco-related disease) or by smokeless tobacco products 

(such as the ability to use them where smoking is prohibited) (Grana and Ling 2014). However, under the deeming 

rule that was published in May 2016, after August 8, 2016, 

e-cigarette manufacturers cannot make modified risk 

claims (Federal Register 2016) (although this provision 

has been challenged in pending lawsuits).

Formal analyses of marketing claims of branded 

e-cigarette sites that both promote and sell e-cigarettes 

provide details on the types of claims made in these channels. The study by Grana and Ling (2014) analyzed claims 

from 59 English-language websites over a 2-month period 

in 2011 and found four major thematic content areas: 

health- and cessation-related benefits, avoiding smokefree 

policies, lifestyle benefits, and product-engineering claims. 

Ninety-five percent of websites made explicit or implicit 

health-related claims, and 64% made claims related to 

cessation, often through the use of testimonials. Almost 

all (98%) included a comparison of the risks and benefits 

of e-cigarettes and conventional cigarettes; 95% included 

claims that e-cigarettes are cleaner; and 93% said they 

were cheaper. Claims regarding where e-cigarettes 

could be used were also common—with 88%  claiming 

e-cigarettes can be used anywhere, and 71% pointing to 

e-cigarette use as a means of circumventing clean air policies. Figure 4.6 shows advertising that exemplifies these 

marketing claims for e-cigarettes.

Grana and Ling’s (2014) analysis also points to the 

common use of lifestyle-related claims, a hallmark of traditional tobacco marketing: 73% of websites contained 

images or claims of being modern or glamorous. Websites 

also pointed to social advantages for users of their particular brand: 44% of claims pointed to increased social 

status and 32% to enhanced social activity, 31% suggested 

romantic advantages, and 22% used celebrities. Claims 

of increased social status, opportunity, and romance as 

well as the use of celebrities may resonate especially with 

youth and young adults (Grana et al. 2011).

A different content analysis, this one of the marketing messages of English-language branded e-cigarette 
A Report of the Surgeon General

164 Chapter 4

retail sites, examined and compared websites for two different time periods (May–August 2012 and December 

2013–January 2014) and found differences in claims between 

the two timeframes (Zhu et al. 2014). In comparing claims 

for brands available during both time periods with those 

that were newly available in 2013–2014, the authors found 

that products and advertising messages varied between the 

two samples. Brands analyzed from 2012 were significantly 

more likely than those in the later period to (a) claim that 

their products were healthier and less expensive than conventional cigarettes and could be used where smoking is 

prohibited and (b)  indirectly claim their products were 

effective for smoking cessation through testimonials and 

other methods (Zhu et al. 2014). The study also found an 

increase from one period to the next in the number of 

branded retail websites and the number of flavors per brand 

advertised on a website, as well as the likelihood of a website offering e-cigarette hardware and such other products 

as e-liquids and e-hookahs or other products that did not 

resemble cigalikes (Zhu et al. 2014). The study’s findings 

suggested that the emphasis for newer brands had shifted 

from comparing them with conventional cigarettes to a 

focus on their role as new nicotine delivery systems.

Williams and colleagues (in press) used a standardized search strategy employed in their earlier study 

of websites selling cigarettes (Ribisl 2003) to identify 

995  English-language websites selling e-cigarettes in 

2014. The authors performed a content analysis on the 

281 most popular websites, as judged by data on traffic. 

Most of the websites were based in the United States 

(71.9%), the United Kingdom (16.7%), and China (5.3%), 

and they offered a variety of products, but more sold 

e-cigarette starter kits (92.5%) than disposables (55.2%). 

Most offered flavors, with the most popular being fruit 

(79.4%), candy (75.2%), coffee (68.0%), and alcohol 

(45.6%). Although 71.5% featured some type of health 

warning, 69.4%  claimed health advantages over other 

tobacco products, and 32.7% claimed that the product 

helped people to quit smoking conventional cigarettes. 

The sites also featured endorsements or mentions of 

celebrities using the products (Stanford Research into 

the Impact of Tobacco Advertising n.d.a.). Physicians and 

other health professionals provided endorsements as well.

Elsewhere, Cobb and colleagues (2015) conducted a 

forensic analysis of websites that sold e-cigarettes and participated in affiliate advertising on the Internet. In addition to identifying multiple layers of redirection between 

online advertising by affiliates and websites selling 

e-cigarettes, the authors found that online advertisements 

and affiliate websites included cessation claims. 

Research suggests Internet e-cigarette vendors have 

not routinely verified the age and identity of website visitors or blocked sales to minors. However, after August 8, 

2016, due to the deeming rule, it has become illegal for 

online retailers to sell e-cigarettes to those under 18 

(Federal Register 2016). In a survey of purchasing by 

youth, Williams and colleagues (2015) identified 98 websites selling e-cigarettes on which youth, 14–17 years of 

age, made purchase attempts using prepaid credit cards. 

In all, 18 (of 98) order attempts failed because of technical 

problems with the website or the payment system, all of 

which were unrelated to age verification. Of the remaining 

80 orders, 75 (93.8%) were filled. Five vendors claimed to 

use a service offered by shipping companies to verify age 

at delivery, but none actually did. Although data are not 

available on the proportion of youth who purchase their 

e-cigarettes online versus buying them at retail outlets, 

this study suggests that youth would have ready access if 

they tried to purchase e-cigarettes online. The Prevent All 

Cigarette Trafficking Act of 2009 requires Internet sellers 

of cigarettes and smokeless tobacco to, among other provisions, verify age of customers at the time of purchase and 

ensure that the deliverer checks identification at the time 

of delivery; stop Internet sales to minors; and pay applicable 

local, state, federal, and territorial taxes to reduce the price 

advantage of online sales. FDA regulation now prohibits 

the Internet sales of e-cigarettes to minors. However, there 

are currently no federal requirements for Internet vendors 

of e-cigarettes to check identification upon delivery or pay 

applicable taxes (Campaign for Tobacco Free Kids 2016).

The marketing of candy and fruit flavors may be one 

of the reasons that e-cigarettes appeal to youth (Grana 

and Ling 2014; Richtel 2014a; Zhu et al. 2014). Young 

adults (18–24 years of age) are more likely to use flavored 

tobacco products than are adults in the next age group 

(25–34 years of age) (Villanti et al. 2013). Zhu and colleagues (2014), who used three search engines (Google, 

Yahoo!, and Bing) and various keywords from May 2012 

to January 2014 to identify a wide variety of e-cigarette 

brands and flavors, found 466 brands and 7,764 unique flavors, with 242 new flavors appearing each month. Other 

than tobacco flavor, the most popular flavors were menthol 

(92.1%), fruit (84.2%), dessert/candy (79.9%), and alcohol/

drinks (77.5%). Additionally, in their content analysis of 

e-cigarette retail websites, Grana and Ling (2014) found 

that such flavors as coffee, fruit, and candy were offered on 

most sites. Further, flavors were being sold under brand 

names similar to cereal and candy products that appeal to 

youth, such as Wrigley’s Big Red Gum (Daniels 2015).

Tobacco Industry Corporate and Brand 

Websites

Three categories of e-cigarette brands have emerged 

within the U.S. market: brands developed by cigarette 

manufacturers (i.e., MarkTen, VUSE), brands acquired 
Activities of the E-Cigarette Companies 165

E-Cigarette Use Among Youth and Young Adults

by cigarette manufacturers (i.e., blu, Green Smoke) 

(Table 4.3), and brands that have no affiliation with a cigarette manufacturer (e.g., NJOY, FIN). A content analysis 

of websites for these three types of brands suggested that 

those developed by cigarette manufacturers may be marketed more cautiously than brands acquired by cigarette 

manufacturers or brands that have no affiliation with a 

cigarette manufacturer (Seidenberg et al. 2016). 

Table 4.3 Mergers, acquisitions, partnerships, and other agreements in the e-cigarette industry

Date Purchaser Acquisition target

Partnerships and 

other agreements Deal sizea Geographyb

December 2011 Japan Tobacco — Ploom (partnership) Not disclosed United States

December 2012 BAT CN Creative — £40 million United Kingdom

April 2012 Lorillard blu — $135 million United States

April 2013 National Tobacco — V2 Cigs 

(partnership)

Not disclosed United States

August 2013 Imperial Dragonite — $75 million China

October 2013 Lorillard SKYCIG — £60 million United Kingdom

January 2014 ECIG VAPESTICK — $70 million United Kingdom

January 2014 Gilla Drinan — Not disclosed Ireland

February 2014 Altria Green Smoke — $110 million United States

March 2014 ECIG FIN — $170 million United States

April 2014 ECIG VIP — $58 million United Kingdom

June 2014 ECIG Ten Motives — $104 million United Kingdom

June 2014 PMI Nicocigs — Not disclosed United Kingdom

July 2014 ECIG Hardwire — $30 million Internet

November 2014 Japan Tobacco E-Lites — Not disclosed United Kingdom

January 2015 BreatheEcigs/DNA Breathe LLC — Not disclosed United States

February 2015 Japan Tobacco — Ploom (purchased 

the intellectual 

rights to some 

Ploom technology)

Not disclosed United States

March 2015 Gilla An undisclosed 

Florida e-liquid 

company

— $1.5 million United States

April 2015 Japan Tobacco Logic — Not disclosed United States

June 2015 Imperial blu — $7.1 billion United States and 

United Kingdom

December 2015 Gilla The Mad Alchemist — $500,000 United States, 

Canada, Europe, 

and United Arab 

Emirates 

Source: Various news sources and companies’ websites, SEC (Securities and Exchange Commission) reports, and press releases as of 

January 25, 2016.

aDeal size refers to prices at the time of the announcement, not necessarily the final transaction price.

bGeography refers to the country in which the acquisition target was registered.

Table 4.4 

compares and contrasts some key features of the websites by manufacturer affiliation. It shows, for example, 

that access to websites of brands developed by cigarette 

manufacturers (or a subsidiary) was restricted to users 

21  years of age and older (MarkTen), and user registration was required (i.e., the user needed to input personal 

information such as name, address, and birthdate) for 

VUSE. In contrast, websites for brands with no affiliation 
A Report of the Surgeon General

166 Chapter 4

with a cigarette manufacturer and those acquired by cigarette manufacturers were accessible to users 18 years of 

age and older via self-reporting of age, with the exception 

of 21st Century Smoke. In addition, VUSE e-cigarettes 

were not sold online (they were sold only in retail outlets), and they were available in a single nicotine level 

with limited flavor options (except for forthcoming tank 

versions), while MarkTen could be purchased online. The 

websites for both MarkTen and VUSE mentioned selling 

flavored e-cigarettes. As far as e-cigarette brands not 

having an affiliation with a cigarette manufacturer or 

that were acquired by a cigarette manufacturer, all brands 

except Logic offered fruit, candy, or other flavors. Further, 

all of the unaffiliated brand websites sold e-cigarettes 

online and offered multiple nicotine levels. Most websites 

offered nicotine-free options and flavored e-cigarettes as 

well (Seidenberg et al. 2016). The Green Smoke website 

even provided a link to guide customers in finding the 

proper nicotine level for their cartridges (Green Smoke 

E-Vapor n.d.).

Table 4.4 Comparison of website access restrictions, online sales, nicotine levels, and flavors among e-cigarette 

brands with no cigarette manufacturer affiliation, brands acquired by cigarette manufacturers, and brands 

developed by cigarette manufacturers

E-cigarette brands (10)

Not affiliated with a cigarette 

manufacturer: NJOY, Logic, 

21st Century Smoke, FIN, 

Nicotek, and Mistic (6)

Acquired by a cigarette 

manufacturer: blu and Green 

Smoke (2)

Developed by a cigarette manufacturer 

(or subsidiary): MarkTen and 

VUSE (2)

Website access All websites (except 21st 

Century Smoke) have one-click 

accessa or age verification to 

restrict initial access to people 

18 years of age and older; 21st 

Century Smoke does not have 

any website restrictions for 

initial access.

Both sites have one-click 

access or age verification to 

restrict initial access to people 

18 years of age and older (blu) 

and 21 years of age and older 

(Green Smoke).

MarkTen has age verification to restrict 

initial access to people 21 years of age 

and older. Before initial access, VUSE 

requires people 21 years of age and 

older to register first with the website.

Online sales All brands can be purchased 

online.

Both brands can be purchased 

online.

MarkTen can be purchased online; 

VUSE cannot.

Multiple levels of 

nicotine

Among all brands, the level 

of nicotine varies by product. 

Some (e.g., blu, Logic Zero, 

21st Century Smoke, Nicotek) 

offer products with 0% nicotine 

(by volume).

Among both brands, the level of 

nicotine varies by product. 

For MarkTen, the level of nicotine 

varies by product. VUSE e-cigarettes 

contain 4.8% nicotine (by weight).

VUSE tanks, set to come out in 

February 2016, will have different 

levels of nicotine (Kress 2015).

Flavors (other than 

tobacco and/or 

menthol)

All brands offer a variety of 

flavors, such as fruit and candy.

Both brands offer a variety of 

flavors.

MarkTen offers two flavors: fusion and 

wintermint. VUSE offers four flavors: 

crema, chai, berry, and mint (Kress 

2015).

Source: Unless cited otherwise, information was obtained from the companies’ websites (January 2016): https://www.njoy.com/; 

http://store.logicecig.com/; https://www.21stcenturysmoke.com/; https://www.fincigs.com/; http://www.nicotekecigs.com/; 

http://www.misticecigs.com/; http://www.blucigs.com/; https://www.greensmoke.com/; https://www.markten.com/; and 

https://vusevapor.com/.

aWith “one-click access,” visitors to a website self-report on their age by identifying their age from a clickable pop-up box. For 

example, persons 18 years of age and older can browse the website, but those younger than 18 cannot.

Social Media Promoting E-cigarettes

E-cigarettes have been widely promoted on social 

media platforms such as YouTube, Twitter, Instagram, and 

Facebook; most of these social media sites do not require 

age verification. YouTube is the most popular videosharing website globally and features many e-cigarette 

videos. Luo and colleagues (2014) used various search 

terms to identify 196 unique videos in February 2013 

that were portraying e-cigarettes and found that 94% of 

the videos were “pro” e-cigarettes, 4% were neutral, and 
Activities of the E-Cigarette Companies 167

E-Cigarette Use Among Youth and Young Adults

2% were “anti” e-cigarettes. Those authors found that 

the three most common genres were advertising of products, user sharing, and product reviews. Of the “pro” 

e-cigarette videos, 84.3% featured links to websites selling 

e-cigarettes, and 71.4% claimed that e-cigarettes were a 

healthier alternative to conventional cigarettes. Finally, 

the “pro” videos received more visits and were rated more 

favorably than were the small number of “anti” videos.

The authors of another study, this one a content 

analysis of 365 e-cigarette videos on YouTube that ran at 

some time from June 2007 to June 2011, estimated that 

more than 1.2 million youth and a total of 15.5 million 

people worldwide were exposed to these videos (Paek 

et al. 2014). In addition to looking at viewership, the content analysis examined the type, sponsorship, and health 

claims of the videos. Just 16% of the videos were formal 

advertisements or news clips, and 79.2% of the content 

was coded as appearing to have been generated by users. 

Videos emphasized economic, psychological, and social 

benefits, and health claims included e-cigarettes being 

less harmful than conventional cigarettes, healthy, and 

providing help in quitting smoking. Most (85.2%) videos 

in the sample were sponsored by e-cigarette companies 

or their associates, with an additional 10% coming from 

individuals who did not mention a specific website or 

company. Interestingly, videos sponsored by marketers 

contained a significantly lower level of health claims than 

did those from laypeople (users) and, not surprisingly, 

contained a higher level of information cues (e.g., product 

contents, price, distribution channel).

A cross-sectional study of Twitter, a microblogging 

platform, that examined more than 74,000 tweets accessed 

through a licensed Twitter data provider over a 2-month 

period in 2012, found extensive marketing of e-cigarettes 

(Huang et al. 2014a). The majority of e-cigarette content during this period was advertising and promotion. 

In fact, 89.6% of the tweets contained commercial content (e.g., presence of branded promotional messages or 

hyperlinks to commercial websites), and only 11% identified as being non-sponsored or independent, reflecting 

individual opinions or experiences, or being linked to nonpromotional content. Commercial tweets most commonly 

contained price promotions and discounts (34.3%), with 

cessation-related claims included in 10.8% and lower percentages for health or safety (Huang et al. 2014a).

Jo and colleagues (2016), in a study of 2,847 tobaccorelated tweets about price promotions and coupons, found 

that e-cigarettes, not conventional cigarettes, were the 

most frequently mentioned product (90.1%), and about 

one-third of all e-cigarette-related tweets included a discount code. The tweets also touted the relatively low price 

of e-cigarettes and made comparative claims about the 

health risks of the product.

Sponsored Online and Video Advertising

The study by Richardson and colleagues (2015) 

used information from the monitoring service 

Competitrack to analyze the volume and characteristics of 

industry-sponsored tobacco and e-cigarette online banner/

video advertisements in the United States and Canada in 

2012–2013. This study found that online banner/video 

advertising—which embeds an ad or video on a website—was more commonly used for e-cigarettes than 

for conventional cigarettes. E-cigarette ads were often 

placed on music or entertainment (39.1%) sites, which 

the authors noted attract a sizeable number of youth and 

young adults. The most frequent theme for the 24 online 

banner or video e-cigarette ads (promoting five e-cigarette 

brands) analyzed was that the product was more “green” 

or environmentally friendly than conventional cigarettes 

(54.2%), followed by less harmful than cigarettes (37.5%), 

and being an alternative to conventional cigarettes when 

someone could not smoke (33.3%).

E-Cigarettes in the Retail 

Environment

Conventional Tobacco Retailers (Convenience 

Stores, Pharmacies, Tobacco Shops)

As of December 2015, 48 of the 50 states prohibited 

sales of e-cigarettes to minors (National Conference of 

State Legislatures 2015), but compliance of retailers with 

youth-access laws has not yet been studied. FDA is actively 

enforcing the federal minimum age requirements. As of 

August 8, 2016, the federal deeming rule bans the sale of 

e-cigarettes to minors under the age of 18 and requires 

photo identification for those under age 27 (Federal 

Register 2016). In the past few years, brick-and-mortar 

retailers have surpassed the Internet as the dominant 

distribution channel for e-cigarettes. For example, after 

Lorillard acquired blu in 2012, the number of retailers 

selling this brand increased from 13,000 to 127,000 in 

just 1 year (Esterl 2012; Bannon 2013). In California, 

the proportion of licensed tobacco retailers that sold 

e-cigarettes increased from 12% in 2011 to 67% in 2014 

(Chapman 2015).

E-cigarettes are widely available in convenience 

stores, a type of establishment that 4.1 million U.S. 

teenagers visit at least once per week (Rose et al. 2014; 

Sanders-Jackson et al. 2015a). According to a 2013 statesponsored survey that included a sample of approximately 

7,300 licensed tobacco retailers in California, e-cigarettes 

were sold in more than half of convenience stores, pharmacies, and liquor stores and in nearly all tobacco shops 
A Report of the Surgeon General

168 Chapter 4

(California Department of Public Health and California 

Tobacco Control Program 2014).

Only three studies have examined the retail availability of e-cigarettes near schools. In a 2012 nationally 

representative sample of tobacco retailers, the presence of 

a public school within 1,000 feet was not related to the 

availability of e-cigarettes (Rose et al. 2014). In a study 

that examined a much larger buffer zone in Kentucky, 

88% of schools in two counties were located within 1 mile 

of a retailer that sold e-cigarettes (Hahn et al. 2015). As 

for colleges, disposable and/or rechargeable e-cigarettes 

were available at 60% of tobacco retailers near campuses 

in North Carolina and Virginia in 2013, a more than twofold increase from the previous year (Wagoner et al. 2014).

A pilot study examining tobacco point-of-sale advertising and promotion in the central Harlem neighborhood 

of New York City found that 26% of stores had e-cigarette 

advertising on the building’s exterior (Ganz et al. 2015). 

External ads included those located less than 3 feet above 

the ground at the eye level of children—a placement that 

was outlawed for conventional cigarettes by the Master 

Settlement Agreement—and featured flavored products 

(Ganz et al. 2015).

Unlike conventional cigarettes, e-cigarettes appear 

to be relatively less prevalent at stores in economically 

disadvantaged communities. In an analysis that examined 

data from two studies that had used representative samples of U.S. tobacco retailers, e-cigarettes were less likely 

to be sold than conventional cigarettes at stores located in 

economically disadvantaged neighborhoods and in neighborhoods with a higher proportion of African American 

residents (Rose et al. 2014). These patterns are consistent 

with evidence that e-cigarette marketing in other channels 

targets higher income non-Hispanic White males (Emery 

et al. 2014). However, the retail availability of e-cigarettes 

has changed at different rates in different neighborhoods. 

In a study of U.S. food stores, only 3% of stores located 

in non-Hispanic White and Hispanic neighborhoods sold 

e-cigarettes in 2010; none of the stores in predominantly 

African American neighborhoods sold them (Khan et al. 

2014). Three years later, the figures were 36% in predominantly non-Hispanic White neighborhoods, 18% in 

Hispanic-majority neighborhoods, and 19% in African 

American-majority neighborhoods. Notably, these data 

were collected before the two largest U.S. tobacco companies launched MarkTen (Altria) and VUSE (Reynolds 

American) in late 2013. Thus, the industry’s current 

influence on disparities in the retail availability and marketing of e-cigarettes cannot be readily estimated from the 

studies reviewed.

Two studies examined retail data about e-cigarettes 

as a function of state and/or county smokefree air laws 

(Huang et al. 2014b; Rose et al. 2014). In one of the 

studies, which used data collected in two studies that used 

independent samples of U.S. tobacco retailers, the odds 

of selling e-cigarettes were greater for retailers in states 

with weaker smokefree air policies, even after controlling for store type, price of conventional cigarettes, and 

neighborhood demographics (Rose et al. 2014). A similar 

inverse relationship was found between sales of disposable e-cigarettes (as measured by retail scanner data in 

52 U.S. markets from 2009 to 2012) and the proportion 

of the population protected by 100% smokefree policies 

covering all indoor areas of bars, restaurants, and workplaces (Huang et al. 2014b). Taken together, these results 

suggest that e-cigarettes are, at least initially, more likely 

to be sold in communities with weaker smokefree policies.

Few retail surveillance studies have characterized 

promotion, placement, or price for e-cigarettes (Hsu et al. 

2013; Wagoner et al. 2014; Ganz et al. 2015). In a study 

of licensed tobacco retailers in Florida, advertising for 

e-cigarettes was more prevalent on the exterior than the 

interior (50% vs. 11%) (Kim et al. 2015). In the study by 

Wagoner and colleagues (2014), the presence of e-cigarette 

advertising near college campuses in North Carolina and 

Virginia tripled on store exteriors and quadrupled in store 

interiors in just 1 year. Although the price of rechargeable units decreased significantly, there was little evidence 

of price discounting for any e-cigarettes (Wagoner et al. 

2014). The low visibility of price discounts at the point 

of sale suggests that marketing for e-cigarettes favors a 

“pull” strategy, relying on direct mail and e-mail coupons 

and special offers to entice customers to retail locations.

“Vape Shops”

“Vape shops” specialize in the sale of refillable devices 

and tank systems, typically offer a tasting menu of flavors, 

and sometimes feature a lounge area where customers can 

“vape” while socializing (Lee and Kim 2015; Sussman et al. 

2016). “Vape shops” have been excluded from most studies 

about the retail marketing of e-cigarettes, in part because 

the environment is so different from that of conventional 

tobacco retailers (Lee and Kim 2015) and because so few 

states require these establishments to obtain a tobacco 

retailer license, effectively keeping them out of the sampling frame for many studies and making the monitoring 

and enforcement of laws difficult (Lee et al. 2014).

Anecdotal evidence suggests that “vape shops” currently do not have readily visible branded signs and displays 

that characterize the retail marketing of other tobacco 

products. Even though the relationship between the “vape 

shop” industry and the tobacco industry can be adversarial 

(Sussman et al. 2016), one study found that the marketing 

practices of these establishments closely resemble the current and former strategies that tobacco companies have 
Activities of the E-Cigarette Companies 169

E-Cigarette Use Among Youth and Young Adults

used to market other tobacco products (Cheney et al. 2015). 

According to this study, “vape shop” owners and managers 

in Oklahoma used free samples, loyalty programs, sponsored events, direct mail, advertising through social media, 

and price promotions targeted at particular consumers, 

such as college students (Cheney et  al. 2015). No other 

study about marketing by “vape shops” has been published.

Numerous gaps exist in research about “vape shops,” 

including information on consumer behavior, the use of 

tracking systems for sales data, marketing surveillance, 

purchases by youth, and the opinions of retailers and 

the general public about regulations. Spatial analyses 

are needed to determine whether “vape shops” are clustered near schools or college campuses, whether other 

neighborhood demographics are correlated with the location of these establishments, and how such associations, 

if present, have changed over time and in response to state 

and local policy interventions. The proportion of “vape 

shops” where workers mix solutions of liquid nicotine on 

site is not known, and the absence of uniform safety precautions regarding handling and spills poses additional 

concern for regulation (ChangeLab Solutions 2014). Under 

the deeming rule that was published in May 2016, “vape 

shops” that mix and sell e-liquids are both retailers and 

manufacturers and, therefore, are subject to the provisions 

in the deeming rule and the Tobacco Control Act that apply 

to both (Federal Register 2016).

Exposure and Receptivity to 

Advertising for E-Cigarettes

Exposure

Given industry data about increasing expenditures 

for e-cigarette advertising and extending its reach, the 

high levels of advertising awareness reported in studies of 

youth and/or young adults are not surprising. An online 

panel of U.S. youth (13–17 years of age) and young adults 

(18–21 years of age) conducted in February 2014 found 

that awareness of e-cigarette advertising was greatest for 

retail advertising, followed by awareness of advertising 

on television and online (Truth Initiative 2015). In this 

study, and compared with the entire population, awareness among current smokers of e-cigarette advertising 

was higher across all channels and higher for online ads 

than for television ads (Legacy for Health 2014).

In school-based surveys of middle and high school 

students in Connecticut, gas stations and television were 

the dominant channels in which students reported recently 

seeing e-cigarettes advertised or sold (Krishnan-Sarin et al. 

2015). A different pattern was observed in a convenience 

sample of college students in Hawaii, where the figures for 

seeing ads were 59%, online; 58%, television; 71%, malls; 

41%, gas stations; and 47%, convenience stores (Pokhrel 

et al. 2015). Elsewhere, in an online experiment, 56% 

of adolescents (13–17 years of age) who had never used 

e-cigarettes reported seeing at least one televised advertisement previously, and there were modest, but statistically 

insignificant differences in exposure by smoking status and 

race/ethnicity (p<.10) (Farrelly et al. 2015).

The National Youth Tobacco Survey reported that in 

2014, 18.3 million middle and high school students were 

exposed to e-cigarette advertising from at least one source 

(CDC 2016b). In this nationally representative sample of 

U.S. middle and high school students, nearly 7 out of 10 

reported seeing an e-cigarette advertisement in that year. 

The most common places for exposure among middle 

school students were retail stores (52.8%), the Internet 

(35.8%), television and movies (34.1%), and newspapers 

and magazines (25.0%). Similarly, high school students 

reported the highest exposure at retail stores (56.3%) and 

then the Internet (42.9%), television and movies (38.4%), 

and newspapers and magazines (34.6%). Among both 

middle school and high school students, exposure through 

retail stores was higher among non-Hispanic Whites than 

non-Hispanic Blacks. However, non-Hispanic Blacks had 

higher exposure to e-cigarette advertisements on television and in movies than non-Hispanic Whites. Females 

had higher exposure than males to advertisements on the 

Internet and in newspapers and magazines.

Receptivity to Advertising

Receptivity to tobacco marketing is a well-established 

risk factor for tobacco use by adolescents and young adults 

(NCI 2008; USDHHS 2012), and two studies adapted measures of receptivity to the marketing of tobacco in research 

on e-cigarettes. In one study, college students from 

a  southwestern state who watched three advertisements 

for different brands of e-cigarettes in an online survey 

used a 7-point scale to rate how enjoyable, likable, and 

appealing the ads were; results suggested moderate receptivity (mean of 51 on a scale ranging from 7 to 126) and 

significant differences between brands (Trumbo and Kim 

2015). In the other study, Pokhrel and colleagues (2015), 

using a sample of college students from Hawaii, adapted 

a multi-item scale of liking advertisements from studies 

about alcohol (Unger et al. 2003) and two items from the 

most commonly used measure of receptivity to tobacco 

marketing (Pierce et al. 1998). This study observed low 

levels of liking advertisements (all below the scale midpoint) (Pokhrel et al. 2015). The extent to which youth 

and young adults who are receptive to e-cigarette marketing are also receptive to tobacco marketing has not 

been studied. However, the extent to which advertising 
A Report of the Surgeon General

170 Chapter 4

strategies for e-cigarettes mimic strategies used by tobacco 

companies suggests that the two measures of receptivity 

could be highly correlated.

Effect of E-Cigarette Advertising on 

Behavior

Associations with E-Cigarette Use and Intentions 

to Use

Evidence that advertising for conventional cigarettes increases product initiation among never users, 

discourages quit attempts in current users, and encourages relapse in those trying to quit is well established (NCI 

2008; USDHHS 2012). However, while fewer studies have 

focused on e-cigarette advertising in particular, the available evidence suggests that e-cigarette advertising has 

similar effects, although additional research is recommended. A search for studies of youth or adults that either 

(a) manipulated exposure to e-cigarette advertising or measured self-reported recall of advertisements, (b)  assessed 

the frequency of exposure to advertising in one or more 

channels, or (c) measured receptivity to e-cigarette advertising yielded 10 studies that addressed the impact of 

advertising on the use of or intentions to use e-cigarettes.

One experiment tested whether seeing television 

advertising for e-cigarettes predisposed adolescents to try 

these products (Farrelly et al. 2015). Among adolescents 

(13–17 years of age) who had never used e-cigarettes, 

a single exposure to a set of four televised advertisements 

for popular brands resulted in significantly greater intention to try e-cigarettes—more than 50% higher in the 

treatment group than the control group (Farrelly et al. 

2015). Another study examined responses to e-cigarette 

advertisements among young adults (Trumbo and Kim 

2015); among a convenience sample of college students 

who watched three television ads for e-cigarettes, greater 

receptivity to e-cigarette advertising was associated with 

significantly higher odds of intending to use e-cigarettes 

in the future, but the analysis did not adjust for prior use 

or individual demographics (Trumbo and Kim 2015).

Very few cross-sectional or longitudinal surveys have 

examined associations between adolescents’ exposure to 

e-cigarette advertising and either trial or regular use of 

such products. An analysis of the 2011 National Youth 

Tobacco Survey found that adolescents who reported frequent exposure to protobacco advertising at the point 

of sale and on the Internet (e.g., seeing ads most of the 

time or always) had significantly higher odds of ever using 

e-cigarettes, and there was a dose-response association 

between the number of marketing channels to which they 

were exposed and ever use (Agaku and Ayo-Yusuf 2014).

Surveillance research that differentiates exposure to 

advertising for e-cigarettes from exposure to ads for conventional tobacco products would be useful to establish 

whether exposure to e-cigarette advertising is correlated 

with product use and contributes to product initiation and 

product use among young people who were not tobacco 

users to start. It bears mentioning here that a generation of U.S. youth has grown up without any television or 

billboard ads for conventional cigarettes. In this context, 

research is needed to understand at what age young people 

understand that e-cigarette advertising depicts the use of 

e-cigarettes rather than the smoking of conventional cigarettes and to examine whether there are spillover effects 

of marketing for e-cigarettes on the use of conventional 

tobacco products.

In the study from Hawaii (Pokhrel et al. 2015), 

researchers examined the association between exposure 

to e-cigarette advertising and product use using a convenience sample of approximately 300 college students in 

that state. The study found that more frequent exposure 

to e-cigarette advertising—as measured by exposure in 

any of multiple channels (e.g., newspapers, magazines, 

Internet, television billboards, sporting/cultural events, 

convenience stores, gas stations, grocery stores, and 

malls)—was associated with significantly higher odds 

of ever using e-cigarettes, and receptivity to e-cigarette 

advertising was associated with higher odds of past-month 

use, even after adjustments for smoking status and individual demographics.

Two studies strongly support the association between 

exposure to e-cigarette advertising and youth susceptibility to and use of e-cigarettes (CDC 2016a; Mantey et al. 

2016). Both studies examined data from the 2014 National 

Youth Tobacco Survey, a survey of more than 20,000 U.S. 

middle and high school students. The studies assessed 

self-reported levels of exposure to e-cigarette ads on the 

Internet, in newspapers and magazines, at retail stores, 

and on television or in movies, and used multivariate 

logistic regression models to examine the relationships 

between marketing exposure and e-cigarette susceptibility 

and use. Exposure to each type of e-cigarette marketing 

was significantly associated with increased likelihood of 

ever having used and current use of e-cigarettes among 

middle and high school students (CDC 2016a; Mantey et 

al. 2016). Exposure was also associated with susceptibility 

to use e-cigarettes among current nonusers. In multivariate models, as the number of channels of e-cigarette 

marketing exposure increased, the likelihood of use and 

susceptibility also increased (Mantey et al. 2016).

One concern is that e-cigarette advertising may 

perpetuate dual use of conventional cigarettes and 

e-cigarettes, a concern that comes from the visual depictions of e-cigarette use that may serve as smoking cues 
Activities of the E-Cigarette Companies 171

E-Cigarette Use Among Youth and Young Adults

to current and former smokers of conventional cigarettes, increasing the urge to smoke and decreasing intentions and efficacy to quit or abstain from smoking (Glynn 

2014; Grana and Ling 2014; Maloney and Cappella 2016). 

Consistent with cue-reactivity studies about conventional 

cigarettes, exposure to e-cigarette use in a laboratory was 

associated with increased urge to smoke conventional cigarettes among smokers and an urge to use e-cigarettes 

among users of that product (King et al. 2015). Whether 

exposure to depictions in advertising of the use of 

e-cigarettes triggers urges to begin or continue to smoke 

conventional cigarettes or weakens users’ resolve to quit 

has received little attention. This is particularly important 

because rates of cigarette smoking among youth in the 

United States are at an historic low (CDC 2014).

Associations with Knowledge, Risk Perceptions, 

and Other Attitudes 

Advertising is an important source of information 

about e-cigarettes for youth and adults (de Andrade et al. 

2013; Pepper et al. 2014a), and there is emerging evidence 

about how unregulated advertising for e-cigarettes may 

influence consumer perceptions about product safety. 

One study of adolescents (Farrelly et al. 2015) and three 

studies of adults (Pokhrel et al. 2015; Sanders-Jackson 

et al. 2015b; Tan et al. 2015a) examined the associations 

between exposure to e-cigarette advertising and knowledge or perceptions of these products.

Among U.S. adolescents (13–17 years of age) who 

had never used e-cigarettes, a single exposure to a set of 

four televised advertisements was associated with significantly higher odds of agreeing that the products can be 

used without affecting those around you and with lower 

odds of agreeing that the products are harmful (Farrelly 

et al. 2015). Compared with the control group, the treatment group reported significantly more positive attitudes 

about the benefits of using e-cigarettes. Elsewhere, in an 

online survey representative of U.S. households, 57% of 

young adults (18–34 years of age) were aware that some 

e-cigarettes contain nicotine, but more frequent exposure to e-cigarette advertising at point of sale, in mass 

media, and in social media (the three variables combined) 

was associated with a significantly higher likelihood of 

answering this question incorrectly (Sanders-Jackson 

et al. 2015b).

In the previously cited study of college students 

in Hawaii (Pokhrel et al. 2015), greater receptivity to 

e-cigarette marketing—but not more frequent exposure 

to the advertising of these products—was associated with 

significantly greater endorsement of beliefs about harm 

reduction for e-cigarettes (e.g., safer, improves health, 

helps to quit). A  different study referred to an online 

survey of U.S. adults (the Annenberg National Health 

Communication Survey [ANHCS]) in which surveyors 

measured the frequency of exposure to e-cigarette advertising (point of sale, mass media, and social media) and 

the degree to which participants perceived those messages as negative or positive (Tan et al. 2015a). Compared 

with those who reported no exposure to advertising, 

those who held negative perceptions of these messages 

reported significantly greater perceptions of harm from 

breathing e-cigarette vapor. Taken together, the available 

evidence suggests that continued exposure to unregulated 

advertising likely promotes reduced perceptions of harm 

and toxicity and increased perceptions of the efficacy of 

e-cigarettes for quitting conventional cigarettes.

Whether the increasing amount of advertising and 

promotional activities for e-cigarettes serves to renormalize the smoking of conventional cigarettes—that 

is, to shift public norms back to acceptance of cigarette 

smoking—is also not known. In focus groups of adult 

smokers 45 years of age and older, participants expressed 

almost unanimous agreement, after seeing selected ads, 

that e-cigarette advertisements promote smoking as 

a socially desirable behavior (Cataldo et al. 2015). The 

analysis by Farrelly and colleagues (2015) also looked at 

outcomes for conventional cigarettes. After exposure to 

e-cigarette advertising, there were no significant differences between the treatment and control groups on intentions to smoke conventional cigarettes, attitudes toward 

those products, or perceived harm from cigarettes (even 

though there were differences between groups on their 

perceptions of e-cigarettes, as noted previously).

The study that used data from the ANHCS also tested 

the hypothesis that greater exposure to e-cigarette advertising was associated with weaker support for restricting 

cigarette smoking in public spaces (Tan et al. 2015b). Both 

more frequent exposure to e-cigarette advertising and the 

degree to which participants perceived those messages as 

positive correlated negatively with support for smoking 

restrictions. However, in models adjusted for demographic 

variables, neither measure predicted support for restricting 

smoking. Further research is needed to address whether 

the large amount of advertising for e-cigarettes weakens 

support for smokefree air laws and other tobacco control 

policies or supports other potential indicators of renormalizing smoking, particularly those indicators that are known 

risk factors for tobacco use by adolescents and young 

adults, such as descriptive norms (e.g., perceived prevalence), injunctive norms (e.g., peer acceptance or social 

acceptability), outcome expectations (e.g., perceived benefits), and attitudes toward the tobacco industry. Additional 

research is also needed to assess whether e-cigarette advertising that draws comparisons to conventional cigarettes 

could serve to undermine antismoking messages.
A Report of the Surgeon General

172 Chapter 4

Evidence Summary

Although the e-cigarette marketplace is complicated 

by the differences in brands that are owned by tobacco 

companies versus independent brands, e-cigarette companies continue to change and to influence the manufacturing, price, marketing and promotion, and distribution 

of e-cigarette products and accessories. The e-cigarette 

market continues to grow, with projected sales of $3.5 billion in 2015. Consolidation of e-cigarette companies has 

been rapid, with the first major merger taking place in 

2012. These mergers and acquisitions are likely to continue, but the rate of consolidation may slow down as sales 

of cigalikes decelerate, and “vape shops” could have the 

potential to influence the e-cigarette marketplace based 

on the current structure of the marketplace and a regulatory landscape where federal regulation is just beginning 

to be implemented. All of these factors create additional 

uncertainties and risks for both the existing independent 

e-cigarette companies and the large cigarette companies. 

This chapter has shown that many of the marketing techniques used by e-cigarette companies are similar to those 

used by the tobacco industry for conventional cigarettes, 

and that awareness by youth and young adults of this marketing, and their levels of exposure to it, is high. Further, 

tracking marketing expenditures and product sales is difficult because of the rapidly changing venues, including 

“vape shops,” use of social media, and online advertising.

Conclusions

1. The e-cigarette market has grown and changed 

rapidly, with notable increases in total sales of 

e-cigarette products, types of products, consolidation of companies, marketing expenses, and sales 

channels.

2. Prices of e-cigarette products are inversely related 

to sales volume: as prices have declined, sales have 

sharply increased.

3. E-cigarette products are marketed in a wide variety 

of channels that have broad reach among youth and 

young adults, including television, point-of-sale, 

magazines, promotional activities, radio, and the 

Internet. 

4. Themes in e-cigarette marketing, including sexual 

content and customer satisfaction, are parallel to 

themes and techniques that have been found to be 

appealing to youth and young adults in conventional 

cigarette advertising and promotion.
Activities of the E-Cigarette Companies 173

E-Cigarette Use Among Youth and Young Adults

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2015b. 

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Williams RS, Derrick J, Ribisl KM. Electronic cigarette 

sales to minors via the Internet. JAMA Pediatrics

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Tobacco Control 2014;23(Suppl 3):iii3–iii9.

181

Chapter 5 

E-Cigarette Policy and Practice Implications

Introduction 183

Critical Issues Related to Policies on E-Cigarettes in 2016 184

The E-Cigarette Landscape Is Dynamic and Evolving 184

Risk Tradeoffs Are Inherent for E-Cigarettes 184

Additional Evidence Suggested for Future Research 185

Potential Public Policy Approaches 187

Clean Indoor Air Policies 188

Prevent Youth Access 203

Licensing 203

Taxation and Other Price Policies 204

Restrictions on Marketing 205

Educational Initiatives 206

Implications for Health Care Practice 206

Case Studies 224

Summary and Recommendations 225

Conclusions 226

References 227

E-Cigarette Policy and Practice Implications 183

E-Cigarette Use Among Youth and Young Adults

Introduction

The previous chapters have set out what is currently 

known and not known about e-cigarettes. Despite the 

identified gaps in evidence and the dynamic, evolving patterns of the use of e-cigarettes, policy options are needed. 

These policy options are particularly important as they 

affect the use of e-cigarettes by youth and young adults. 

As this report has demonstrated, e-cigarettes are widely 

used by youth and young adults and are particularly risky 

for these age groups, and efforts to prevent their use by 

young people are needed. This chapter explores the policy 

landscape of e-cigarettes and sets forth recommendations 

that should protect the public’s health, particularly as 

these policies relate to the short- and long-term health of 

youth and young adults.

The Family Smoking Prevention and Tobacco 

Control Act of 2009 (or Tobacco Control Act) (2009) is 

meant to protect the health of the public, including young 

people. As previously discussed, on May 10, 2016, FDA 

published a final rule which deemed all other products, 

including e-cigarettes, meeting the definition of a tobacco 

product, except accessories of such products, to be subject to the Federal Food, Drug, and Cosmetic Act. This 

rule went into effect on August 8, 2016 (Federal Register 

2016). Under the Tobacco Control Act, FDA likely will be 

required to consider the consequences of e-cigarette use 

for those who do not use tobacco products (as well as for 

those who do).

It can be stated that public health will be harmed if

the availability of e-cigarettes:

• Increases exposure to nicotine among youth and 

young adults;

• Leads to the initiation of combustible tobacco 

smoking;

• Slows or prevents cessation of combustible products 

by nicotine-addicted smokers; or

• Increases the likelihood that former smokers will 

again become addicted to nicotine and/or use combustible products after being reintroduced to nicotine by e-cigarettes.

Potential harm also comes from secondhand exposure to the vapor or aerosol expelled from e-cigarette 

users. Secondhand exposure comes from inhaling the 

aerosol or contacting vapor-contaminated surfaces. Each 

of the potential negative consequences of the availability 

of e-cigarettes could lead to additional disease and premature mortality (Chapter 3).

Relative to efforts in cigarette and smokeless tobacco 

use prevention and control, a polarized debate has been in 

progress for several years over the role of e-cigarettes. There 

is general agreement that exclusive use of e-cigarettes poses 

a lower health risk to the individual than the extremely high 

health risks of using conventional, combustible tobacco 

products (Farsalinos and Polosa 2014; Grana et al. 2014a,b), 

although more research is needed on this as more becomes 

known about the harmful constituents of e-cigarettes 

(Sleiman et al. 2016). The controversy reflects the relative 

degree of emphasis given to the potential harm to adolescents and young adults from using e-cigarettes at one pole 

compared with the potential for reduced risk for established adult users of conventional cigarettes at the other (if 

they transition completely to e-cigarettes). Although this 

characterization does not reflect the complexity of the situation, it is useful in defining the potential tradeoffs that 

are implicit: increased numbers of young people who are 

exposed to nicotine (and who may go on to conventional 

tobacco products) versus reduced health risks to individuals who completely switch from conventional, combustible tobacco products with their extremely high health 

risks. The discussion has become increasingly complicated 

as e-cigarette use has increased, and still-incomplete evidence potentially supports the views of those holding to 

both poles of the argument about reducing harm for the 

overall population. However, the majority of currently 

available scientific evidence does not support the recommendation to use e-cigarettes for the cessation of cigarette smoking (Hartmann-Boyce et al. 2016). Additionally, 

the use of e-cigarettes does not pose benefits to youth and 

young adults, and some data suggest that use of e-cigarettes 

could lead to the more harmful use of conventional cigarettes. In the context of young people, the precautionary 

principle should apply. The precautionary principle is 

defined by the United Nations Educational, Scientific and 

Cultural Organization (2005) as appropriate “when human 

activities may lead to morally unacceptable harm that is scientifically plausible but uncertain, actions shall be taken to 

avoid or diminish that harm” (p.14).
A Report of the Surgeon General

184 Chapter 5

Critical Issues Related to Policies on E-Cigarettes in 2016

The E-Cigarette Landscape Is 

Dynamic and Evolving

Considerations of policy approaches to e-cigarettes 

offered in this report are made in the context of a rapidly changing marketplace for nicotine-containing products that now includes primarily conventional cigarettes, cigars, smokeless products, hookahs, and 

e-cigarettes (see Chapter 2). The manufacture and sales 

of nicotine-containing products, once dominated by a few 

large companies selling conventional cigarettes, have been 

transformed and now include many smaller companies 

that manufacture and sell through stores and “vape shops.” 

E-cigarettes are also sold through websites and in places 

where conventional cigarettes have long been available—

convenience stores, pharmacies, gas stations, and grocery 

stores. Currently, hundreds of different e-cigarette products 

are on the market: designs are evolving rapidly, and major 

tobacco companies have their own lines of e-cigarette products. However, unlike the situation in the past in which the 

marketing of conventional tobacco products changed relatively slowly and there were limited media outlets, information about e-cigarettes is now promoted quickly through 

new media, as well as television, in part to reach key target 

groups, including youth and young adults.

As documented in Chapter 2, patterns of use are rapidly changing among adolescents and young adults, and 

likely among other groups within the population. For some 

of the most critical issues related to e-cigarettes, longitudinal data are not yet available because the use of these 

products is recent and constantly changing, and whether 

and when the patterns of use will stabilize is uncertain. 

Additionally, surveillance data and research on the wideranging consequences of e-cigarette use, including such 

key issues as the likelihood of addiction and other health 

problems for users and those passively exposed, are lagging behind the highly dynamic changes in the nicotineproduct marketplace and the impact of these changes on 

the use of tobacco products, including e-cigarettes.

 With regard to the potential health consequences of 

using e-cigarettes, estimates can be made based on knowledge of the characteristics and components of the aerosols 

that are then inhaled. Unfortunately, evidence on shortterm risks is limited, and long-term risks have not yet been 

identified because this would require monitoring users for 

years. For example, the impact of long-term inhalation of 

flavorings is not yet known. While some of the flavorings 

used in e-cigarettes are generally recognized as safe for 

ingestion as food, the health effects of their inhalation are 

generally unknown, and some flavorings have been shown 

to cause a serious lung disease, bronchiolitis obliterans, 

when inhaled (Kreiss et al. 2002; Barrington-Trimis et al. 

2014). Whether the risk of lung disease or other disorders 

is truly substantial will require longer term epidemiologic 

and other research (Allen et al. 2016).

Thus, policy approaches must support control measures that (a) are as dynamic as the rapidly changing marketplace for e-cigarettes; (b) are supported by surveillance 

data; and (c) document in timely fashion the current status 

of the use of multiple types of tobacco products (including 

e-cigarettes); the emergence of state, local, tribal, and territorial policies; and the strategies being used to market these 

products.

Risk Tradeoffs Are Inherent for 

E-Cigarettes

Policy discussions about e-cigarettes have highlighted 

the potential tradeoffs in risk that could occur, particularly 

if e-cigarettes are positioned as a harm-reducing alternative to combustible tobacco products. Some have characterized these products as new technologies that might lead 

to a dramatic decline in the use of more dangerous forms 

of nicotine delivery, particularly conventional cigarettes 

and other combustible tobacco products (Abrams 2014; 

Cobb and Abrams 2014; Fagerström and Bridgman 2014; 

Grana et al. 2014a; Hajek et al. 2014; Henningfield 2014; 

Schraufnagel et al. 2014; West and Brown 2014; Lindblom 

2015). Correspondingly, e-cigarettes have been proposed by 

some as a harm-reduction strategy and as a tool for smoking 

cessation, but the data to date do not support e-cigarettes 

for harm reduction or cessation (Siegel et al. 2011; Abrams 

2014). By contrast, others are concerned that the availability of these new products will expand the number of 

youth and young adults who are exposed to nicotine and 

will eventually lead to exclusive use of other conventional 

tobacco products or dual use of both (e-cigarettes and conventional cigarettes) (Leventhal et al. 2015; Primack et al. 

2015). Early longitudinal evidence provides some support 

for these concerns, although further research on this issue 

is still warranted.

As reviewed in Chapter 3, uncertainty remains 

about the health effects of e-cigarettes, particularly in the 

long term. Such effects will remain unknown until sufficient observations can be made over time. However, current knowledge of the characteristics of the inhaled aerosol 

from e-cigarettes suggests that if a current adult smoker of 
E-Cigarette Policy and Practice Implications 185

E-Cigarette Use Among Youth and Young Adults

conventional cigarettes or other combustible tobacco products would use e-cigarettes exclusively instead of combustibles as a substitute nicotine delivery system, either en route 

to quitting tobacco completely or even as a long-term 

alternative, the risks of tobacco-related diseases would be 

reduced substantially compared with the risk imparted by 

continued smoking of conventional cigarettes (Fiore et al. 

2014; USDHHS 2014; McNeill et al. 2015).

Still, as documented in Chapter 3, immediate and 

future health risks for youth and young adults who use 

e-cigarettes can be anticipated from exposure to nicotine, 

including addiction and harmful effects on brain development. Research must continue to characterize and quantify the full spectrum of potential health risks. Thus, in 

formulating policies related to the role of e-cigarettes 

in tobacco control and reducing the burden of tobaccorelated disease, particularly among youth and young 

adults, e-cigarette products that deliver nicotine cannot 

be considered a risk-free alternative to conventional cigarettes or other combustible tobacco products.

Any analysis of the potential increased risks and 

reduced harms of e-cigarette use also needs to consider 

data on the actual patterns of use because more of the 

risks affect youth and young adults and most of the potential benefits from reduced risk to health largely accrue 

to older cigarette smokers (Chapter 2). However, the 

reports of the tobacco industry to investors indicate the 

industry’s interest in maintaining a broad pattern of use 

of nicotine-containing products, including conventional 

cigarettes, for decades to come (Calantzopoulos 2015). 

When considered in the context of the tobacco industry’s 

past changes to product design (e.g., the creation of socalled “low-tar” cigarettes), the broader array of tobacco 

products now being discussed within the tobacco industry’s plans (e.g.,  “Heat-Not-Burn” products) could slow 

cessation (because smokers have historically been drawn 

to reduced-harm products) and thus the overall decline of 

tobacco-related diseases (USDHHS 2014).

The dynamic balancing between risks and potential 

benefits of e-cigarette use will be swayed by the impact of 

such use on the use of other tobacco products by youth 

and young adults over time. The availability of e-cigarettes 

could adversely affect the use of tobacco products in 

this group by slowing the decline of smoking because 

this population will be exposed to nicotine and possibly 

become addicted to that substance. Indeed, data reviewed 

in Chapter 2 show evidence of such trends. Although 

the decline in rates of smoking conventional cigarettes 

and other combustible tobacco products is viewed universally as positive, the increasing number of youth and 

young adults who use e-cigarettes is a serious concern for 

all the reasons cited above. West and Brown (2014) and 

McNeill and colleagues (2015) suggest that the limited 

evidence from the United Kingdom does not support the 

concern that using e-cigarettes leads to the use of other 

tobacco products, and they maintain that the new adolescent users of these e-cigarette products include very few 

never smokers. However, the marketing of e-cigarettes is 

quite different between the United Kingom and the United 

States, and the patterns of use, particularly among youth, 

are also quite different (European Parliament and Council 

2014; England et al. 2015; Klein 2015; Leventhal et al. 

2015; Primack et al. 2015; Barrington-Trimis et al. 2016; 

Wills et at. 2016; Institute for Global Tobacco Control 

n.d.). This pattern is also evident in some U.S. survey 

data from early in the era of e-cigarette use (as reviewed 

in Chapter 2), but not in more recent data, which indicate that e-cigarette products may contribute to nicotine 

addiction in a new generation of young people and thereby 

lead to increased use of a variety of nicotine delivery products, including combustible tobacco (Bauld et al. 2016; 

CDC 2016).

Fundamentally, the public health challenge and the 

charge to policy development can be framed as balancing 

the potential use of e-cigarettes as a new technology to 

reduce the use of combustible tobacco products against 

the possibility of expanding tobacco use among non-using 

youth and young adults, long-term former smokers, and 

other vulnerable populations (e.g., women of reproductive age and individuals with significant comorbidities, 

including those with mental health problems). Already, the 

e-cigarette companies are increasing the appeal of their 

offerings by enhancing the efficiency of nicotine delivery 

and using flavorings while they continue to advertise and 

promote their products aggressively.

Additional Evidence Suggested for 

Future Research

To characterize the critical balance for public health 

between the harms and potential benefits of e-cigarettes, 

more evidence on each of the elements that determine 

that balance would be useful (Table 5.1). The needed 

data would come from surveillance of patterns of adoption of e-cigarettes and their use among the population generally, and particularly among the most critical 

populations for uptake: youth and young adults, former 

smokers, smokers, and other populations that are particularly at risk for adverse outcomes. Few studies have been 

done on the health risks posed by e-cigarettes and their 

potential effectiveness for smoking cessation (HartmannBoyce et al. 2016). However, as discussed in Chapter 2, 

there are still no standardized questions for research on 
A Report of the Surgeon General

186 Chapter 5

e-cigarettes, and there is a need for further testing and 

development of e-cigarette questions and measurements.

Table 5.1 Comparative risk assessment: Potential harms and benefits of e-cigarettes

Harms Benefits

Increased youth exposure to nicotine and potentially greater 

initiation of conventional cigarettes

Reduced disease risk for current smokers who completely switch 

to e-cigarettes 

Slowing cessation by smokers due to nicotine addiction Reduced disease morbidity for smokers with existing heart or 

lung disease who switch to e-cigarettes 

Nicotine addiction in former smokers who begin to use 

e-cigarettes and possibly transition back to smoking

Potential for cessation of combustible products

Renormalization of nicotine use and smoking as acceptable Fewer users of combustible products in the entire population

Future disease risks for youth who are exposed to nicotine

Increasing the dual use of e-cigarettes with combustible 

products 

Serving as a “gateway” to the initiation of tobacco smoking 

Increased disease risk vs. complete cessation among those who 

use both e-cigarettes and combustible products

Exposure to secondhand aerosol and lack of clean air

To characterize the harms and benefits of e-cigarettes 

to public health, models are used to project their overall 

impact on public health (Levy et al. 2016). The use of modeling was described in detail in the 2014 Surgeon General’s 

report (USDHHS 2014). Conceptual models are needed to 

define the potential scenarios of changes in patterns of use 

among youth, young adults, adult smokers, former smokers, 

and other significant vulnerable populations. Figure 5.1 displays the range of patterns that are emerging with the wider 

adoption of e-cigarettes (Cobb et al. 2015; Vugrin et al. 2015). 

Researchers and public health officials can use dynamic 

population models (Mejia et al. 2010; Kalkhoran and Glantz 

2015; Vugrin et al. 2015; Levy et al. 2016) to analyze the 

potential impact on population health of the relative probabilities of these various paths. Initial modeling has shown 

that the potential population health benefits are very sensitive to several factors: the levels of product risk, particularly 

those of e-cigarettes; patterns of initiation and switching; and 

the extent of dual use (Mejia et al. 2010; Cobb et al. 2015; 

Kalkhoran and Glantz 2015; Vugrin et al. 2015). The benefits of smoking cessation, particularly as early in life as possible, are well documented, but the epidemiologic evidence 

that reducing (but not quitting) cigarette consumption can 

lower the risk of all-cause mortality, or mortality from cardiovascular diseases, remains inconclusive (USDHHS 2014). 

Thus, more research is needed to better characterize the 

health consequences of dual use, in particular, in comparison to the recognized health benefits of complete smoking 

cessation (or potentially only e-cigarette use). Similarly, the 

health risks to former smokers who become exposed again 

to nicotine through e-cigarettes are uncertain. Data are still 

limited on the risk of starting (or not starting) to smoke conventional cigarettes again (after successful cessation) following exposure to nicotine via e-cigarettes.

As reviewed in Chapter 3, the long-term health risks 

of e-cigarettes will not be known for decades, although evidence to date suggests that they are generally less harmful 

than combustible products. However, less harmful is not 

the same as harmless. A substantial amount of evidence 

is available on some components of the aerosols inhaled 

by e-cigarette users. For many people, exposure to aerosol 

could occur across much of the life span, beginning in 

adolescence and even in childhood, when the lungs and 

brain are still developing. Flavorings are of particular concern with regard to pulmonary toxicity, as are the various 

effects of nicotine on the brain. Although the National 

Institutes of Health is now supporting a growing program 

of research on e-cigarettes, critical questions have not yet 

been answered. Given experiences with conventional cigarettes, long-term studies will be needed to identify the full 

health consequences of using e-cigarettes.

Thus, policies related to e-cigarettes will necessarily 

be made in the context of accumulating but incomplete 

evidence. The landscape is changing rapidly and, inevitably, research cannot keep pace. Quoting Sir Austin 

Bradford Hill’s landmark paper on environment and disease: “All scientific work is incomplete—whether it be 

observational or experimental. All scientific work is liable 

to be upset or modified by advancing knowledge. That 

does not confer on us a freedom to ignore the knowledge 

we already have, or to postpone the action that it appears 

to demand at a given time” (Hill 1965, p. 300).
E-Cigarette Policy and Practice Implications 187

E-Cigarette Use Among Youth and Young Adults

Figure 5.1 Potential patterns of use of combustible products (CPs) and e-cigarettes (e-cigs)

Source: USDHHS (2014). Adapted for this report.

Potential Public Policy Approaches

In formulating public policies related to e-cigarettes, 

the context and possibilities vary across the national, 

state, local, tribal, and territorial governments and public 

entities. At the national level, progressive steps are being 

taken by FDA under the Tobacco Control Act. In 2010, 

the U.S. Court of Appeals for the D.C. Circuit determined 

that e-cigarettes and other products made or derived from 

tobacco may be regulated by FDA as tobacco products 

under the Tobacco Control Act and are not drugs or devices 

unless marketed for therapeutic purposes, such as being 

an aid to smoking cessation (Sottera, Inc. v. Food and 

Drug Administration 2010). In May 2016, FDA released 

its deeming rule to regulate the sale and distribution of 

e-cigarettes as a tobacco product (see Chapter 1) (Federal 

Register 2016). The rule is currently under litigation. The 

rule restricts the age of sale to those 18 years of age and 

older and requires retailers to check the age identification 

of young people under age 27, restricts vending machines 

to adult-only facilities, prohibits free samples, requires a 

health-warning statement about nicotine on packaging 

and in advertisements, requires domestic manufacturers 

to register their products and disclose the ingredients 

of their products, requires the reporting of the levels of 

harmful and potentially harmful constituents to FDA, 

allows FDA to review any new or changed products before 

being sold, and requires manufacturers to show scientific 

evidence that demonstrates the overall public health benefit of any product before it can be marketed as a modified 

risk tobacco product (Federal Register 2016). The Tobacco 

Control Act does not provide FDA with authority to impose 

taxes on tobacco products (Bhatnagar et al. 2014; Huang 

et al. 2014; Tobacco Control Legal Consortium 2015) or 
A Report of the Surgeon General

188 Chapter 5

regulate indoor air quality (Schripp et al. 2013; Bam et al. 

2014; Bhatnagar et al. 2014; Brandon et al. 2015a), occupational health and safety (USDHHS 2015; Whitsel et al. 

2015), or hazardous waste disposal (Chang 2014; Krause 

and Townsend 2015).

FDA is not the only federal agency with potential 

jurisdiction over some aspect of e-cigarettes (Table 5.2). 

For example, the U.S. Department of Defense and U.S. 

Department of Veterans Affairs relate to specific populations, and other agencies relate to regulatory activities, such 

as the U.S. Federal Trade Commission, U.S. Department 

of Transportation, and the U.S. Environmental Protection 

Agency. Some agencies have coverage over specific areas, 

such as the General Services Administration and the 

National Park Service.

State, local, tribal, and territorial governments, as well 

as private entities, may also address these and other matters that are covered by the Tobacco Control Act (Freiberg 

2012), and since 2010 many actions have been taken at 

the nonfederal level. State and local governments may utilize effective interventions that would also be expected to 

apply to e-cigarettes: increasing the price of tobacco products through taxation (Community Preventive Services 

Task Force 2012); creating and enforcing clean air policies 

(Hopkins et al. 2010); and passing comprehensive laws prohibiting sales to minors, combined with active enforcement 

(Community Preventive Services Task Force 2001). In addition, based on evidence that new e-cigarette products may 

addict a generation of young people to nicotine (Bunnell 

et al. 2015; CDC 2015b) and on mounting indications about 

potential harm from the use of these products in this population (Flouris et al. 2013; Barrington-Trimis et al. 2014; 

Goniewicz et  al. 2014; Grana et al. 2014a; Pisinger and 

Dossing 2014; Goniewicz and Lee 2015), numerous health 

organizations have called for the extension of smokingrelated policies to e-cigarettes (Association of State and 

Territorial Health Officials 2014; Bam et al. 2014; Bhatnagar 

et al. 2014; Offermann 2014; Schraufnagel et al. 2014; World 

Health Organization 2014a; Brandon et al. 2015a; USDHHS 

2015). In the absence of causal findings that have guided 

evidence-based tobacco control for decades, the “precautionary principle” is relevant to decision makers as a guide 

to action to address e-cigarettes among youth and young 

adults. This principle supports intervention to avoid possible health risks when the potential risks remain uncertain 

and have been as yet partially undefined (Bialous and Sarma 

2014; Saitta et al. 2014; Hagopian et al. 2015). However, the 

interventions should be appropriate to the currently perceived risk for future health consequences, in this case 

from e-cigarette use by youth, young adults, and pregnant 

women, as well as from the secondhand exposure of nonusers to e-cigarette vapor.

Clean Indoor Air Policies

Clean indoor air or smokefree policies prohibit 

the use of conventional tobacco products in indoor 

public places, such as worksites, restaurants, bars, and 

casinos. Because most of these policies predate the rise 

of e-cigarettes, their language does not necessarily 

cover emissions from these products. To protect the 

public from both secondhand smoke and secondhand 

aerosol, smokefree air policies should be modernized 

to include e-cigarettes. Such policies will maintain current standards for clean indoor air, reduce the potential 

for renormalization of tobacco product use, and prevent 

involuntary exposure to nicotine and other aerosolized 

emissions from e-cigarettes (Ingebrethsen et al. 2012; 

Schripp et al. 2013; Goniewicz et al. 2014; Offermann 

2014; Schober et al. 2014). Updating existing policies to 

cover e-cigarettes (and all electronic nicotine delivery systems) will eliminate the introduction of airborne toxins 

into enclosed spaces and establish a uniform standard for 

preventing the use of both combustible and electronic 

tobacco products in public and private spaces, including 

schools, offices, restaurants, bars, casinos, and airplanes.

Prohibiting the use of e-cigarettes in enclosed 

spaces eliminates potential health risks to nonusers and 

ensures their right to clean air; may discourage the dual 

use of electronic and combustible tobacco products; simplifies public compliance with and enforcement of existing 

clean indoor air laws; facilitates reduced consumption of 

these products; and maintains clear, comprehensive nonsmoking norms (Richardson et al. 2014; World Health 

Organization 2014a). As of January 1, 2016, six states 

(Delaware, Hawaii, New Jersey, North Dakota, Oregon, 

and Utah) had passed comprehensive smokefree indoor 

air laws that include e-cigarettes (CDC 2015a). These laws 

prohibit smoking and the use of e-cigarettes in indoor 

areas of private worksites, restaurants, and bars. Sixteen 

additional states had prohibited the use of e-cigarettes on 

some or all state property, and 475 local laws restricted 

e-cigarette use in 100% smokefree venues (Americans for 

Nonsmokers’ Rights Foundation 2015). Nationwide, more 

than 400 local jurisdictions prohibit e-cigarette use in 

100%-smokefree workplaces (Americans for Nonsmokers’ 

Rights Foundation 2015). Major cities that have addressed 

e-cigarettes include Austin, Boston, El Paso, Chicago, Los 

Angeles, Minneapolis, San Francisco, and New York City.
E-Cigarette Use Among Youth and Young Adults

E-Cigarette Policy and Practice Implications 189

Table 5.2 Principle federal policies and regulations of tobacco that emphasize e-cigarettes

Agency

Authority and 

description Current Potential 

Executive Office 

of the President 

(EOP) and Office 

of Management 

and Budget 

(OMB)

— Executive Order 13058, issued on August 9, 1997 (EOP 1997), generally prohibits 

the smoking of tobacco products in all interior space owned, rented, or leased by 

the executive branch of the federal government, and in any outdoor areas under 

executive branch control in front of air intake ducts. The Executive Order carves 

out an exception to its smoking prohibition for any residential accommodation for 

persons voluntarily or involuntarily residing, on a temporary or long-term basis, 

in a building owned, leased, or rented by the federal government.

—

Executive Office 

of the President 

(EOP) and Office 

of the U.S. Trade 

Representative 

(USTR)

— Executive Order 13193, issued January 18, 2001 (EOP 2001), prohibits all U.S. 

executive branch agencies from promoting the sale or export of tobacco. It also 

prohibits using U.S. trade initiatives to restrict tobacco marketing and advertising 

regulations in other countries, unless those regulations discriminate against U.S. 

tobacco products in favor of that country’s domestic tobacco products.

—

Federal 

Communications 

Commission 

(FCC)

Has broad 

regulatory power 

over commercial 

communication, 

including television, 

radio, and the 

Internet. 

15 U.S.C. § 1335 (the “Broadcast Ban”), 15 U.S.C. § 4402(f): Prohibits advertising 

for cigarettes, little cigars, smokeless tobacco, and chewing tobacco on radio, TV, 

or any other medium of electronic communication under FCC’s jurisdiction.

Prohibit the advertising of smoking 

accessories, cigars, pipes, pipe tobacco, or 

cigarette-making machines on television; 

prohibit the advertising of e-cigarettes on 

television; and regulate the advertising of 

tobacco products on the Internet.

Federal Trade 

Commission 

(FTC)

Publishes annual 

report on tobacco 

products.

Reviews tobacco 

manufacturerproposed schedules 

to rotate mandatory 

package warnings.

Protects consumers.

Enforces antitrust 

laws.

15 U.S.C. § 46 authorizes FTC to require entities to file special reports. On an 

annual basis, FTC collects and publishes information on the practices of the 

largest manufacturers of cigarettes and smokeless tobacco in the United States. 

Among other things, the information collected includes sales and, in several 

categories, expenditures for marketing.

15 U.S.C. § 45: FTC has broad authority to prevent “unfair or deceptive” 

business practices. It is an unfair and deceptive act or practice for a firm to make 

unsubstantiated claims, express or implied, about such matters as a product’s 

efficacy, safety, or health benefits (FTC 1983).

FTC is broadly authorized to prevent companies from using “unfair methods of 

competition” that affect commerce. FTC uses its antitrust authority to review and 

impose conditions on those proposed mergers of tobacco companies that raise 

anticompetitive concerns.

Collect sales, advertising, and information 

on promotion expenditures from 

e-cigarette companies and issue reports 

on same.

Take enforcement action against unfair or 

deceptive advertising of tobacco products 

or e-cigarettes.
A Report of the Surgeon General

190 Chapter 5

Agency

Authority and 

description Current Potential 

General Services 

Administration 

(GSA)

In its role as an 

independent agency, 

GSA manages and 

maintains more 

than 1,550 federally 

owned buildings 

and leases space 

in an additional 

7,100 buildings in 

the United States. 

GSA manages 

the federal 

government’s 

automobile fleet and 

is the acquisition 

arm of the federal 

government.

GSA Order ADM, 5800. 1C: Smoking in GSA-occupied space and governmentowned or -leased vehicles assigned to GSA is prohibited “to protect GSA 

employees, GSA contractors, and the visiting public from exposure to tobacco 

smoke in the Federal workplace.” The Order prohibits smoking in or on all 

“interior GSA-occupied space, exterior GSA-occupied space, including courtyards, 

garages, loading docks, stairwells, rooftops and balconies, and other outdoor areas 

under GSA control within 25 feet of doorways and building air intake ducts; and 

government-owned or leased vehicles assigned to GSA” (U.S. General Services 

Administration 2009).

Clarify that existing policies include 

e-cigarettes.

Implement a tobacco-free campus policy 

in GSA-occupied space.

Office of 

Personnel 

Management 

(OPM)

— While not regulatory in nature, OPM and GSA coordinate standard responses to 

frequently asked questions about the use of e-cigarettes in government facilities.

—

U.S. Department 

of Agriculture 

(USDA)

Commodity and 

inspection standards 

for agricultural 

products.

Administers SNAP 

and WIC programs.

7 U.S.C. § 30: USDA provides commodity standards for tobacco.

7 U.S.C. § 2012: Under the Food and Nutrition Act of 2008, tobacco products 

cannot be purchased with SNAP benefits. ENDS are included in the policy because 

the USDA interprets ENDS to be tobacco products.

7 CFR 246.10: USDA identifies requirements for WIC-eligible foods. 

—

Table 5.2 Continued
E-Cigarette Use Among Youth and Young Adults

E-Cigarette Policy and Practice Implications 191

Agency

Authority and 

description Current Potential 

U.S. Department 

of Defense (DoD)

May issue general 

instructions and 

restrictions in 

regulating the 

sale and/or use of 

tobacco products. 

Individual service 

branches may 

expand these 

regulations. 

Individual bases 

may also draft 

regulations. 

These typically 

are based on DoD 

instructions, 

directives, or service 

policies. DoD has 

authority over 

TRICARE.

DoD follows the smoking policy in federal facilities covered in 41 CFR 102-74.315, 

which states, “pursuant to Executive Order 13058, ‘Protecting Federal Employees 

and the Public From Exposure to Tobacco Smoke in the Federal Workplace’ it 

is the policy of the Executive Branch to establish a smokefree environment for 

federal employees and members of the public visiting or using federal facilities. 

The smoking of tobacco products is prohibited in all interior space owned, rented 

or leased by the Executive Branch of the federal government” (Federal Register

2008, p. 77518).

Each of the armed services has issued statements clarifying that the prohibition on 

smoking tobacco products extends to the use of e-cigarettes.

The 2015 NDAA directs the sale of cigarettes, cigars, and chewing tobacco at 

military commissaries. These items cannot be sold on military bases at prices 

lower than the most competitive prices in the local community. The NDAA 

replaced Directive 1330.09 (U.S. Department of Defense 2005), which established 

that tobacco prices on U.S. military bases should be no lower than 5% below the 

most competitive commercial price in the local community.

Branches of the armed services have tobacco policies:

• U.S. Navy and Marines, Instruction 5100.13E (U.S. Navy 2002)

• U.S. Army, Army Health Promotion Policy Regulation 600–63 (U.S. Army 1996)

• U.S. Air Force, Instruction 40-102, Air Force Tobacco Policy (U.S. Air Force 

2013)

TRICARE covers limited tobacco cessation counseling from any TRICAREauthorized provider in the United States. This coverage includes up to 

18 counseling sessions per quit attempt, with up to 4 individual counseling 

sessions per quit attempt. Two quit attempts per fiscal year are automatically 

covered, with coverage extending to a third with a doctor’s justification and 

pre-authorization. TRICARE also covers tobacco cessation products, including 

prescriptions and over-the-counter products, with 120 days’ use of a tobacco 

cessation product per quit attempt.

DoD-unified regulations on tobacco use in 

common housing.

Increased restrictions on commissary 

sales. 

Table 5.2 Continued
A Report of the Surgeon General

192 Chapter 5

Agency

Authority and 

description Current Potential 

U.S. Department 

of Education 

(ED)

Funding for tobacco 

control programs 

In FY 2014, pursuant to 20 U.S.C. § 7131, Safe and Drug-Free Schools and 

Communities Act, ED awarded the first round of 5-year grant awards under 

the School Climate Transformation Grant—Local Educational Agency Grants 

program. These FY 2014, Year 1 grant awards provided more than $35.8 million 

to 71 school districts in 23 states; Washington, DC; and the U.S. Virgin Islands. 

The funds should be used to develop, enhance, or expand systems of support for 

implementing evidence-based, multitiered behavioral frameworks for improving 

behavioral outcomes and learning conditions among students. The goals of the 

program are to connect children, youth, and families to appropriate services and 

supports; improve conditions for learning and behavioral outcomes for schoolaged youth; and increase awareness of mental health issues and the ability to 

respond to such issues among school-aged youth. School districts can also use 

the funds to implement models for reform and evidence-based practices. Drug 

prevention, including preventing tobacco use by youth, is an allowable activity. 

Grantees are encouraged, as part of their local needs assessment, to measure 

drug use among students along with other relevant issues and problems. This 

assessment of local needs will also be used by grantees to help identify and 

select the most appropriate evidence-based programs and practices. If the needs 

assessment indicates that drug abuse is an issue for students, prevention of drug 

abuse should be addressed by a multitiered behavioral framework.

—

U.S. Department 

of Education 

(ED)

Restrictions on 

tobacco use 

20 U.S.C. § 7181: The Pro-Children Act of 2001 prohibits smoking in any indoor 

facility that provides routine or regular kindergarten, elementary, or secondary 

education and library, health, or day care services to children, if such services 

and/or facilities are funded by the federal government, whether directly or through 

state or local governments, by federal grant, loan, loan guarantee, or contract 

programs.

—

Table 5.2 Continued
E-Cigarette Use Among Youth and Young Adults

E-Cigarette Policy and Practice Implications 193

Agency

Authority and 

description Current Potential 

U.S. Department 

of Health 

and Human 

Services, Centers 

for Medicare 

& Medicaid 

Services (CMS) 

(continues on 

next page)

Sets policies 

regarding Medicaid 

coverage for tobacco 

cessation products 

and counseling.

42 U.S.C. § 1396r–8(d)(7): Tobacco cessation medications cannot be excluded from 

coverage under Medicaid prescription drug benefits. Section 2502 of the Affordable 

Care Act amends section 1927(d)(2) of the Social Security Act by removing 

barbiturates, benzodiazepines, and agents used to promote smoking cessation 

from the list of drugs that a state Medicaid program may exclude from coverage or 

otherwise restrict.

42 U.S.C. §§ 18021(a)(1)(B), 18022(b)(1): Tobacco use screening and cessation 

must be provided at no cost as an essential health benefit and a preventive benefit. 

This includes Medicaid expansion plans, plans sold on insurance exchanges, and 

private plans.

For youth: Tobacco cessation services are coverable as part of EPSDT, the Medicaid 

benefit for children and adolescents. EPSDT provides a comprehensive array of 

prevention, diagnostic, and treatment services for low-income infants, children, 

and adolescents under age 21, as specified in Section 1905I of the Social Security 

Act.

For pregnant women: Section 4107 of the Affordable Care Act amends 

section 1905 of the Social Security Act to require coverage of counseling and 

pharmacotherapy for cessation of tobacco use by pregnant women. Section 

1905(bb)(2) of the Social Security Act defines the new tobacco cessation coverage 

services for pregnant women as services recommended in the 2008 PHS Guideline, 

or any subsequent modification of this Guideline, and such other services that 

the Secretary recognizes to be effective for cessation of tobacco use by pregnant 

women.

Affordable Care Act, Section 4108, Medicaid Incentives for Chronic Disease 

Prevention Program: This is a grant program in which states apply for funds to 

incentivize Medicaid recipients to prevent chronic disease, including through 

tobacco cessation.

—

Table 5.2 Continued
A Report of the Surgeon General

194 Chapter 5

Agency

Authority and 

description Current Potential 

(continued from 

previous page) 

U.S. Department 

of Health 

and Human 

Services, Centers 

for Medicare 

& Medicaid 

Services (CMS)

— 42 U.S.C. § 1395x (ddd): Medicare covers tobacco cessation programs (Centers 

for Medicare & Medicaid Services 2010): Effective for claims with dates of service 

on or after August 25, 2010, CMS will cover tobacco cessation counseling for 

outpatient and hospitalized Medicare beneficiaries:

• Who use tobacco, regardless of whether they have signs or symptoms of 

tobacco-related disease;

• Who are competent and alert at the time that counseling is provided; and

• Whose counseling is furnished by a qualified physician or other Medicarerecognized practitioner.

Intermediate and intensive tobacco cessation counseling services are covered 

under Medicare Parts A and B when the above conditions of coverage are met, 

subject to frequency and other limitations. Medicare covers two individual 

tobacco cessation counseling attempts per 12-month period. Each attempt may 

include a maximum of four intermediate or intensive sessions, with a total benefit 

covering up to eight sessions per 12-month period per Medicare beneficiary who 

uses tobacco. The practitioner and patient have the flexibility to choose between 

intermediate (more than 3 minutes, up to 10 minutes) and intensive (more than 

10 minutes) cessation counseling sessions for each attempt. Medicare beneficiaries 

also have access to smoking cessation prescription medication through Medicare 

Part D.

—

U.S. Department 

of Health 

and Human 

Services, Centers 

for Medicare 

& Medicaid 

Services (CMS)

Sets policies 

regarding private 

and marketplace 

health plan 

coverage of tobacco 

cessation products 

and counseling.

42 U.S.C. §§ 18021(a)(1)(B), 18022(b)(1): Tobacco cessation must be provided at 

no cost as an essential health benefit. This includes Medicaid expansion plans, 

plans sold on insurance exchanges, and private plans.

42 U.S.C. § 300gg-6 (Public Law 114-38): Tobacco cessation must be covered 

in employer plans. Plans should cover two cessation attempts per year, 

including (1) all FDA-approved cessation medications (both prescription and 

over-the-counter) and (2) four tobacco cessation counseling sessions, including 

telephone, group, and individual counseling.

42 U.S.C. § 300gg(a)(1(iv)): Tobacco users may be charged 50% more for 

insurance than nonusers of tobacco.

42 U.S.C. § 300gg–4(j)-(k): Employers may reward or penalize employees by up to 

50% of the cost of health care coverage based on their tobacco use, if the employer 

offers a health-contingent wellness program designed to prevent or reduce tobacco 

use.

—

Table 5.2 Continued
E-Cigarette Use Among Youth and Young Adults

E-Cigarette Policy and Practice Implications 195

Agency

Authority and 

description Current Potential 

U.S. Department 

of Health and 

Human Services, 

National 

Institutes of 

Health (NIH)

NIH is a tobaccofree campus.NIH’s policy specifically includes e-cigarettes. In accordance with the tobacco-free 

initiative from HHS, the use of cigarettes, e-cigarettes, cigars, pipes, smokeless 

tobacco (“snuff”), and any other tobacco product is prohibited on the NIH campus 

in Bethesda, MD (NIH 2016).

—

U.S. Department 

of Health and 

Human Services, 

National 

Institutes of 

Health, National 

Institute on 

Drug Abuse 

(NIDA), National 

Advisory Council 

on Drug Abuse 

(NACDA)

The mission 

of NIDA is to 

advance science 

on the causes and 

consequences 

of drug use and 

addiction and 

to apply that 

knowledge to 

improve individual 

and public health. 

NACDA serves 

crucial roles in 

advising NIDA on 

research priorities 

and policy and 

in providing a 

secondary level 

of review for 

applications under 

consideration for 

federal funding.

NIDA (2016) urges grantees to recognize that:

• Receiving funding from the tobacco industry may compromise the perceived 

objectivity of their research results, which in turn could impact the overall 

credibility of their research findings, including its interpretation, acceptance, 

and implementation;

• Acceptance of tobacco industry funds is viewed by many as contributing directly 

or indirectly to the industry’s interests, and thus harmful to the public health; 

and

• Any connection between tobacco industry-supported research (or tobacco 

industry scientists) and NIDA could negatively impact NIDA’s credibility and the 

public’s trust in NIDA-funded research.

—

Table 5.2 Continued
A Report of the Surgeon General

196 Chapter 5

Agency

Authority and 

description Current Potential 

U.S. Department 

of Health and 

Human Services, 

Substance Abuse 

and Mental 

Health Services 

Administration 

(SAMHSA)

Implements the 

Synar Amendment, 

which requires 

states, in order to 

receive their full 

Substance Abuse 

Prevention and 

Treatment Block 

Grant awards, 

to enact and 

enforce laws that 

prohibit the sale 

or distribution of 

tobacco products to 

individuals under 

the age of 18.

More information about the Synar Program is available online: http://www.

samhsa.gov/synar/about

SAMHSA is exploring opportunities to 

align the Synar regulation with the federal 

statutory definition of tobacco products, 

which includes e-cigarettes.

U.S. Department 

of Homeland 

Security (DHS)

Sales and use 

restrictions for the 

U.S. Coast Guard.

DHS Management 

DirectorateDirective No. 06603 

Smoking Policy. 

COMDTINST M6200.1B limits smoking to designated outdoor areas, prohibits use 

of tobacco by recruits, and prohibits tobacco use in any Coast Guard-controlled 

living quarters, including common areas. This policy includes extensive sales and 

advertising restrictions, but it does not consider NRT to be a tobacco product.

Implement a policy to enforce a ban on 

e-cigarette use on federal property.

U.S. Department 

of Homeland 

Security (DHS), 

Bureau of 

Immigration 

and Customs 

Enforcement 

(ICE)

Issues standards for 

facilities housing 

immigration 

detainees

Detainee smoking is prohibited in all buildings, including detainee-housing units. 

If smoking is permitted at a particular facility, the only designated smoking areas 

are outside of all buildings (Immigration and Naturalization Service 2000).

—

Table 5.2 Continued
E-Cigarette Use Among Youth and Young Adults

E-Cigarette Policy and Practice Implications 197

Agency

Authority and 

description Current Potential 

U.S. Department 

of Housing 

and Urban 

Development 

(HUD)

Resident health in 

assisted housing

Public and Indian Housing (PIH) Notice 2009-21 strongly encourages HUD-funded 

public housing agencies to adopt smokefree policies in some or all of their public 

housing units.

Housing Notice 2010-21 encourages owners and management agents of HUDassisted multifamily housing to implement smokefree housing policies in one or 

all of the properties they own or manage.

Both notices focus on cigarettes that “burn” as their mechanism for generating 

smoke, and so their applicability to e-cigarettes is uncertain.

Regarding its Weaver Building headquarters (the only building for which GSA has 

designated HUD as the facility management authority), HUD follows GSA Order 

ADM 5800.1C, GSA’s smoking policy for federal offices (U.S. General Services 

Administration 2009). This GSA policy permits smoking in exterior space under 

GSA control that is beyond “25 feet of doorways and building air intake ducts,” 

except for “courtyards, garages, loading docks, stairwells, rooftops, and balconies.” 

The management of HUD’s other facilities, federally owned or leased, is not 

delegated to the Department, and so GSA makes the decision on smoking policy 

for those campuses.

HUD’s Office of PIH published its 

proposed rule on Instituting SmokeFree Public Housing (80 FR 71762) on 

November 17, 2015, accepting comments 

through January 19, 2016 (Federal 

Register 2015). In addition to inviting 

comments on all aspects of the proposed 

rule, the notice specifically solicited public 

comments on nine questions (e.g., should 

the policy extend to electronic nicotine 

delivery systems, such as e-cigarettes, 

and/or to waterpipe tobacco smoking?).

Based on responses to HUD’s Request for 

Information on Adopting Smoke-Free 

Policies in PHAs and Multifamily Housing 

(77 FR 60712) (Federal Register 2012), 

HUD may consider drafting a regulation 

or notice that could prohibit smoking 

in some or all HUD-assisted multifamily 

housing. Such a proposal could cover 

e-cigarettes.

HUD is beginning to prepare for the 

adoption and implementation of a 

campus-wide tobacco-free policy, which 

would include e-cigarette use, 

at the Weaver Building headquarters by 

January 1, 2017.

Table 5.2 Continued
A Report of the Surgeon General

198 Chapter 5

Agency

Authority and 

description Current Potential 

U.S. Department 

of Justice, 

Bureau of 

Alcohol, 

Tobacco, 

Firearms and 

Explosives (ATF)

ATF is given 

primary jurisdiction 

to combat cigarette 

trafficking and 

administration 

(via the CCTA) and 

to stop tobacco 

diversion (via the 

PACT).

18 U.S.C. § 2342: Under the CCTA, it is illegal to possess more than 10,000 

unstamped cigarettes in a state that requires a tax stamp.

18 U.S.C. § 2343: Any person who distributes more than 10,000 cigarettes must 

keep accurate records pertaining to the shipment, receipt, sale, and distribution of 

cigarettes.

18 U.S.C § 2320: Trafficking in counterfeit cigarettes.

15 U.S.C. § 375: It is illegal to ship cigarettes to a non-licensee in a state without 

notifying the state taxation authority.

15 U.S.C. § 375–377: Requires online retailers to check the identification of 

customers at purchase and delivery: section 375 covers definitions; section 

376 covers reports to state tobacco administrators; and section 377 covers 

penalties.

The Smuggled Tobacco Prevention (STOP) Act amends the IRC to restrict the sale, 

lease, export or import, or delivery of tobacco production machines to persons 

lawfully engaged in (1) the sale, lease, export or import, or delivery of such 

machines; (2) the manufacture or packaging of tobacco products or processed 

tobacco; or (3) the application of unique identification markings onto tobacco 

products or processed tobacco packages.

—

U.S. Department 

of Justice, 

Bureau of 

Prisons (BOP)

BOP has authority 

to govern the 

control and 

management 

of federal penal 

and correctional 

institutions.

28 C.F.R. § 551.162: Smoking is generally prohibited in and on the grounds of 

BOP institutions and offices, with exceptions for smoking as part of an authorized 

inmate religious activity, and for smoking only in smoking areas designated by the 

warden, for BOP staff and official visitors.

28 C.F.R. § 551.163: Possession of smoking apparatus and tobacco in any form is 

prohibited for inmates, unless as part of an authorized inmate religious activity.

BOP Operations Memorandum 006-

2015 (BOP 2015) sets out guidelines 

for e-cigarette use. Guidelines state 

that e-cigarette use is to be limited 

to designated outdoor areas that are 

reasonably accessible to employees and 

provide a measure of protection from the 

elements. These areas may only be used by 

employees, but must be separate from the 

areas presently designated as “smoking 

areas” for use of tobacco products. Indoor 

use of e-cigarettes shall not be permitted 

in BOP facilities, except in perimeter 

towers and perimeter patrol vehicles when 

occupied by one person.

Table 5.2 Continued
E-Cigarette Use Among Youth and Young Adults

E-Cigarette Policy and Practice Implications 199

Agency

Authority and 

description Current Potential 

U.S. Department 

of Labor, 

Occupational 

Safety and 

Health 

Administration 

(OSHA)

Sets standards for 

indoor air quality.

29 CFR 1910.1000, Air Contaminants: This policy restricts employee exposure to 

several of the main chemical components found in tobacco smoke. OSHA rules 

apply to tobacco smoke only in rare and extreme circumstances, such as when 

contaminants created by a manufacturing process combine with tobacco smoke 

to create a dangerous air supply that fails OSHA standards for the workplace. In 

normal situations, exposures would not exceed permissible exposure limits and, as 

a matter of prosecutorial discretion, OSHA will not apply the General Duty Clause 

to environmental tobacco smoke.

Have smokefree workplaces. In the 

1990s, OSHA proposed a regulation 

setting indoor air quality standards for 

environmental tobacco smoke, but this 

rulemaking was terminated (Federal 

Register 2001).

U.S. Department 

of Transportation 

(DOT)

Sets restrictions 

on tobacco use on 

commercial and 

personal aircraft.

49 U.S.C. § 41706: Prohibits smoking on passenger flights.

14 CFR Part 252: DOT rule implementing 49 U.S.C. § 41706, and prohibiting 

smoking on most passenger flights. DOT interprets current Part 252 to include 

e-cigarettes in smokefree policies.

Note: FAA regulations also prohibit smoking on most aircraft from an aircraft 

safety perspective, not from a health perspective (see notes to 14 CFR Part 252).

In early 2016, DOT issued a final rule 

(RIN 2105-AE06). In keeping with 

section 41706, the rule amends Part 252 

to prohibit smoking on charter flights 

where a flight attendant is a required crew 

member. The rule also makes explicit the 

determination that the use of e-cigarettes 

falls within the definition of smoking.

DOT’s Pipeline and Hazardous Materials 

Safety Administration has proposed a rule 

to prohibit the charging of e-cigarettes in 

an aircraft cabin, and to prohibit stowage 

of e-cigarettes in the cargo hold of an 

aircraft (this is a hazardous material/safety 

rule, not a health/tobacco rule).

Table 5.2 Continued
A Report of the Surgeon General

200 Chapter 5

Agency

Authority and 

description Current Potential 

U.S. Department 

of Treasury, 

Alcohol and 

Tobacco Tax and 

Trade Bureau 

(TTB)

TTB administers the 

provisions of the 

Internal Revenue 

Code (IRC) of 1986, 

as amended, that 

impose federal 

excise taxes on 

tobacco products 

and cigarette 

papers and tubes, 

and it establishes 

a comprehensive 

civil and criminal 

framework to 

protect the revenue.

Among other issues, 

TTB investigates 

illegal production, 

underreporting 

of production, 

smuggling 

or unlawful 

importation, 

and diversion of 

domestic tobacco 

products intended 

for export.

26 U.S.C. 26 § 5701–5763, Tobacco Products and Cigarette Papers and Tubes: 

Under the IRC, the tobacco products that are subject to tax and TTB regulation 

are cigars, cigarettes, smokeless tobacco (chewing tobacco and snuff), pipe 

tobacco, and roll-your-own tobacco. Each of these tobacco products is defined with 

reference to “tobacco.” TTB also has regulatory authority over processed tobacco, 

which is not subject to tax. TTB regulations define processed tobacco to mean 

any tobacco that has undergone processing but that does not include tobacco 

products. The processing of tobacco includes, but is not limited to, stemming 

(i.e., removing the stem from the tobacco leaf); fermenting, threshing, cutting, 

or flavoring the tobacco; or otherwise combining the tobacco with nontobacco 

ingredients.

To protect revenue, the IRC and its implementing regulations establish 

qualification criteria to engage in businesses related to manufacturing, importing, 

or exporting tobacco products or in manufacturing or importing processed 

tobacco, and they require that persons obtain permits to engage in these activities. 

Under the IRC, manufacturers of tobacco products and export warehouse 

proprietors must file a bond that relates to the tax liability for the tobacco 

products on the premises covered by the permit. The IRC and implementing 

regulations also include recordkeeping and reporting requirements designed to 

ensure that TTB can verify that the tax on tobacco products is paid or determined 

or that adequate documentation exists to confirm that a tax exemption applies. 

The IRC also provides TTB with certain enforced-collection options (e.g., liens and 

levies), civil and criminal penalties, permit suspension and revocation procedures, 

and forfeiture provisions to ensure that the tax is collected.

ENDS that do not contain nicotine derived from tobacco are not tobacco products 

under the IRC and are not subject to taxation or TTB regulation. ENDS containing 

nicotine derived from tobacco may meet the definition of a tobacco product under 

the IRC, in which case they would be regulated by TTB and taxed accordingly.

TTB will collaborate with foreigncounterpart tax administrators to share 

information and best practices in the 

administration of tobacco excise taxes 

and their enforcement. Areas of possible 

technical assistance include setting up an 

auditing system and permitting regimen 

and conducting investigations.

TTB’s tobacco laboratory provides 

technical assistance to TTB program 

offices on tobacco products for regulatory 

compliance and enforcement purposes. 

TTB’s tobacco laboratory develops and 

validates analytical methods and protocols 

on tobacco products. It also collaborates 

with national and international tobacco 

regulatory federal agencies and has 

established a collaborative partnership 

with the World Health Organization’s 

Tobacco Laboratory Network and the 

North America Tobacco Regulatory 

Laboratory Network.

Table 5.2 Continued
E-Cigarette Use Among Youth and Young Adults

E-Cigarette Policy and Practice Implications 201

Agency

Authority and 

description Current Potential 

U.S. Department 

of Veterans 

Affairs (VA)

Can restrict the 

use of e-cigarettes 

and combustible 

cigarettes on facility 

grounds of the 

Veterans Health 

Administration to 

designated outdoor 

smoking areas only.

Public Law 102-585: Requires medical centers, nursing homes, and domiciliary 

care facilities of the Veterans Health Administration to establish smoking areas for 

patients and residents in a way that is consistent with medical requirements and 

limitations.

Include language about restrictions on the 

use of e-cigarettes in local and national 

guidance regarding smokefree policies.

U.S. Department 

of Veterans 

Affairs (VA)

Provides evidencebased tobacco 

cessation treatment 

to veterans 

receiving care in 

the VA health care 

system.

38 CFR Part 17: Eliminated in 2006 the copayment for smoking cessation 

counseling for veterans in care facilities of the Veterans Health Administration 

(Federal Register 2006).

Continue to provide clinical guidance 

for the health care professionals and 

patients in facilities of the Veterans Health 

Administration on the evidence base of 

(a) potential health effects of e-cigarettes 

and (b) comparisons to FDA-approved 

NRT for cessation treatment.

U.S. 

Environmental 

Protection 

Agency (EPA)

Sets policies 

regarding the 

hazardous 

waste status of 

e-cigarettes under 

the RCRA.

Nicotine is a commercial chemical product listed in 40 CFR 261.33(e) and is an 

acute hazardous waste (EPA waste code P075) when disposed. EPA has concluded 

that nicotine is the sole active ingredient of the e-liquid in e-cigarettes and thus 

a commercial chemical product, that e-cigarettes are not manufactured articles, 

and that e-cigarette cartridges are considered containers of nicotine. Therefore, 

e-cigarettes may be regulated as acute hazardous waste code P075 when disposed. 

If the nicotine e-liquid is legitimately recycled, it is not considered a solid 

waste under 261.2 because it is considered a commercial chemical product, and 

therefore it is not subject to hazardous waste regulation. E-cigarettes that are 

disposed of by consumers at their residences are considered exempt household 

hazardous waste under 261.4(b)(1) and are not subject to regulation as hazardous 

waste under the federal RCRA regulations.

• Regulatory Citation(s): 261.2, 261.4(b)(1), 261.33.

• Statutory Citation(s): 3006 Read U.S. Code 42, Chapter 82.

—

Note: ATF = Bureau of Alcohol, Tobacco, Firearms and Explosives; BOP = Bureau of Prisons; CCTA = Contraband Cigarette Trafficking Act; CFR = Code of Federal 

Regulations; CMS = Centers for Medicare & Medicaid Services; DHS = U.S. Department of Homeland Security; DoD = U.S. Department of Defense; DOT = U.S. Department 

of Transportation; ED = U.S. Department of Education; ENDS = electronic nicotine delivery systems; EOP = Executive Office of the President; EPA = U.S. Environmental 

Protection Agency; EPSDT = Early and Periodic Screening, Diagnosis and Treatment; FAA = Federal Aviation Administration; FCC = Federal Communications 

Table 5.2 Continued
A Report of the Surgeon General

202 Chapter 5

Commission; FDA = Food and Drug Administration; FTC = U.S. Federal Trade Commission; FY = fiscal year; GSA = General Services Administration; 

HUD = U.S. Department of Housing and Urban Development; ICE = Bureau of Immigration and Customs Enforcement; IRC = Internal Revenue Code; NACDA = National 

Advisory Council on Drug Abuse; NDAA = National Defense Authorization Act; NIDA = National Institute on Drug Abuse; NIH = National Institutes of Health; 

NRT = nicotine replacement therapy; OMB = Office of Management and Budget; OPM = Office of Personnel Management; OSHA = Occupational Safety and Health 

Administration; PACT = Prevent All Cigarette Trafficking Act; PHS = Public Health Service; PIH = Public and Indian Housing; RCRA = Resource Conservation and 

Recovery Act; SAMHSA = Substance Abuse and Mental Health Services Administration; SNAP = Special Supplemental Nutrition Program; TTB = Alcohol and Tobacco Tax 

and Trade Bureau; U.S.C. = United States Code; USDA = U.S. Department of Agriculture; USTR = U.S. Trade Representative; VA = U.S. Department of Veterans Affairs; 

WIC = Women, Infants, and Children.

Table 5.2 Continued
E-Cigarette Policy and Practice Implications 203

E-Cigarette Use Among Youth and Young Adults

Prevent Youth Access

Ensuring that laws on youth access include 

e-cigarettes is intended to protect youth from exposure 

to nicotine, which can lead to addiction and other health 

problems. Additionally, ensuring that these laws include 

e-cigarettes helps to capture the full diversity of the 

tobacco product landscape, including combustible, noncombustible, and electronic tobacco products. Effective 

strategies to deter access to e-cigarettes by youth and the 

use of these products in this population include restricting 

sales of e-cigarettes to minors, requiring verification of 

age, mandating clear signage about minimum age where 

sales take place, prohibiting the sale of e-cigarettes from 

vending machines, eliminating self-service displays of 

e-cigarettes, and actively enforcing existing laws with a 

focus on retailers. Compliance with laws that regulate 

the sale and distribution of e-cigarettes is facilitated by 

requiring retailers to be licensed. To date, 46 states have 

prohibited the sale of e-cigarettes to minors younger than 

a specified age (National Conference of State Legislatures 

2015; The Council of State Governments 2015). Federally, 

aligning youth tobacco access control regulations with 

the statutory definition of tobacco products in the Tobacco 

Control Act, which includes e-cigarettes, could provide 

consistent framework to help ensure that restrictions on 

youth access to e-cigarettes are prioritized and enforced 

(Federal Register 2016). This could include modifications 

to the Synar regulation, which requires states, U.S. territories, and jurisdictions to enact and enforce laws prohibiting the sale or distribution of tobacco products to 

youth. Substance Abuse Prevention and Treatment Block 

Grant recipients must comply with the Synar amendment 

and implement regulations in order to receive their full 

awards (U.S. Food and Drug Administration, Center for 

Tobacco Products n.d.).

Licensing

Licensing is used to regulate professional practice 

and business operations and represents one strategy to control the rising use of e-cigarettes among youth. In general, 

in the case of tobacco-related licensing, a business is authorized to manufacture, distribute, or sell tobacco products 

as long as it complies with all relevant laws (McLaughlin 

2010). Typically, tobacco-related licensing requirements 

for retailers and/or manufacturers help to prevent evasion 

of excise taxes, ensure that licensees comply with tobaccorelated laws, and promote safe manufacturing practices 

(ChangeLab Solutions 2012). Repeat violators of relevant 

laws may be subject to suspension or permanent revocation 

of their license, an outcome that provides a strong incentive 

to comply with existing requirements. As in the conventional cigarette industry, licensing of e-cigarette retailers 

and manufacturers is designed in part to prevent the use 

of these products by youth and to facilitate safe manufacturing practices. Unlike traditional tobacco products, for 

which retailers sell prepackaged products and the number 

of manufacturers is limited, a growing number of businesses engage in both the retail sale and manufacturing of 

devices and liquids used in the devices (e-liquids). Stores 

devoted exclusively to the sale of e-cigarettes are known as 

“vape shops.” These shops frequently offer a social environment for using products, and they may also sell food and 

beverages (Sussman et al. 2014).

As of April 2015, 99 cities and counties in California 

required a retailer to obtain a license to sell e-cigarettes. 

The majority of these jurisdictions did so by broadening 

the definition of tobacco products to include “electronic 

smoking devices” (ChangeLab Solutions 2015a). The 

definition was purposely broadened to include products that do not include nicotine to decrease the complexity of enforcement and in recognition of the fact 

that e-cigarette devices are sometimes used with liquids 

that do not contain nicotine but may contain marijuana 

oil (The Center for Tobacco Policy & Organizing 2015a). 

Licensing requirements also may be used to restrict the 

sale of flavored products or to address issues of consumer 

and worker safety relative to the mixing of e-liquids.

Imposing a moratorium is another potential 

approach that has been used in some communities to stop 

new “vape shops” from entering the market while a more 

comprehensive approach was being considered. A moratorium is a land-use law that takes effect immediately to stop 

temporarily the issuance of a business license, building 

permit, or use permit. Typically, a moratorium is enacted 

to provide a jurisdiction with time to research and study 

how to regulate a type of business (ChangeLab Solutions 

2015b). In California, several communities enacted moratoria that are initially 45 days but can be extended for 

up to 2 years (ChangeLab Solutions 2014, 2015b). A fourfifths vote, however, is required to establish a moratorium 

in California. Hayward and Union City, California, are 

examples of cities that have enacted moratoria and later 

adopted both retail licensing requirements for existing 

e-cigarette retailers and zoning restrictions to prohibit 

new vapor and hookah bars and lounges from opening 

within city limits (ChangeLab Solutions 2014; The Center 

for Tobacco Policy & Organizing 2015b).
A Report of the Surgeon General

204 Chapter 5

Taxation and Other Price Policies

Taxation and other price policies directed at making 

e-cigarettes more expensive may be implemented at multiple levels of government, from local to federal. Increasing 

the price of conventional cigarettes, including those 

increases resulting from excise taxes, significantly prevents 

and reduces tobacco use, particularly among youth and 

young adults (USDHHS 2014), and has potentially more 

impact on prevalence of current use in this population than 

on first use (Bader et al. 2011). Similarly, price policies are 

likely to reduce the use of e-cigarettes: a 10% increase in 

the price of e-cigarettes has been estimated to reduce sales 

of disposable e-cigarettes by approximately 12% and reusable products by about 19% (Bader et al. 2011; Huang et al. 

2014). Data are currently lacking on the potential effects 

that taxing e-cigarettes might have on conventional cigarettes. Tobacco products are taxed in two main ways:

1. A “specific” excise tax is levied based on the quantity 

of the product sold (e.g., as measured by number of 

cigarettes, weight, or volume). This type of mechanism applies the same tax across low-end and premium brands and is generally simple to administer. 

The disadvantages to specific excise taxes are that 

the real value of the tax declines over time with 

inflation, making products more affordable, and 

that super-lightweight products—such as snus, 

orbs, sticks, and dissolvables—are grossly undertaxed if the tax is based on weight (Freiberg 2012; 

Boonn 2013; Shang et al. 2015).

2. The second tax mechanism is an ad valorem excise 

tax, which is levied on a percentage of the value of 

the tobacco product (e.g., the retailer’s, wholesaler’s, or manufacturer’s price). This type of tax keeps 

up with inflation and establishes a flat tax rate across 

all brands, product types, weights, and packaging. 

The disadvantages to this kind of tax include the 

potential for tax evasion through predatory (belowcost) or anticompetitive pricing; increasing the 

price differential between products with different 

pretax prices, leading to greater price variability and 

more opportunity for tax avoidance; a governmentprovided subsidy for manufacturers’ price cuts; and 

more expensive brands being subjected to a larger 

tax (Freiberg 2012; Boonn 2013; Shang et al. 2015). 

Governments use uniform, tiered, and mixed-tax 

approaches to implement specific and ad valorem tobacco 

excise taxes. Uniform systems apply the same tax rate 

across all products; tiered systems levy taxes based on 

such product characteristics as toxicity, nicotine content, 

type of production (handmade versus machine made), 

sales volume, packaging, or whether the products are 

domestic or imported; and mixed systems use a combination of uniform and tiered-tax approaches (Shang et al. 

2015). Tiered-tax approaches, such as those based on nicotine content, could steer consumers to a less toxic product 

or one with lower nicotine (Benowitz 2014). Tiered-tax 

approaches are more complex to administer and may 

provide greater opportunity for tax evasion as a result of 

manipulation of the product or its packaging by the manufacturer (Shang et al. 2015). In recognition of nicotine’s 

toxicity, particularly to youth, several health groups have 

endorsed imposing excise taxes on e-cigarettes to discourage their use by youth (American Thoracic Society 

2013; Association of State and Territorial Health Officials 

2014; Bhatnagar et al. 2014; Brandon et al. 2015a; Crowley 

and Health Public Policy Committee of the American 

College of Physicians 2015; National Association of 

County and City Health Officials 2014). E-cigarettes are 

likely less toxic than combustible products (such as conventional cigarettes), and therefore, some contend should 

be taxed at a lower rate (Benowitz 2014; Bhatnagar et al. 

2014). Yet others argue that e-cigarettes should be taxed 

at the same rate as other tobacco products (Freiberg 2012; 

American Thoracic Society 2013; National Association of 

County and City Health Officials April 2014).

As of January 2016, four states (Kansas, Louisiana, 

Minnesota, and North Carolina) and six localities (Juneau, 

Matanuska-Susitna, Petersburg, and Sitka, Alaska; 

Montgomery County, Maryland; and Chicago, Illinois) 

had enacted e-cigarette taxation policies. Minnesota’s 

ad valorem tobacco tax equates to 95% of the wholesale 

cost of any product containing or derived from tobacco 

(Minnesota Revenue 2014; Tobacco Control Legal 

Consortium 2015). It taxes e-liquids and e-cigarettes 

sold with nicotine cartridges that cannot be removed 

(i.e., disposables). In Minnesota, devices without a nicotine cartridge are not taxed as a tobacco product. On the 

other hand, North Carolina applies a specific excise tax, 

taxing e-liquids based on volume at 5 cents per milliliter 

(National Conference of State Legislatures 2015).

The Tobacco Control Legal Consortium, which 

is based at William Mitchell College of Law in St. Paul, 

Minnesota, recommends using an ad valorem tax for 

e-cigarettes applied at the retail level to the “essential” 

components of these devices. The tax is simple, captures 

both disposable and refillable devices, and could exclude 

accessories and universal parts sold separately, such 

as batteries or charging cords (Tobacco Control Legal 

Consortium 2015).

Numerous major health organizations support 

raising the price of e-cigarettes through non-tax options, 

such as limiting rebates, discounts, and coupons (Freiberg 
E-Cigarette Policy and Practice Implications 205

E-Cigarette Use Among Youth and Young Adults

2012; Association of State and Territorial Health Officials 

2014; Bhatnagar et al. 2014; Huang et al. 2014; Brandon 

et al. 2015a).

Finally, Chaloupka and colleagues (2015) have proposed that differential taxation of tobacco products can 

be used to incentivize a move away from combustible 

products to less hazardous noncombustible products, 

including e-cigarettes. They have argued that taxation 

could be part of a harm-reduction system. In their view, 

future determinations by FDA as to whether a product 

poses a substantially reduced risk would be one criterion 

in determining the relative rate of taxation.

Restrictions on Marketing

As described in Chapter 4, the marketing of 

e-cigarettes drives consumer demand for these products. Such marketing also may promote misperceptions 

about the safety and efficacy of these products for use 

as cessation devices (Choi and Forster 2014; Mark et al. 

2015; Pokhrel et al. 2015). For some populations—such 

as pregnant women, adolescents, former smokers, and 

young adults—the adverse health consequences of nicotine intake are substantial. Several groups have supported 

extending marketing restrictions that apply to conventional cigarettes and other tobacco products to e-cigarettes 

(Association of State and Territorial Health Officials 2014; 

Bam et al. 2014; Bhatnagar et al. 2014; Partnership for 

Prevention 2014; Brandon et al. 2015a). Significant barriers still exist to regulating commercial speech, including 

the First Amendment rights of the e-cigarette companies 

(Laird-Metke 2010).

Additionally, for traditional tobacco products, partial 

advertising bans and voluntary agreements have generally been ineffective in reducing consumption because the 

tobacco industry circumvents the restrictions by shifting 

the marketing platforms used to unregulated platforms 

(National Cancer Institute 2008). This response would 

be expected to be similar with regard to e-cigarettes. 

Therefore, despite the numerous barriers, public health 

groups and state, local, tribal, and territorial governments 

should take steps to stem the proliferation of e-cigarette 

marketing likely to appeal to young people by using tools 

designed to curb youth-oriented tobacco marketing and 

expanding evidence to inform future restrictions on the 

marketing of e-cigarettes to youth and young adults.

Surveillance of e-cigarette marketing, performing 

content analyses of the messages used, and conducting 

studies to assess the link between exposure to e-cigarette 

marketing and the use of e-cigarette products, particularly 

among youth and young adults, will facilitate the development of an evidence base of the type that informed prior 

federal and Master Settlement Agreement restrictions on 

tobacco advertising. Observations of retailers’ practices, 

assessments of outdoor advertising, and identification 

of event sponsorships and promotional activities at bars 

and community events are actions that state, local, tribal, 

and territorial public health agencies have taken related 

to traditional tobacco products. Many of these actions 

can be adapted to monitor and document the presence of 

e-cigarette marketing in communities (Pucci et al. 1998; 

Feighery et al. 2001; Rigotti et al. 2005; Roeseler et al. 2010; 

Rose et al. 2014).

In the absence of legal restrictions on e-cigarette 

marketing, and apart from the issue of the previous promulgation by some companies of unsubstantiated health 

and cessation claims, public health groups can advocate 

for television and radio broadcasters, print and outdoor 

media companies, the management of event venues and 

sports events, digital media outlets, retailers, and others 

to voluntarily refuse to air or place e-cigarette advertising, 

offer sponsorships, or give out free samples at fairs and festivals. Although the impact of a voluntary approach may 

be low, such actions raise awareness, build concern, and 

help to denormalize the proliferation of e-cigarette marketing. In California, surveillance plus voluntary efforts 

to promote restrictions on sponsorship of events by the 

tobacco industry facilitated a modest decline in tobacco 

industry-sponsored events and youth-oriented activities 

at those events that promoted the interests of the tobacco 

companies, and it led to a productive partnership with the 

tobacco litigation unit of the California attorney general’s office that resulted in several settlements with tobacco 

companies (Roeseler et al. 2010).

State, local, tribal, and territorial public health 

agencies may be able to contribute to the stimulation 

of enforcement and compliance with existing rules that 

constrain marketing. Some states have brought lawsuits 

against e-cigarette companies, alleging that distributors 

of these products violated state law by selling to minors 

or making unsubstantiated health claims; some of those 

lawsuits resulted in financial damages and agreements to 

stop making claims that e-cigarettes are safer than conventional cigarettes unless confirmed by rigorous science 

(Center for Public Health and Tobacco Policy 2013).

 Finally, another area to address is the use of “advertorials” employed by e-cigarette retailers to promote 

cessation and health claims. Advertorials are paid advertisements designed to look like an independent editorial. 

Although there are no specific rules for how a publisher 

should distinguish actual editorial content from paid editorial content in terms of their appearance, the Federal 

Trade Commission (FTC) stated in an advisory opinion 

that disclosure of the source is necessary when content 

“uses the format and has the general appearance of a news 
A Report of the Surgeon General

206 Chapter 5

feature and/or article for public information which purports to give an independent, impartial and unbiased view” 

(Federal Register 1972, p. 154). Additionally, paid advertising must be disclosed clearly and conspicuously in a 

manner that is understandable to consumers (FTC 1984). 

State and local public health agencies can play an important role by monitoring and providing substantiation to 

their state attorney general or FTC regarding advertising 

that makes improper claims or is not clearly identified as 

advertising.

Educational Initiatives

The extensive data reviewed in Chapter 2 highlighted the limited knowledge that members of the general public, particularly adolescents and young adults, 

have about e-cigarettes and their potential for nicotine 

addiction and other adverse health consequences. FDA 

has jurisdiction for product warnings that can reach 

users, but that agency, along with other federal entities 

and state and local governmental and nongovernmental 

organizations, can also carry out educational campaigns 

to enhance such limited knowledge levels. Potentially 

effective initiatives with youth and young adults to prevent 

smoking were reviewed in the 2012 Surgeon General’s 

report and may be applicable to preventing e-cigarette 

use. That report concluded that sufficient evidence exists 

to conclude that mass media campaigns, comprehensive 

community programs, comprehensive statewide tobacco 

control programs, and school-based programs that have 

shown evidence of effectiveness, if they contain specific 

components, can produce at least short-term effects and 

reduce the prevalence of tobacco use among school-aged 

youth (USDHHS 2012).

Implications for Health Care 

Practice

Although the issues are not well documented, health 

care practitioners face questions about e-cigarettes from 

their patients and their communities, including what are 

the risks of using e-cigarettes, how do these risks compare 

with those of cigarettes or other combustible products, 

and is e-cigarette use an effective way to quit smoking? 

Chapter 3 set out the limited evidence base related to 

these questions. Clinicians need to respond to these questions and guide their patients in the context of considerable uncertainty. At this time, practitioners can turn to 

the various statements from medical organizations, which 

generally urge caution regarding e-cigarettes and do not 

find the evidence to be supportive of their use for cessation or for formal harm-reduction strategies (Table 5.3). 

In fact, any recommendation to use e-cigarettes for the 

cessation of smoking is not supported by the bulk of 

the available scientific evidence (Hartmann-Boyce et al. 

2016). Both the American Association of Cancer Research 

and the American Society of Clinical Oncology recommend against advising the use of e-cigarettes for cessation (Brandon et al. 2015b). The U.S. Preventive Services 

Task Force found that there is insufficient evidence that 

e-cigarettes are an effective smoking cessation tool in 

adults, including pregnant women (Agency for Healthcare 

Research and Quality 2015).

The clinical care setting is a critical venue for taking 

evidence-based approaches for enhancing smoking cessation and increasing the protection of susceptible groups 

against exposure to secondhand smoke (USDHHS 2014). 

However, research on e-cigarettes in relation to this set of 

venues is lacking and urgently needed. Regardless, some 

pragmatic approaches have been proposed. For example, 

the American Academy of Pediatrics (AAP) gives advice 

on how pediatricians can approach questioning about the 

use of e-cigarettes. As of October 2015, the AAP’s position 

on e-cigarettes is that sales to minors should be prohibited; flavors that appeal to youth should be prohibited; 

and measures against the use of e-cigarette products need 

to be included in requirements for maintaining smokefree environments, such as in restaurants and workplaces 

(AAP 2015a).
E-Cigarette Use Among Youth and Young Adults

E-Cigarette Policy and Practice Implications 207

Table 5.3 Medical organizations

A. Positions of professional organizations

Organization

Organizational 

position on cessation Organizational position on harm Organizational position on regulation General comments

American 

Academy of 

Pediatrics 

(2015b)

— • “Concentrated nicotine solution 

for electronic nicotine delivery 

systems should be sold in 

child-resistant containers with 

amounts limited to that which 

would not be lethal to a young 

child if ingested.”

• “Prohibitions on smoking and 

use of tobacco products should 

include prohibitions on use of 

electronic delivery systems.”

• “The promotion and sale of electronic nicotine delivery 

systems to youth should be prohibited by federal, state, and 

local regulations.”

• “Prohibitions on promotion should include all media that can 

be viewed by youth, including broadcast, print, and electronic 

(Web- or Internet-based) media.”

• “Prohibitions on promotion should include prohibitions 

on sponsorships, such as sports, cultural event, and 

entertainment sponsorships. Any promotional activities that 

can be accessed by children and/or adolescents should be 

considered promoting to children.”

• “Electronic nicotine delivery systems should be subject 

to the same restrictions on advertising and promotion at 

least as restrictive as that on combustible cigarettes. Until 

government agencies institute these prohibitions, media 

companies, entertainment companies, sports teams, and 

promoters should voluntarily institute these prohibitions.”

• “Celebrities should not use their privileged position to model 

tobacco product use, including electronic nicotine delivery 

systems and other existing or emerging tobacco products.”

—
A Report of the Surgeon General

208 Chapter 5

Organization

Organizational 

position on cessation Organizational position on harm Organizational position on regulation General comments

American 

Association 

for Cancer 

Research 

(AACR) and 

the American 

Society of 

Clinical 

Oncology 

(2015)

(continues 

on next 

page)

• FDA has not 

approved e-cigarettes 

as smoking cessation 

aids, and current 

data are inconclusive 

with regard to their 

efficacy as quitsmoking products.

• “Oncologists would 

be wise to refrain 

from recommending 

e-cigarettes to 

patients as a firstline therapy for 

smoking cessation.”

• “The evidence regarding the 

risks and benefits of e-cigarettes 

is difficult to interpret, and data 

on the long-term consequences 

of e-cigarette use are not yet 

available.”

• “Chemicals and ultrafine 

particles known to be toxic 

and carcinogenic and/or to 

cause respiratory and heart 

distress have been identified in 

e-cigarettes.”

• “Studies find the levels of the 

toxicants in e-cigarette aerosol 

to be significantly lower than in 

cigarette smoke and, in many 

cases, comparable with trace 

amounts found in a medicinal 

nicotine inhaler. It is unclear 

what effects these toxicants 

might have on e-cigarette users 

after chronic and frequent use.”

• “The vast majority of e-cigarette 

users use products containing 

nicotine. Nicotine is an addictive 

chemical, adversely affects 

maternal and fetal health 

during pregnancy, has adverse 

consequences for fetal brain 

development, and may adversely 

affect the adolescent brain. It 

is unclear what effect nicotine 

intake via e-cigarettes has on 

health or on the addictiveness of 

these products.”

• “The FDA CTP should regulate all ENDS that meet the 

statutory definition of tobacco products and their component 

parts. ENDS delivery systems and e-liquids containing 

tobacco-derived nicotine should be regulated whether they 

are sold together or separately.”

• “ENDS manufacturers should be required to register with 

FDA and report all product and ingredient listings, as well as 

the nicotine concentration in the ENDS solution.”

• “ENDS packaging and advertising should be required to 

carry health warnings and safety labels—including a warning 

regarding nicotine addiction.”

• “Youth-oriented ENDS advertising and marketing should 

be prohibited, including: self-service ENDS displays, the 

provision of gifts and other giveaways with purchase of ENDS, 

the sale and distribution of items such as hats or t-shirts 

with ENDS brand logos, brand name sponsorship of social or 

cultural events, or of any team entry into those events, and 

youth-oriented advertising of tobacco products.”

• “Internet and other mail-order sellers of ENDS should be 

required to check the age and identification of customers at 

the point of purchase and delivery; to comply with all laws 

in the purchaser’s state or local jurisdiction; and pay all 

applicable federal, state, and local taxes.”

• “Childproof caps should be required for all e-liquid 

containers.”

• “ENDS and ENDS liquid containing candy and other youthfriendly flavors should be banned unless there is evidence 

demonstrating that these products do not encourage youth 

uptake.”

• “ENDS use should be prohibited in places where combustible 

tobacco product use is prohibited by federal, state, or local 

law until the safety of second- and thirdhand aerosol exposure 

is established.”

• “There are 

insufficient data on 

health consequences 

of e-cigarette use, 

their value as tobacco 

cessation aids, and 

their effects on the 

use of combustible 

tobacco products 

by smokers and 

nonsmokers.”

• “Oncologists should 

advise all smokers 

to quit smoking 

combustible 

cigarettes, encourage 

use of FDAapproved cessation 

medications, refer 

patients for smoking 

cessation counseling, 

and provide 

education about 

the potential risks 

and lack of known 

benefits of long-term 

e-cigarette use.”

Table 5.3 A Continued
E-Cigarette Use Among Youth and Young Adults

E-Cigarette Policy and Practice Implications 209

Organization

Organizational 

position on cessation Organizational position on harm Organizational position on regulation General comments

(continued 

from 

previous 

page) 

American 

Association 

for Cancer 

Research 

(AACR) and 

the American 

Society of 

Clinical 

Oncology 

(2015)

— • “Data from the [CDC] showed 

a significant increase in 

e-cigarette-related calls to poison 

centers between 2010 and 2014 

as a result of accidental ingestion 

or absorption of e-cigarette 

liquid.”

• “Secondhand exposure to 

toxicants and nicotine from 

e-cigarette aerosol has been 

documented, though there are 

not current data suggesting 

that exposure to the aerosol has 

adverse health effects.”

• “There are no published 

studies evaluating thirdhand 

(i.e., residue that builds up on 

surfaces over time) exposure 

to e-cigarette aerosol in indoor 

environments, although 

preliminary data suggest that 

nicotine from e-cigarettes can 

stick to surfaces.”

• “Funding generated through tobacco product taxes, including 

any potential taxes levied on ENDS, should be used to help 

support research on ENDS and other tobacco products, but 

should not preclude the allocation of federal funding for this 

research.”

• “All data related to ENDS composition, use, and health effects 

should be disclosed for dissemination and independent review 

as well as to enhance policy decisions for ENDS product 

regulation.”

• “Tobacco products should be taxed proportionate to their 

harm; therefore, ENDS should not be taxed at equal or higher 

rates than combustible cigarettes.”

• “State and local governments should implement ENDS 

regulations within their authorities that are appropriate for 

protecting the public health, including restricting the sale, 

distribution, marketing, and advertising of ENDS to youth.”

• “International cooperation is needed to develop standards 

for the regulation of ENDS, and these regulations should 

prioritize protection of the public’s health and draw upon the 

best available scientific evidence whenever possible.”

—

American 

Association 

for 

Respiratory 

Care (AARC) 

(2015)

• “Even though the 

concept of using 

the e-cigarettes for 

smoking cessation 

is attractive, they 

have not been fully 

studied and the 

use among middle 

school children is 

increasing year after 

year.”

• “There is no evidence as to the 

amount of nicotine or other 

potentially harmful chemicals 

being inhaled during use or if 

there are any benefits associated 

with using these products.”

— • Date effective: April 

2014

• “The [AARC] opposes 

the use of the 

electronic cigarette 

(e-cigarette).”

Table 5.3 A Continued
A Report of the Surgeon General

210 Chapter 5

Organization

Organizational 

position on cessation Organizational position on harm Organizational position on regulation General comments

American 

College of 

Physicians 

(ACP) 

(Crowley 

and Health 

Public Policy 

Committee 

of the ACP 

2015)

• “ENDS, which 

include electronic 

cigarettes, or 

e-cigarettes, 

are growing in 

popularity, but their 

safety and efficacy as 

a smoking cessation 

aid are not well 

understood.”

• “[There is concern] that the 

health effects of ENDS use are 

unknown, that they may appeal 

to young people, and that they 

may encourage dual use of 

ENDS and traditional tobacco 

products.”

• “The Food and Drug Administration [should] extend its 

regulatory authority granted through the Family Smoking 

Prevention and Tobacco Control Act to cover electronic 

nicotine delivery systems (ENDS).”

• “Characterizing flavors should be banned from all tobacco 

products, including ENDS.”

• “The [ACP] supports taxing tobacco products, including 

ENDS devices and nicotine liquids, to discourage use among 

children and adolescents. Local governments should be 

permitted to establish higher tax rates for ENDS and related 

products than state levels.”

• “The [ACP] supports legislative or regulatory efforts to 

restrict promotion, advertising, and marketing for ENDS 

products in the same manner as for combustible cigarettes, 

including a prohibition on television advertising.”

• “Youth tobacco prevention efforts, such as antismoking media 

campaigns and school-based interventions, should include 

information about the potential risks of ENDS use.”

• “The federal, state, and local regulators should take action to 

extend indoor and public place clean air laws that prohibit 

smoking in public places, places of employment, commercial 

aircraft, and other areas to ENDS products.”

• “The federal government should authorize and appropriate 

funding to rigorously research the health effects of ENDS 

use, chemical content, and toxicity; effects of ENDS vapor 

exposure; dual-use rates; and effects of ENDS-derived nicotine 

on human health.”

• “The [ACP] supports 

strong regulations to 

ensure product safety 

and transparency, 

policies that prevent 

use among young 

people, increased 

research to better 

determine their 

health effects, strong 

limits on marketing 

and promotion to 

discourage interest 

among young people, 

and application of 

indoor air laws to 

protect the health of 

bystanders.”

• “This paper is not 

intended to offer 

clinical guidance or 

serve as an exhaustive 

literature review 

of existing ENDSrelated evidence but 

to help direct the 

[ACP], policymakers, 

and regulators on 

how to address these 

products.”

Table 5.3 A Continued
E-Cigarette Use Among Youth and Young Adults

E-Cigarette Policy and Practice Implications 211

Organization

Organizational 

position on cessation Organizational position on harm Organizational position on regulation General comments

American 

Thoracic 

Society 

(2013, 2015)

(continues 

on next 

page)

• “The new CDC 

data show that Big 

Tobacco is once 

again peddling a new 

product intended to 

get youth hooked 

on nicotine, and 

that e-cigarettes 

are not about 

harm reduction or 

smoking cessation, 

but about addiction.”

• “The short- and long-term health 

risks of these nicotine-delivery 

devices are largely unknown.”

• “States should regulate e-cigarettes as tobacco products. 

E-cigarettes should not be sold to those younger than 18, and 

regulations requiring identification and proof of age at the 

time of purchase should apply. Internet sales of e-cigarettes 

should be strictly regulated.”

• “E-cigarettes should be taxed at rates equivalent with 

traditional cigarettes and other tobacco products.”

• “E-cigarettes should be subject to the same restrictions 

regarding public use as combustible tobacco products, and 

e-cigarettes should not be used in smoke-free areas.”

• “The FDA should deem regulatory authority over 

e-cigarettes.”

• “Candy and menthol flavored e-cigarettes should be banned.”

• “E-cigarette packaging should include warning labels, similar 

in size and scope to those required of combustible tobacco 

packaging. Where risks are known, the consumer should be 

informed of those risks in clear and direct language. Where 

data regarding risk is [sic] unavailable or inconclusive, the 

consumer should be informed of the lack of reliable safety 

testing data.”

• “The FDA should regulate the form and content of e-cigarette 

advertising.”

• “Both direct and implied health and safety claims by 

e-cigarette manufacturers should be subject to the same 

evidentiary review process currently required for other 

products making such claims.”

• “The FDA should require e-cigarette manufacturers to adopt 

Good Manufacturing Processes similar to those that exist for 

other regulated products, including lot numbers, securing 

packaging, etc.”

• “Given that nicotine is an addictive drug, with the dependence 

liability related to the pharmacokinetic characteristics of 

the delivery device, delivery characteristics of the e-cigarette 

should be evaluated and disclosed, and periodically monitored 

to ensure consistency of the product’s dependence potential 

over time.”

• “[E]-cigarettes need 

to be subject to the 

same marketing 

and manufacturing 

restrictions as 

tobacco products.”

• “For the first time, 

e-cigarette use 

among young people 

is higher than for 

any other tobacco 

product.”

Table 5.3 A Continued
A Report of the Surgeon General

212 Chapter 5

Organization

Organizational 

position on cessation Organizational position on harm Organizational position on regulation General comments

(continued 

from 

previous 

page) 

American 

Thoracic 

Society 

(2013, 2015)

— — • “Content of e-cigarette cartridges should be disclosed and 

regulated.”

• “The nicotine content of the e-cigarette cartridge should not 

exceed that of similar user volume of combustible tobacco.”

• “Deliverable nicotine levels should be consistent between 

cartridges.”

• “Researchers and clinicians, along with scientific societies 

and publications, receiving funding from e-cigarette 

manufacturers should disclose this relationship and the 

potential for conflict of interest in a manner equivalent to 

disclosures required for funding from the remainder of the 

tobacco industry.”

—

Table 5.3 A Continued
E-Cigarette Use Among Youth and Young Adults

E-Cigarette Policy and Practice Implications 213

Organization

Organizational 

position on cessation Organizational position on harm Organizational position on regulation General comments

European 

Respiratory 

Society 

(ERS) (2014)

• “Electronic 

cigarettes are 

designed for the 

purpose of direct 

nicotine delivery 

to the respiratory 

system, and they fall 

into a regulatory gap 

in most countries, 

escaping regulation 

as medicinal 

products and 

avoiding the controls 

applicable to tobacco 

products.”

• “For ERS, the priority of the 

Revision of the Tobacco Products 

Directive is to protect children 

and youth from becoming 

smokers by preventing them 

from picking up their first 

cigarette.”

• “There is no adequate scientific 

research available on the overall 

health risk or the long-term 

effects of electronic cigarette use 

on humans.”

• “Mandatory reporting system of ingredients used in tobacco 

products.”

• “Harmonised regulation of the ingredients of tobacco 

products.”

• “80% pictorial health warnings, covering the front and back 

of packages. Based on evidence, the larger the pictorial health 

warnings are, the more effective they are.”

• “Plain/standardised packaging of tobacco products.”

• “Introduction of both visible and invisible security features on 

tobacco packaging and ensuring that the storage and access 

to such data is [sic] independent from tobacco companies.”

• “Prohibition on the cross-border distance sale of tobacco 

products.”

• “Strong regulatory framework and independent research for 

electronic cigarettes. Any regulation of electronic nicotine 

delivery systems should be science based.”

• “Ensuring the adoption of delegated acts is not exposed to the 

interests of the tobacco industry, which would jeopardise the 

achievement of high level of health protection.” 

• “ERS supports 

the European 

Commission’s 

Proposal for the 

Tobacco Products 

Directive and 

Rapporteur Linda 

McAvan’s efforts to 

improve it.”

• “Introduction of 

standard packs with 

increased health 

warnings.”

• “Prohibition of 

characterizing 

flavours.”

• “Strengthening 

of traceability and 

security features for 

combating illicit 

trade.”

• “Prohibiting 

misleading features, 

including slim 

cigarettes.”

• “Approximately 

700,000 EU citizens 

die prematurely 

every year because 

of tobacco 

consumption.”

Table 5.3 A Continued
A Report of the Surgeon General

214 Chapter 5

Organization

Organizational 

position on cessation Organizational position on harm Organizational position on regulation General comments

Forum of 

International 

Respiratory 

Societies 

(American 

College 

of Chest 

Physicians 

2014; 

Schraufnagel 

et al. 2014)

• “Studies looking at 

whether electronic 

cigarettes can 

aid smoking 

cessation have had 

inconsistent results.”

• “The safety of electronic 

cigarettes has not been 

adequately demonstrated.”

• “The addictive power of nicotine 

and its untoward effects should 

not be under-estimated.

• “Potential benefits to an 

individual smoker should be 

weighed against harm to the 

population of increased social 

acceptability of smoking and use 

of nicotine.”

• “Adverse health effects for third 

parties exposed to the emissions 

of electronic cigarettes cannot be 

excluded.”

• “Health and safety claims regarding electronic nicotine 

delivery devices should be subject to evidentiary review.”

• “If ENDS devices are permitted, they should be regulated as 

tobacco products.”

• “Research, supported by sources other than the tobacco 

or electronic cigarette industry, should be carried out to 

determine the impact of electronic nicotine delivery devices 

on health in a wide variety of settings.”

• “The use and population effects of END devices should be 

monitored.”

• “All information derived from this research should be 

conveyed to the public in a clear manner.”

• “ENDS should be 

restricted or banned, 

at least until more 

information about 

their safety is 

available.”

Table 5.3 A Continued
E-Cigarette Use Among Youth and Young Adults

E-Cigarette Policy and Practice Implications 215

B. Voluntary health organizations

Organization

Organizational 

position on cessation Organizational position on harm Organizational position on regulation General comments

American 

Cancer 

Society 

(ACS) (2014)

• “Because the 

American Cancer 

Society doesn’t 

yet know whether 

e-cigarettes are safe 

and effective, we 

cannot recommend 

them to help people 

quit smoking.”

• “There are proven 

methods available 

to help people quit, 

including pure forms 

of inhalable nicotine 

as well as nasal 

sprays, gums, and 

patches.”

• “[E]-cigarettes are not labeled 

with their ingredients, so the 

user doesn’t know what’s in 

them.”

• “Inhaling a substance is not the 

same as swallowing it.”

• “Studies have shown that 

e-cigarettes can cause short-term 

lung changes that are much 

like those caused by regular 

cigarettes.”

• “E-cigarettes need to be researched and regulated.” • “Until electronic 

cigarettes are 

scientifically 

proven to be safe 

and effective, 

ACS will support 

the regulation of 

e-cigarettes and laws 

that treat them like 

all other tobacco 

products.”

Table 5.3 Continued
A Report of the Surgeon General

216 Chapter 5

Organization

Organizational 

position on cessation Organizational position on harm Organizational position on regulation General comments

American 

Heart 

Association 

(AHA) 

(Bhatnagar 

et al. 2014)

(continues 

on next 

page)

• “Current evidence 

evaluating the 

efficacy of these 

products as a 

cessation aid is 

sparse, confined 

to 2 randomized 

controlled trials 

and 1 large crosssectional study, 

anecdotal reports, 

and Internet-based 

surveys.”

• “[R]eports are 

confounded by a 

self-selection bias in 

that the respondents 

are often e-cigarette 

enthusiasts.”

• “The AHA maintains 

that e-cigarette 

use should be 

part of tobacco 

screening questions 

incorporated into 

clinical visits and 

worksite/community 

health screenings 

that are tied into 

healthcare delivery.”

• “Low levels of harmful or 

potentially harmful metals such 

as lead, nickel, and chromium 

are listed as having been 

detected.”

• “Trace levels of tobacco-specific 

N-nitrosamines, polycyclic 

aromatic hydrocarbons, and 

volatile organic compounds in 

the e-liquid and vapor have been 

reported.”

• “The FDA has issued warnings 

to several e-cigarette companies 

for selling e-cartridges with 

[diethylene glycol, weightloss chemical rimonabant 

(Zimulti), and the erectile 

dysfunction medication tadalafil 

(active ingredient in Cialis)] 

contaminants.”

• “There are no reports of 

e-cigarette safety in patients with 

known cardiovascular disease.”

• “The regulation should allow for quality-controlled products 

for adults who want to transition from conventional cigarettes 

to e-cigarettes or to quit or reduce smoking.”

• “Bottles containing nicotine refill liquids can be toxic if 

swallowed, so cartridges and bottles should have proper 

warning labeling and child-proofing packaging.”

• “It is important that the relevant government agency monitor 

whether these devices are used for delivery of other drugs and 

medications.”

• “Companies should not be able to claim that e-cigarettes are 

a cessation aid unless they are approved by the FDA for that 

purpose.”

• “The [AHA] supports 

effective regulation 

that addresses 

marketing, labeling, 

quality control of 

manufacturing, 

and standards for 

contaminants.”

• “[It] also supports 

including 

e-cigarettes in 

smoke-free air laws 

and prohibiting the 

sales of e-cigarettes 

to youth.”

Table 5.3 B Continued
E-Cigarette Use Among Youth and Young Adults

E-Cigarette Policy and Practice Implications 217

Organization

Organizational 

position on cessation Organizational position on harm Organizational position on regulation General comments

(continued 

from 

previous 

page) 

American 

Heart 

Association 

(AHA) 

(Bhatnagar 

et al. 2014)

• “Clinicians should 

be educated about 

e-cigarettes and 

should be prepared 

to counsel their 

patients who are 

using combustible 

tobacco products to 

use e-cigarettes as 

a primary cessation 

aid.”

• “For patients 

with existing 

cardiovascular 

disease and stroke, 

or at risk of a 

cardiovascular 

disease event, 

intensive cessation 

counseling should 

be offered as soon as 

possible.”

— — —

Table 5.3 B Continued
A Report of the Surgeon General

218 Chapter 5

Organization

Organizational 

position on cessation Organizational position on harm Organizational position on regulation General comments

American 

Lung 

Association 

(2014, 2015)

• “Until and unless 

the FDA approves a 

specific e-cigarette 

for use as a tobacco 

cessation aid, the 

American Lung 

Association does not 

support any direct 

or implied claims 

that e-cigarettes help 

smokers quit.”

• “There is currently no scientific 

evidence establishing the safety 

of e-cigarettes.”

• “FDA found detectable levels of 

toxic cancer-causing chemicals, 

including an ingredient used in 

anti-freeze, in two leading brands 

of e-cigarettes and 18 various 

cartridges.”

• “The lab tests also found that 

cartridges labeled as nicotinefree had traceable levels of 

nicotine.”

• “Nicotine is believed to 

contribute to increased incidence 

of premature birth, and low birth 

weight.”

• “Research has also shown a 

negative impact on pulmonary 

function in newborns.”

• “The FDA has not approved any e-cigarettes as a safe or 

effective method to help smokers quit.”

• “Including 

e-cigarettes in 

smokefree laws and 

ordinances.”

• “State laws that 

would prohibit the 

sale of any flavored 

e-cigarette product.”

• “Taxing e-cigarettes 

at a rate equivalent 

with all tobacco 

products, including 

cigarettes.”

• “Eliminating 

e-cigarette sales to 

youth, otherwise 

restricting youth 

access to e-cigarettes 

and requiring 

e-cigarette retailers 

to be licensed.”

• “E-cigarettes should 

be defined as tobacco 

products.”

• “Opposes creating 

new definitions for 

‘vapor products’ 

and/or ‘alternative 

nicotine products’ in 

state laws.”

Table 5.3 B Continued
E-Cigarette Use Among Youth and Young Adults

E-Cigarette Policy and Practice Implications 219

Organization

Organizational 

position on cessation Organizational position on harm Organizational position on regulation General comments

Americans 

for 

Nonsmokers’ 

Rights (ANR) 

(n.d.a; n.d.b)

• “ESDs are not 

proven cessation 

devices.”

• “Many people 

become ‘stable 

dual-users’ who use 

both cigarettes and 

ESDs.”

• “Americans for Nonsmokers’ 

Rights recommends that 

e-cigarettes not be used in areas 

where people will be exposed to 

the vapors they emit.”

• “Electronic smoking device 

aerosol is not water vapor. . . . 

The aerosol (incorrectly called 

vapor) contains nicotine, 

hazardous ultrafine particles that 

lodge deeply in the lungs . . . and 

toxins known to cause cancer.”

• “Electronic smoking devices are currently unregulated 

products.”

• “[ANR] . . . encourages municipalities and states to prohibit 

the use of ESDs in all smokefree venues.”

• “Electronic cigarettes 

are not a safe 

alternative!”

C. World Health Organization

Organization

Organizational 

position on cessation Organizational position on harm Organizational position on regulation General comments

World Health 

Organization 

(WHO) (Bates 

2014; WHO 

2014b)

(continues on 

next page)

• “Prohibit 

manufacturers and 

third parties from 

making health 

claims for ENDS, 

including that 

ENDS are smoking 

cessation aids.”

• “The regulatory 

standard for 

cessation claims 

and approval as 

cessation aids 

should remain an 

appropriate body 

of evidence, based 

on well-controlled 

clinical trials.”

• “ENDS users should be legally 

requested not to use ENDS 

indoors, especially where smoking 

is banned until exhaled vapour 

is proven to be not harmful 

to bystanders and reasonable 

evidence exists that smokefree policy enforcement is not 

undermined. If smoke-free 

legislation is not fully developed 

according to Article 8 of the WHO 

FCTC and the guidelines for its 

implementation, this should be 

done as soon as possible.”

• “Health warnings should be 

commensurate with proven health 

risks.”

• “Parties should contemplate putting in place an effective 

restriction on ENDS advertising, promotion and sponsorship.”

• “Protection from vested commercial interests.”

• “Governments are recommended to use or strengthen their 

existing tobacco surveillance and monitoring systems to assess 

developments in ENDS and nicotine use by sex and age.”

• “Overall, in 

its public 

communication 

WHO portrays 

e-cigarettes as a 

threat to public 

health.”

• “Encourage 

smoking cessation 

and provide a 

quitline number if 

one exists.”

Table 5.3 B Continued
A Report of the Surgeon General

220 Chapter 5

Organization

Organizational 

position on cessation Organizational position on harm Organizational position on regulation General comments

(continued 

from previous 

page) 

World Health 

Organization 

(WHO) (Bates 

2014; WHO 

2014b)

• “For ENDS 

products to be 

approved for 

smoking cessation 

by the suitable 

regulatory agency, 

the appropriate 

balance should 

be reached 

between providing 

accurate scientific 

information 

to the public 

about the risk of 

ENDS use and its 

potential benefits 

as compared with 

smoking.”

— — —

Table 5.3 C Continued
E-Cigarette Use Among Youth and Young Adults

E-Cigarette Policy and Practice Implications 221

Table 5.3 Continued

D. Government health

Organization

Organizational 

position on cessation Organizational position on harm Organizational position on regulation General comments

European 

Union (EU) 

(European 

Parliament 

and Council 

2014; WHO 

Framework 

Convention 

on Tobacco 

Control 2014)

— • “Certain additives used to create 

the impression that tobacco 

products have health benefits, as 

well as those with [carcinogenic, 

mutagenic, or reprotoxic] 

properties in unburnt form, 

should be prohibited in order to 

ensure uniform rules throughout 

the Union and a high level of 

protection of human health.”

• “Electronic cigarettes and 

refill containers could create a 

health risk when in the hands 

of children—it is necessary to 

ensure products are child and 

tamperproof.”

• “Nicotine-containing liquid should 

only be placed on the market in 

electronic cigarettes or in refill 

containers that meet certain safety 

and quality requirements.”

• “The prohibition of tobacco products with characterizing 

flavours does not preclude the use of individual additives 

outright, but it does oblige manufacturers to reduce the 

additive or the combination of additives.”

• “Electronic cigarettes and refill containers should be 

regulated by this Directive.”

• “Where the manufacturer of the relevant product is not 

established in the Union, the importer of that product should 

bear the responsibilities relating to the compliance of those 

products with this Directive.”

• “Nicotine-containing liquid should only be allowed to be 

placed on the market, where the nicotine concentration does 

not exceed 20 mg/ml.”

• “Only electronic cigarettes that deliver nicotine doses at 

consistent levels should be allowed to be placed on the 

market.”

• “The labeling and packaging of [e-cigarettes] should display 

sufficient and appropriate information on their safe use.”

• New directive: May 

2014.

• New rules applied: 

First half of 2016.

• “Aims at ensuring 

equal treatment 

across the EU for 

nicotine-containing 

e-cigarettes 

(products that do 

not contain nicotine 

are not covered by 

the Directive).”

• “Electronic 

cigarettes can 

develop into 

a gateway to 

nicotine addiction 

and ultimately 

traditional tobacco 

consumption, as 

they mimic and 

normalize the 

action of smoking. 

For this reason, it 

is appropriate to 

adopt a restrictive 

approach to 

advertising 

electronic 

cigarettes and refill 

containers.”
A Report of the Surgeon General

222 Chapter 5

Organization

Organizational 

position on cessation Organizational position on harm Organizational position on regulation General comments

CAP/BCAP 

(UK) (2014)

— • “Ads cannot convey health benefits 

or claim that they are safer or 

healthier than smoking tobacco.”

• “Ads must not be likely to appeal particularly to people under 

18, especially by reflecting or being associated with youth 

culture.”

• “People shown using e-cigarettes or playing a significant role 

must neither be, nor seem to be, under 25.”

• “Ads must not be directed at people under 18 through the 

selection of media or the context in which they appear.”

• “Ads must not encourage nonsmokers or nonnicotine users to 

use e-cigarettes.”

• “Ads must make clear that the product is an e-cigarette and 

not a tobacco product.”

• “Ads on TV and radio will be subject to scheduling restrictions 

to reduce the chance of e-cigarette advertisements being seen 

or heard by children.”

• Effective date: 

November 10, 2014.

• “The rules place an 

emphasis on the 

protection of young 

people and ads must 

avoid containing 

anything that 

promotes the use of 

a tobacco product 

or that shows the 

use of a tobacco 

product in a positive 

light.”

• CAP: Write and 

maintain the UK 

advertising codes.

Public Health 

England (UK) 

(Britton and 

Bogdanovica 

2014; 

CAMQUIT 

n.d.)

— — • “Under the terms of the new Tobacco Product Directive 

(TPD) . . . advertising of nicotine-containing devices that are 

not licensed as medicines will be prohibited, products will be 

required to carry health warnings, meet purity and emission 

standards that are yet to be defined.”

• Effective date: 2016.

• “The UK [Medicines 

and Healthcare 

products Regulatory 

Agency] announced 

that from 2016, it 

intended to regulate 

electronic cigarettes 

and other nicotinecontaining products 

as medicines by 

function, and 

thus require 

manufacture to 

medicinal purity 

and delivery 

standards, and 

proactive controls 

on advertising.”

Table 5.3 D Continued
E-Cigarette Use Among Youth and Young Adults

E-Cigarette Policy and Practice Implications 223

Organization

Organizational 

position on cessation Organizational position on harm Organizational position on regulation General comments

International 

Union Against 

Tuberculosis 

and Lung 

Cancer (2013)

• “The benefits 

of e-cigarettes 

have not been 

scientifically 

proven.”

• “Very few studies 

have assessed ECs/

ENDS as a harm 

reduction and 

cessation aid and 

with conflicting 

findings.”

• “The safety of ECs or ENDS has not 

been scientifically demonstrated.”

• “Adverse health effects for 

[secondhand smoke] cannot 

be excluded because the use of 

electronic cigarettes leads to 

emission of fine and ultrafine 

inhalable liquid particles, nicotine 

and cancer-causing substances into 

indoor air.”

• “A range of current and proposed legislative and regulatory 

options exists.”

• “Brazil, Norway, and Singapore have banned ECs/ENDS 

completely.”

• “ENDS could undermine the implementation of WHO FCTC 

Article 12 (de-normalisation of tobacco use).”

• “Use of ENDS could also hamper the implementation of 

Article 8 (protection from exposure to tobacco smoke).”

• “The Union 

strongly supports 

the regulation of 

the manufacture, 

marketing and 

sale of Electronic 

cigarettes (ECs) 

or electronic 

nicotine delivery 

systems (ENDS); 

the preferred option 

is to regulate 

ECs or ENDS as 

medicines.”

• “The Union is 

concerned that 

the marketing, 

awareness and use 

of ECs or ENDS is 

growing rapidly.”

Note: AARC = American Association for Respiratory Care; ACP = American College of Physicians; ACS = American Cancer Society; AHA = American Heart Association; 

ANR = Americans for Nonsmokers’ Rights; CAP/BCAP = Committees of Advertising Practice/Broadcast Committee of Advertising Practice; CDC = Centers for Disease 

Control and Prevention; CTP = Center for Tobacco Products; ECs = electronic cigarettes; ENDS = electronic nicotine delivery systems; ERS = European Respiratory 

Society; ESDs = electronic smoking devices; EU = European Union; FCTC = Framework Convention for Tobacco Control; FDA = U.S. Food and Drug Administration; 

UK = United Kingdom; WHO = World Health Organization.

Table 5.3 D Continued
A Report of the Surgeon General

224 Chapter 5

Case Studies

Case studies in California and North Dakota demonstrate how e-cigarette policies have been enacted at the 

local and state levels, and they provide potential models 

of how cities, counties, and other states might address 

e-cigarettes in their jurisdictions.

City of Hayward Takes Bold Steps to Address Tobacco Products Aimed 

at Kids

In response to the “D” grade that the city of Hayward received in 2011 from the American Lung Association in 

California for its efforts to protect youth from tobacco sales, the city council directed its staff to develop regulations 

to address the problem of youth tobacco sales. Draft regulations were presented at a city planning meeting in 2012, 

followed by a series of community meetings and hearings that culminated in the Hayward city council’s adoption of 

a 45-day moratorium to begin in January 2014 on the issuance of business licenses or building permits for any new 

tobacco retailers. The following month, the moratorium was extended another 15 months to provide more time to 

research and consider the issue (City of Hayward 2014).

On July 1, 2014, the Hayward city council unanimously adopted an ordinance that requires sellers of tobacco 

products and “electronic smoking devices” to obtain annually a $400 tobacco retailer license that covers the cost of 

an annual inspection for compliance with federal, state, local, tribal, and territorial tobacco control laws. The ordinance allowed the city’s existing 142 tobacco retailers, 8 e-cigarette retailers, and 2 hookah lounges to continue 

operating at their current locations; however, new sellers must obtain a conditional use permit, are restricted to special commercial zones, and may not locate within 500 feet of residential areas or child-sensitive areas (e.g., schools 

and parks) or within 500 feet of an existing tobacco seller. It also prohibits new hookah lounges or vaping lounges 

from opening within the city.

The ordinance also contains provisions to prohibit self-service displays of tobacco products and e-cigarettes 

and to regulate the sales of cigars, flavored products, and imitation tobacco products. Cigars selling for less than 

$5 each are required to be sold in pack sizes of five or more, and the sale of flavored traditional tobacco products, 

e-cigarettes, and imitation tobacco products (e.g., candy cigarettes, bubble gum chew) is prohibited within 500 feet 

of schools for any business not selling these products before July 1, 2014.

Penalties range from $1,500 for a first violation and possible suspension to a complete revocation of a license 

after three violations within a 3-year period (City of Hayward 2014; n.d.a.). Active enforcement of the ordinance 

began in April 2015 (City of Hayward n.d.b.).

Throughout the process, Hayward officials and staff relied heavily on materials from the American Lung 

Association, the Center for Tobacco Policy and Organizing, and ChangeLab Solutions to provide the public health 

and legal rationale for supporting the provisions. Hayward’s tobacco retail licensing effort was also supported by 

the tobacco control program of the Alameda County public health department, which used monies from its Master 

Settlement Agreement to fund the Hayward police department to conduct youth decoy operations and local community and youth organizations to conduct educational outreach (City of Hayward 2014). Collectively, these resources 

informed the Hayward city council’s decision-making process.
E-Cigarette Policy and Practice Implications 225

E-Cigarette Use Among Youth and Young Adults

North Dakota’s Statewide Clean Indoor Air Law Prohibits Conventional 

Tobacco Products and E-Cigarettes

In November 2012, North Dakota achieved a remarkable victory for statewide clean indoor air (BreatheND 

n.d.a.) despite major obstacles, including a harsh winter climate, an adult smoking rate of 21.9% (CDC 2013), and 

several prior failed legislative attempts to close exemptions in the state’s 2005 clean indoor air law (CDC 2014). 

Despite these impediments, two-thirds of the state voted to prohibit both the smoking of conventional tobacco products and use of e-cigarettes in all non-hospitality workplaces; restaurants; bars; hotel guest rooms and communal 

areas; health care facilities; assisted living facilities; all licensed child and adult day care facilities; gaming facilities; indoor areas of sports arenas; and within 20 feet of entrances, exits, operable windows, air intakes, and ventilation systems of enclosed areas where smoking is not allowed (BreatheND n.d.b.). Additionally, the law provided 

no exemptions for tobacco-only retail or “vape shops” (Americans for Nonsmokers’ Rights Foundation 2015, n.d.).

The 2012 ballot initiative on statewide clean indoor air resulted from the lack of progress in working with the 

legislature to try to close smoking exemptions in the state law. The initiative’s sponsors, Tobacco Free North Dakota 

and the American Lung Association in North Dakota, worked closely with the Tobacco Control Legal Consortium 

to draft policy language, which included prohibiting the use of e-cigarettes anywhere smoking was prohibited. The 

sponsors approached stakeholders and assessed public support. Little opposition was encountered to prohibiting the 

use of e-cigarettes indoors. In addition to the sponsors’ efforts, the North Dakota Center for Tobacco Prevention and 

Control Policy conducted a media campaign and worked with local partners to educate their communities, resulting 

in 11 smokefree ordinances prior to the issuing of the statewide ballot initiative. The landslide victory (66% vs. 33%) 

in favor of clean indoor air, with the initiative successfully carried in every one of North Dakota’s 53 counties, demonstrated widespread public support for clean indoor air (Ballotpedia 2012).

Only a few years later, the law continues to enjoy strong public support from nonsmokers (84.4%) and smokers 

(58%) alike. Compliance with the law is comparable to cigarette smoking; just 16.8% of North Dakotans reported 

having observed smoking indoors in areas where it was prohibited, and 23.2% reported having seen e-cigarettes 

used indoors in such places. Local enforcement personnel confirm a high level of compliance, reporting violations 

primarily related to smoking within 20 feet of entrances. To date, the only prosecuted violation of the law involved 

the sampling of an e-cigarette product inside a “vape shop” (BreatheND 2014). In hindsight, the decision to include 

e-cigarettes in North Dakota’s smokefree law was helpful, given increasing concerns about involuntary exposure to 

nicotine and other aerosolized e-cigarette emissions.

Summary and Recommendations

The Surgeon General has long played a leading role 

in identifying the harms of tobacco use and documenting 

the most effective ways to reduce them. This report comes 

amid the rising use of e-cigarettes among the nation’s 

youth and young adults. It calls attention to this problem 

and the need to implement immediately a comprehensive 

strategy to minimize any negative public health impact 

now and in the future, giving consideration to the potential 

for youth to be harmed from e-cigarettes while, simultaneously, acknowledging that gains might be made if the use 

of combustible tobacco products fell among adult smokers. 

Chapters 1–4 documented the particular challenges posed 

by the rapid emergence and dynamic nature of e-cigarette 

use among youth and young adults. The marketplace is 

diverse, and although it includes the large tobacco companies, e-cigarettes are sold in thousands of “vape shops” 

and other small commercial locations and on the Internet. 

Marketing strategies exploit social media, reaching widely 

and with tailored targeting to consumers.

The differences notwithstanding, the principles and 

strategies articulated in the 2014 Surgeon General’s report 

and prior reports remain relevant to e-cigarettes. The 2014 

report was written not long after the use of e-cigarettes 

began to surge dramatically; that report commented on the 

need for rapid elimination of conventional cigarettes and 

other combustible tobacco products but did not specify 

a role for e-cigarettes or discuss strategies to minimize 

adverse effects among youth and young adults (USDHHS 

2014). The report’s final chapter, however, set out an evidence-based strategy for the future. The present report 

builds on this foundation, adding recommendations related 

to e-cigarettes.
A Report of the Surgeon General

226 Chapter 5

Conclusions

1. The dynamic nature of the e-cigarette landscape 

calls for expansion and enhancement of tobaccorelated surveillance to include (a) tracking patterns 

of use in priority populations; (b) monitoring the 

characteristics of the retail market; (c) examining 

policies at the national, state, local, tribal, and territorial levels; (d) examining the channels and messaging for marketing e-cigarettes in order to more 

fully understand the impact future regulations 

could have; and (e) searching for sentinel health 

events in youth and young adult e-cigarette users, 

while longer-term health consequences are tracked.

2. Strategic, comprehensive research is critical to 

identify and characterize the potential health risks 

from e-cigarette use, particularly among youth and 

young adults.

3. The adoption of public health strategies that are precautionary to protect youth and young adults from 

adverse effects related to e-cigarettes is justified.

4. A broad program of behavioral, communications, 

and educational research is crucial to assess how 

youth perceive e-cigarettes and associated marketing messages, and to determine what kinds of 

tobacco control communication strategies and 

channels are most effective.

5. Health professionals represent an important 

channel for education about e-cigarettes, particularly for youth and young adults.

6. Diverse actions, modeled after evidence-based 

tobacco control strategies, can be taken at the 

state, local, tribal, and territorial levels to address 

e-cigarette use among youth and young adults, 

including incorporating e-cigarettes into smokefree policies; preventing the access of youth to 

e-cigarettes; price and tax policies; retail licensure; 

regulation of e-cigarette marketing that is likely to 

attract youth and young adults, to the extent feasible 

under the law; and educational initiatives targeting 

youth and young adults. Among others, research 

focused on policy, economics, and the e-cigarette 

industry will aid in the development and implementation of evidence-based strategies and best 

practices.
E-Cigarette Policy and Practice Implications 227

E-Cigarette Use Among Youth and Young Adults

References

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The Call to Action
 

The Call to Action on E-Cigarette Use Among Youth and Young Adults 237
 

Goal 1. First, Do No Harm 237
 

Goal 2. Provide Information About the Dangers of E-Cigarette Use Among Youth and Young Adults 239
 

Goal 3. Continue to Regulate E-Cigarettes at the Federal Level to Protect Public Health 241
 

Goal 4. Programs and Policies to Prevent E-Cigarette Use Among Youth and Young Adults 243
 

Including E-Cigarettes in Smokefree Indoor Air Policies 243
 

Restricting Youth Access to E-Cigarettes 244
 

Licensing Retailers 245
 

Establishing Specific Packaging Requirements 245
 

Goal 5. Curb Advertising and Marketing that Encourages Youth and Young Adults to Use E-Cigarettes 246
 

Goal 6. Expand Surveillance, Research, and Evaluation Related to E-Cigarettes 247
 

Conclusions 249
 

References 250
 

235 
236
 
The Call to Action 237 

E-Cigarette Use Among Youth and Young Adults

 

The Call to Action on E-Cigarette Use Among Youth and 

Young Adults 

The Surgeon General issues this Call to Action on 

e-cigarettes, specifically focusing on youth and young 

adults, to accelerate policies and programs that can reduce 

e-cigarette use among young people. This Call to Action 

comes amid the dramatic increase in e-cigarette use 

among our nation’s youth and young adults. It highlights 

the need to implement proven strategies that will prevent potentially harmful effects of e-cigarette use among 

young people. The previous chapters explained what we 

know and do not know about e-cigarettes and reviewed 

policy options. Gaps in scientific evidence still exist, and 

this Call to Action is being issued while these products 

and their patterns of use are changing quickly. However, 

policies and strategies are available that can clearly reduce 

the public health threat posed by e-cigarette use among 

young people. 

Use of e-cigarettes is increasing rapidly 

among young people, even among those 

who have never smoked cigarettes. 

This Call to Action presents six goals and related 

strategies that should guide efforts to reduce e-cigarette 

use among youth and young adults. To achieve these 

goals, we must work together, which means working with 

individuals and families; civic and community leaders; 

public health and health care professionals; e-cigarette 

manufacturers and retailers; voluntary health agencies; 

researchers; and other stakeholders. 

Stakeholders Who Can Take Action 

•	 Individuals, parents, and families 

•	 Teachers, coaches, and other youth influencers 

•	 Civic and community leaders 

•	 Public health and health care professionals 

•	 Researchers 

•	 Federal government 

•	 State, local, tribal, and territorial governments 

•	 E-cigarette manufacturers, distributors, and 

retailers 

•	 Voluntary health agencies, non-governmental 

organizations, and other community- and faithbased organizations 

Goal 1. First, Do No Harm
 

Since 1964, reports from the U.S. Surgeon General 

have led the way in identifying the harms of tobacco use 

and detailing the most effective ways to reduce the dangerous effects of tobacco use. For example, reports from 

1994 and 2012 outlined proven strategies to prevent and 

reduce tobacco use among youth and young adults (U.S. 

Department of Health and Human Services [USDHHS] 

1994, 2012). Building on these and other past reports, 

this Call to Action considers the harms of e-cigarette use 

among youth and young adults and stresses the importance of strategies that will protect young people from the 

adverse consequences of these new products. 
A Report of the Surgeon General

 

Strategy 1A. 

Implement a comprehensive strategy to address 

e-cigarettes that will avoid adverse consequences and 

give careful consideration to the risks for youth and 

young adults. This can be done by including e-cigarettes 

in policies and programs related to conventional 

cigarette smoking at the national, state, local, tribal, 

and territorial levels. 

We have many effective strategies to prevent tobacco 

use among youth and young adults (USDHHS 2012), and 

many of these strategies can also be applied to e-cigarettes. 

A strategy to address e-cigarette use among young people 

should be precautionary. A precautionary approach urges 

action to prevent harm when there is scientific uncertainty. That is, when there is inadequate or early knowledge, public health decisions should be made on the basis 

of precaution to prevent harm, rather than on certain 

risk. This approach requires proof that a product is not 

harmful—especially for youth—rather than proof that it 

is harmful. The burden of proof regarding product safety 

should be placed on those who wish to market and sell 

such tobacco products, rather than the public health community charged with protecting the public’s health. The 

harms of nicotine exposure in youth and young adults are 

well-documented in this report and warrant this Call to 

Action (see Chapter 3). We must protect the health of our 

nation’s young people by assuring that there will be no 

harm to youth from e-cigarettes. The stakeholders identified on the previous page should work together to prevent and reduce the use of all forms of tobacco products, 

including e-cigarettes, among our nation’s youth and 

young adults. A comprehensive strategy includes: 

•	 Implementing the U.S. Food and Drug 

Administration’s (FDA’s) authority to regulate 

tobacco products in order to provide oversight of 

the manufacturing, distribution, and marketing of 

e-cigarettes, particularly as they relate to youth and 

young adults; 

•	 Funding comprehensive statewide tobacco control 

programs at levels recommended by the Centers for 

Disease Control and Prevention (CDC); 

•	 Implementing comprehensive clean indoor air policies that protect people from exposure to secondhand tobacco smoke and the aerosol emitted from 

e-cigarettes; 

•	 Raising and strongly enforcing minimum age-of-sale 

laws for all tobacco products, including e-cigarettes, 

to prevent initiation at young ages; 

Use of e-cigarettes can expose young people 

to nicotine. Nicotine can be highly addictive 

and can harm brain development. Nicotine 

use may also lead to the use of other tobacco 

or nicotine-containing products. 

•	 Setting price policies for e-cigarettes, which could 

include taxation policies; 

•	 Restricting advertising and marketing that encourages youth and young adults to use e-cigarettes; 

•	 Sponsoring high-impact media campaigns to educate the public using evidence-based information 

about the consequences of e-cigarette use among 

youth and young adults, including the harms of nicotine on the developing brain; and 

•	 Expanding tobacco control and prevention research 

efforts to increase our understanding of the evolving 

landscape of e-cigarettes. 

These components make up an evidence-based 

strategy. However, the e-cigarette marketplace is diverse 

and continues to evolve. Thus, ongoing efforts should 

rapidly and effectively track and adapt to such changes, 

thereby protecting our nation’s young people from the 

consequences of e-cigarette use and exposure to secondhand aerosol. 

238 The Call to Action 
The Call to Action 239 

E-Cigarette Use Among Youth and Young Adults

 

Strategy 1B. 

Provide consistent and evidence-based messages about 

the health risks of e-cigarette use and exposure to 

secondhand aerosol from e-cigarettes. 

Research on e-cigarettes is ongoing, and the 

e-cigarette marketplace continues to evolve. Even so, a 

sufficient body of evidence justifies actions taken now to 

prevent and reduce the use of e-cigarettes and exposure to 

secondhand aerosol from e-cigarettes, particularly among 

youth and young adults. Most important, many health 

risks are already known, and sufficient information exists 

to take action to minimize potential harms. The evidence 

is most compelling for nicotine. As part of comprehensive 

reviews, previous Surgeon General’s reports have provided 

causal findings on the development of addiction and other 

health consequences of exposure to nicotine (USDHHS 

1988, 2014). Beyond addiction, intake of nicotine by 

young people can harm brain development (Chapter 3). 

Additionally, aerosol from e-cigarettes contains 

toxins that can harm the body, and the flavorings used in 

these products cannot be considered safe for inhalation, 

either firsthand or secondhand (Chapter 3). For example, 

some flavorings have been known to be associated with 

pulmonary toxicity (Allen et al. 2016). 

Messaging about the potential role of e-cigarettes 

in reducing the burden of tobacco-related diseases should 

note that e-cigarette products that deliver nicotine are not 

considered safe, particularly for youth and young adults, 

even before researchers fully characterize and quantify 

all of their health risks, including possible permanent 

changes to the adolescent brain and lungs. 

The use of any tobacco product, including 

e-cigarettes, among young people is unsafe. 

Goal 2. Provide Information About the Dangers of E-Cigarette Use 

Among Youth and Young Adults 

Once youth and young adults start using products 

that contain nicotine, including e-cigarettes, they can 

become addicted. Such addiction has the potential to lead 

to long-term use of products that contain nicotine, such 

as cigarettes. Most adolescents who use tobacco already 

use more than one nicotine-containing product and are 

not just using e-cigarettes alone (Chapter 2). The majority 

of tobacco users start before they are 18 years of age, 

and almost no one starts after age 25 (USDHHS 2012). 

Therefore, the best way to protect young people from the 

harms of tobacco use, including e-cigarettes, is to prevent 

the use of these products altogether. Prevention should 

start with robust public policies that make it easy for 

youth not to use tobacco and harder for them to use any 

tobacco products. Parents, teachers, health professionals, 

and other influencers of youth should be educated about 

the risks of e-cigarette use. They can then help educate 

their own children as well as other young people about the 

harms of e-cigarettes and the risk of a potential lifetime of 

nicotine addiction. 

Use of e-cigarettes and exposure to nicotine 

is particularly dangerous for pregnant 

women. Nicotine is toxic to the fetus and 

impairs fetal brain and lung development. 

Strategy 2A. 

Educate parents, teachers, coaches, and other 

influencers of youth about the risks of e-cigarette use 

among youth and young adults. 

Parents, guardians, teachers, coaches, health professionals, faith leaders, and other persons whose advice and 

behavior influence youth play critical roles in protecting 

youth and young adults from the harms of e-cigarette use 

and exposure to the secondhand aerosol emitted from 

these devices. Most adults are familiar with some of the 

dangers of using tobacco products, especially conventional 

cigarettes, and of exposure to secondhand tobacco smoke. 

Because of these dangers, many adults have taken steps to 

keep children safe. However, most adults are not aware of 

the potential risks of using e-cigarettes and exposure to 

secondhand aerosol, and e-cigarette marketing often promotes these products as safe alternatives to smoking conventional cigarettes. But messaging about the dangers is 

essential. For example, the use of these products can lead 

to nicotine addiction, harm brain development, and lead 

to continued tobacco use. 
A Report of the Surgeon General

 

Parents, teachers, coaches, and others can protect 

their children and other young people by educating them 

about e-cigarettes: 

•	 Talk openly about the harms of nicotine and tobacco 

use. 

•	 Express firmly the idea that young people should not 

use any tobacco products, including e-cigarettes. 

•	 Do not let any individuals use e-cigarettes or other 

tobacco products around children. 

•	 Ask health care providers, adults, and parents to 

discuss with children the health risks of using 

e-cigarettes, such as nicotine addiction. 

•	 Patronize restaurants and other places that do not 

allow the use of e-cigarettes indoors, and let business owners that allow e-cigarette use indoors know 

that it is not as safe as clean air or even legal in many 

places. 

•	 Make sure children’s day care centers, schools, and 

universities are completely tobacco-free, including 

being free of e-cigarettes. A comprehensive tobaccofree campus policy prohibits any tobacco use, 

including e-cigarettes, on school property by anyone 

at any time. These policies should be expanded to 

include school events that are held off campus. 

•	 Prohibit tobacco and e-cigarette company sponsorship of teams or events, promotional activities, 

and offers of educational materials for preventing 

tobacco use among youth. 

•	 Make homes and cars completely tobacco-free, 

including the use of e-cigarettes. This means no 

use by family members, friends, or guests. Opening 

a window does not fully protect against exposure 

to secondhand cigarette smoke or from the secondhand aerosol from e-cigarettes. For youth and 

young adults to be fully protected from indoor exposure, all indoor environments must be 100% free 

from tobacco smoke and e-cigarette aerosol. 

•	 Set an example by being tobacco-free. 

•	 Provide positive support and encouragement to 

anyone who is trying to quit tobacco. 

E-cigarettes are now the most common form 

of tobacco used by young people. High school 

students use e-cigarettes more than adults. 

Research suggests that youth and young adults are 

not as aware of the health consequences of e-cigarette use 

as they are with the consequences of cigarette smoking 

(Chapter 2) (Pearson et al. 2012; Richardson et al. 2014; 

Tan and Bigman 2014). FDA has the authority to require 

health warnings on tobacco products and tobacco advertising. In addition, FDA and other federal entities, along 

with state and local organizations, can carry out educational campaigns to better inform the public, especially 

parents, and increase their understanding of the harms of 

e-cigarette use. 

240 The Call to Action 
The Call to Action 241 

E-Cigarette Use Among Youth and Young Adults

 

Strategy 2B. 

Educate health professionals about the risks of 

e-cigarette use among youth and young adults. 

The health care setting is an ideal place to educate 

people of all ages on the potential risks of e-cigarette use 

and exposure to secondhand aerosol from e-cigarettes. 

Because e-cigarettes are a relatively new product, health 

care professionals frequently face a lot of questions about 

them. These often include questions related to the risks 

of using e-cigarettes and whether these products can 

help people to quit smoking. No e-cigarettes have been 

approved as safe and effective cessation aids. 

For youth, in particular, sufficient evidence shows 

that the use of nicotine is not safe regardless of the 

delivery device: combustible, non-combustible, or electronic (USDHHS 2014; see also Chapter 3). Thus, health 

care professionals should warn youth and youth influencers, such as parents, about the health risks of using 

any product that contains nicotine, including e-cigarettes. 

They should also warn youth about the dangers of using 

other substances, such as marijuana, in e-cigarette devices 

(American Academy of Pediatrics 2015). 

Goal 3. Continue to Regulate E-Cigarettes at the Federal Level to 

Protect Public Health 

In 2009, the Family Smoking Prevention and Tobacco 

Control Act (Tobacco Control Act) provided FDA with 

authority to regulate tobacco products in a manner that 

is “appropriate for the protection of public health” (e.g., 

§§ 906(d)(1), 907(a)(3)(A) & (a)(4)(A), and § 910(c)(2)(A) of 

the Federal Food, Drug, and Cosmetic Act, as amended by 

the Tobacco Control Act) (Family Smoking Prevention and 

Tobacco Control Act 2009, p. 1786). The Tobacco Control Act 

also requires FDA to consider in regulatory actions the health 

effects at the individual and population levels, including the 

impacts on the initiation of measures taken to quit tobacco 

use as well as effects on relapse among former tobacco users. 

But FDA is not the only federal agency that can address certain aspects of e-cigarettes (see Chapter 5, Table 5.2). 

Strategy 3A. 

Implement FDA regulatory authority over the manufacturing, marketing, and distribution of e-cigarettes. 

A federal appellate court decision titled Sottera, 

Inc.  v. Food & Drug Administration (2010) determined 

that FDA can regulate e-cigarettes and other products 

made or derived from tobacco under the Tobacco Control 

Act, and that these products are not drugs or devices under 

the Food, Drug, and Cosmetic Act unless marketed as 

therapeutic or smoking cessation products. In May 2016, 

FDA finalized a rule deeming most products meeting the 

definition of a tobacco product, including e-cigarettes, 

subject to regulation under the Tobacco Control Act. The 

regulation went into effect on August 8, 2016 (but is under 

litigation) (FDA 2016). 

FDA’s rule for e-cigarettes includes several provisions that can help protect youth and young adults from 

the harms of e-cigarettes, such as the following: 

•	 Prohibiting the sale of e-cigarettes to youth who are 

under 18 years of age (both in person and online); 

•	 Requiring proof of age at the point of purchase; 
A Report of the Surgeon General

 

•	 Prohibiting vending machine sales in all facilities 

where children are allowed to enter; 

•	 Prohibiting the distribution of free samples; 

•	 Requiring health warnings about nicotine on packaging and in advertisements; 

•	 Requiring manufacturers to register their e-cigarette 

products with FDA and disclose the ingredients and 

levels of harmful and potentially harmful constituents in those products to that agency; 

•	 Requiring premarket review of new or changed 

tobacco products and authorization by FDA before 

they can be introduced into the marketplace; and 

•	 Requiring manufacturers that intend to market 

e-cigarettes for use to reduce harm or risk of tobaccorelated disease to receive authorization from FDA 

based on scientific evidence that the product is less 

harmful or presents less risk to the public. 

This authority allows FDA to undertake future regulatory actions, if determined appropriate for the protection of public health, including: 

•	 Within constitutional limitations, restricting promotion, marketing, and advertising of e–cigarettes; 

•	 Restricting Internet sales and requiring age verification on websites and upon delivery; 

•	 Prohibiting characterizing flavors; 

•	 Promulgating product standards to reduce the toxicity, addictiveness, or appeal of tobacco products; 

•	 Regulating packaging, including requiring minimum package sizes, mandating child-resistant 

packaging, and requiring health warnings; and 

•	 Prohibiting self-service displays. 

Despite gaining this broad authority, FDA does not 

have specific authority for certain regulatory actions. For 

example, FDA generally does not restrict tobacco use in 

public places, levy taxes on tobacco products, or restrict 

sales to only certain types of retailers (e.g., pharmacies); 

and FDA cannot completely eliminate nicotine in tobacco 

products, require prescriptions for tobacco products, 

or raise the minimum age for sale of tobacco products 

above 18. 

Other complementary comprehensive tobacco control strategies at the state, local, tribal, and territorial 

levels include: 

•	 Implementing comprehensive clean indoor air laws; 

•	 Prohibiting sales to those under 21 years of age; 

•	 Increasing prices of tobacco products; and 

•	 Developing high-impact countermarketing 


campaigns.
 

Effective action at the state and local levels is critical to fully protecting young people from the harms of 

e-cigarettes. 

242 The Call to Action 
The Call to Action 243 

E-Cigarette Use Among Youth and Young Adults

 

Strategy 3B. 

Reinforce other federal agencies as they implement 

programs and policies to address e-cigarettes. 

Of the other federal agencies that play a role in implementing strategies to address e-cigarettes (see Chapter 5, 

Table 5.2), some target specific populations (e.g.,  the 

U.S. Department of Defense and the U.S. Department 

of Veterans Affairs); others cover specific areas (e.g., the 

General Services Administration, National Park Service); 

and some focus on certain aspects of e-cigarettes (e.g., the 

Federal Trade Commission, the U.S. Department of 

Transportation, and the U.S. Environmental Protection 

Agency). Specific strategies to address e-cigarettes could 

include those that protect employees, customers, and visitors from exposure to secondhand aerosol, support and 

encourage tobacco cessation, and curb youth-targeted or 

false advertising. For example, the National Park Service 

(2015) implemented a policy to protect employees and 

visitors from exposure to secondhand aerosol from 

e-cigarettes. 

Goal 4. Programs and Policies to Prevent E-Cigarette Use Among 

Youth and Young Adults 

Subject to certain exceptions, the Tobacco Control 

Act does not limit the authority of state, local, tribal, 

and territorial governments to enact any tobacco-related 

policies related to the sale, distribution, or possession of 

tobacco products; exposure to these products; or access 

to them. This broad preservation of authority enables 

states and localities to adopt many comprehensive tobacco 

control strategies that have been proven to prevent and 

reduce tobacco use among youth and young adults. That 

means that state, local, tribal, and territorial governments 

could act first in developing regulations, policies, and programs that minimize any individual- and population-level 

harms of e-cigarettes. The strongest, most innovative 

tobacco control policies typically have originated at the 

local level before eventually being adopted at the state 

level. However, it is important that these strategies are 

developed with evaluators and epidemiologists that can 

collect robust data to inform the implementation and sustainment of such strategies. 

Strategy 4A. 

State, local, tribal, and territorial governments should 


implement population-level strategies to reduce 


e-cigarette use among youth and young adults, such 


as including e-cigarettes in smokefree indoor air 


policies, restricting youth access to e-cigarettes in retail 


settings, licensing retailers, and establishing specific 


package requirements.
 

Over 50 years of research offers a strong body of 

evidence on the effectiveness of certain tobacco prevention and control measures. Much of this evidence can also 

be applied to e-cigarettes. And from this evidence, state, 

local, tribal, and territorial entities can take a variety of 

actions to address e-cigarettes, such as: 

•	 Including e-cigarettes in smokefree indoor air policies; 

•	 Restricting youth access to e-cigarettes in retail 

settings; 

•	 Licensing retailers; and 

•	 Establishing specific package requirements. 

Including E-Cigarettes in Smokefree 

Indoor Air Policies 

Most smokefree indoor air policies were put in place 

before the great rise in e-cigarette use. Because of that, 

these policies may not cover e-cigarettes or exposure to 
A Report of the Surgeon General

 

the aerosol they produce. Aerosol from e-cigarettes is 

not harmless (CDC 2014). Smokefree indoor air policies 

should be updated to prohibit the use of both conventional cigarettes and e-cigarettes, thereby preserving standards for clean indoor air. Efforts to include e-cigarettes 

in smokefree laws should also uphold or strengthen, not 

weaken, existing protections against exposure to secondhand smoke. 

Including e-cigarettes in smokefree indoor air policies can: 

•	 Eliminate health risks from exposure to secondhand 

aerosol from e-cigarettes; 

•	 Discourage people from using both combustible and 

electronic tobacco products (dual use); 

•	 Simplify compliance with and enforcement of 

existing smokefree laws; 

•	 Help to reduce the use of e-cigarettes among youth 

and young adults; and 

•	 Maintain tobacco-free norms. 

Aerosol from e-cigarettes is not harmless. 

To date, several states and several hundred communities include e-cigarettes in comprehensive smokefree laws that prohibit smoking in all indoor areas of 

public places, including worksites, restaurants, bars, and 

gambling facilities (Americans for Nonsmokers’ Rights 

Foundation 2015; CDC n.d.). 

Restricting Youth Access to 

E-Cigarettes 

When laws prohibiting tobacco sales to youth are 

strong and actively enforced with the education of retailers, 

they successfully reduce tobacco use among youth (Task 

Force on Community Preventive Services 2001; Zaza et al. 

2005). To date, all 50 states and the District of Columbia 

restrict the sale of tobacco products to minors (CDC n.d.). 

Extending such laws to include e-cigarettes can further 

protect youth from exposure to nicotine, which nearly all 

states have done. Specific strategies can be implemented 

to deter the access of youth to e-cigarettes and their use 

in this population: 

•	 Restricting the sale of e-cigarettes to minors; 

•	 Placing restrictions on Internet sales of all tobacco 

products and e-cigarettes, including requirements 

for verifying age and providing identification at the 

time of purchase and upon delivery; 

•	 Requiring age verification at the point of purchase; 

•	 Displaying clear signage in retail locations about 

required age for sale; 

•	 Prohibiting the sale of e-cigarettes from vending 

machines; 

•	 Eliminating self-service displays of e-cigarettes; and 

•	 Enforcing laws on the retail sale of e-cigarettes to 

minors. 

Nearly all states prohibit the sale of e-cigarettes to 

youth under 18 years of age. Some states have a higher 

minimum age for purchase (e.g., 19 or 21 years of age) 

(CDC 2014). Some e-cigarette manufacturers have supported state legislation to prevent minors from purchasing e-cigarettes (Healy 2014). Their actions may, 

to some extent, be responsible for why these age-of-sale 

laws have been adopted more quickly than laws that prohibit e-cigarette use in public indoor spaces. However, 

industry-supported, youth-access bills have contained 

provisions that undermine prevention efforts for youth, 

including preemption of stricter local policies and 

weak requirements for enforcement (USDHHS 2012). 

Additionally, laws prohibiting sales to minors are likely 

244 The Call to Action 
The Call to Action 245 

E-Cigarette Use Among Youth and Young Adults

 

to have limited effectiveness as a prevention strategy if 

they are not aggressively enforced and are not coupled 

with proven interventions, such as comprehensive smokefree laws, pricing strategies, or public health campaigns 

(USDHHS 2012, 2014). Ensuring that e-cigarettes are regulated at the state and local levels can facilitate the application of additional tobacco control policies regarding 

e-cigarettes. 

Many actions can help to protect young 


people from the harms of e-cigarettes, such as 


including e-cigarettes in smokefree indoor air 


policies, restricting youth access to e-cigarettes 


in retail settings, licensing retailers, and 


setting specific package requirements.
 

Licensing Retailers 

Licensing is 

another strategy to control access to e-cigarettes 

among youth and young 

adults. A tobacco-related 

license can authorize 

a business to manufacture, distribute, or 

sell tobacco products 

(McLaughlin 2010). 

Licensing requirements help to prevent 

sales to minors, prevent evasion of tobacco 

excise taxes, ensure that 

licensees comply with 

tobacco-related laws, 

and promote safe manufacturing practices (ChangeLab Solutions 2012). Businesses 

that repeatedly violate these laws can have their right to 

engage in commercial activity suspended or their licenses 

permanently removed. The possibility of these outcomes provides a strong incentive to comply with license 

requirements. Licensing may also be used to restrict the 

sale of flavored products or to address consumer and 

worker safety issues involved with the mixing of liquids 

for e-cigarette products (e-liquids). 

Establishing Specific Packaging 

Requirements 

Federal, state, local, tribal, and territorial governments are actively considering the potential harms of 

e-liquids. Exposure to these liquids may lead to nicotine 

and other types of poisoning. Calls to poison control centers about e-cigarettes and e-liquids have been on the rise, 

and about half of these calls are for incidents involving 

young children (American Association of Poison Control 

Centers 2015). The most common adverse health effects 

of poisoning are vomiting, nausea, and eye irritation, but 

some deaths have occurred as well. Developing strategies 

to monitor and prevent future poisonings is critical. 

Calls to poison control centers about e-cigarettes 


are on the rise. A large portion of these calls 


are for incidents involving young children.
 

Enacting laws that require e-liquids to be labeled 

and sold in childproof packaging is one way to reduce 

the incidence of poisonings, particularly among children. To date, in addition to the federal Child Nicotine 

Poisoning Prevention Act of 2015 (2016) enacted in 

January 2016, more than a dozen states have enacted 

laws requiring childproof packaging for e-liquids 

(Tobacco Control Legal Consortium n.d.). Health care 

providers, the public health community, e-cigarette manufacturers and retailers, and the public should be aware 

that e-liquids pose a serious public health concern, particularly among young children. 

Strategy 4B. 

Coordinate, evaluate, and share best practices from state 

and local entities that have implemented programs and 

policies to address e-cigarette use among youth and 

young adults. 

Many governments at the national, state, local, 

tribal, and territorial levels are involved in the regulation 

of e-cigarettes. To have the biggest impact on reducing the 

use and exposure of e-cigarettes among youth and young 

adults, it is integral for these governments to share best 

practices and coordinate and evaluate efforts as part of a 

comprehensive tobacco prevention and control strategy. 

FDA has asserted regulatory authority over e-cigarettes, 

and other agencies and governments, as discussed previously and in Chapter 5, also have relevant authorities. 
A Report of the Surgeon General

 

Goal 5. Curb Advertising and Marketing that Encourages Youth 

and Young Adults to Use E-Cigarettes 

Unconstrained marketing of e-cigarettes drives consumer demand for these products. E-cigarette manufacturers are using tactics similar to those used to market 

conventional cigarettes to youth, including offering candyflavored products; employing youth-minded themes, such 

as rebellion, glamour, and sex; getting celebrity endorsements; and obtaining sports and music sponsorships 

(Chapter 4). Some groups have called for extending to 

e-cigarettes the same marketing restrictions that already 

apply to conventional cigarettes and other tobacco products 

(Association of State and Territorial Health Officials 2014; 

Partnership for Prevention 2014). But regulating commercial speech is typically met with significant barriers and 

complex legal issues (Laird-Metke 2010), and partial advertising bans and voluntary agreements generally have not 

been fully effective at reducing consumption because the 

tobacco industry adapts by shifting to other types of advertising that are not regulated (National Cancer Institute 

2008). Despite these obstacles, public health organizations and state and local governments must take action to 

control the marketing of e-cigarettes to youth and young 

adults, including (a) seeking legally feasible interventions 

that are proven to curb youth-oriented tobacco marketing, 

including removing advertising from television; and 

(b) continuing to help build an evidence base that informs 

future potential restrictions on e-cigarette marketing. 

Strategy 5A. 

Curb e-cigarette advertising and marketing that are 

likely to attract youth and young adults. 

In the absence or delayed implementation of government restrictions on the marketing of e-cigarettes, 

media outlets, the management staff of special event and 

sports venues, and retailers can voluntarily refuse to air or 

place youth- and young adult-oriented e-cigarette advertising; avoid sponsorships; and not offer free samples of 

these products at fairs, festivals, and other events. 

E-cigarettes are aggressively marketed 

using tactics similar to those proven to lead 

to cigarette smoking among youth. 

Finally, state and local public health agencies can 

stimulate enforcement of and compliance with existing 

rules that limit marketing. For example, they can monitor 

advertising and notify their state’s attorney general or the 

Federal Trade Commission about improper claims or marketing that is not clearly identified as advertising (Federal 

Register 1972; FTC 1984; Center for Public Health and 

Tobacco Policy 2013). 

Strategy 5B. 

Urge the e-cigarette companies to stop advertising and 

marketing that encourages and glamorizes e-cigarette 

use among youth and young adults. 

E-cigarette advertising has increased considerably 

over the years in multiple venues (Legacy for Health 2014; 

Ganz et al. 2015; see also Chapter 4), while the advertising 

for conventional cigarettes on television has been prohibited in the United States since 1971. But e-cigarettes 

are now marketed on television and other mainstream 

media channels, such as radio and magazines, which are 

main sources of information for youth and young adults. 

Emerging research suggests that exposure to television 

advertisements for e-cigarettes increases the likelihood 

that young people will use e-cigarettes in the future and will 

believe that e-cigarettes can be used in places where conventional cigarette smoking is not allowed (Farrelly et al. 

2015). This is not surprising because e-cigarette marketing 

has previously included unproven claims about safety and 

smoking cessation, as well as statements that e-cigarettes 

are exempt from clean air policies that restrict smoking 

(USDHHS 2014). Visual depictions of e-cigarette use in 

advertisements may also serve as smoking cues to both current and former smokers, increasing their urges to smoke 

and undermining their efforts to quit (Maloney and 

Cappella 2015). Advertising for e-cigarettes that encourages and glamorizes the use of e-cigarettes among youth 

and young adults can harm public health by undermining: 

•	 Clean indoor air standards; 

•	 Enforcement of smokefree policies; 

•	 Tobacco-free social norms; and 

•	 Marketing restrictions that prohibit the advertising 

of cigarettes and smokeless tobacco on television 

and radio. 

246 The Call to Action 
The Call to Action 247 

E-Cigarette Use Among Youth and Young Adults

 

Discontinuing advertising and marketing by and features adults (not young adults), does not depict 

e-cigarette companies that intentionally or unintention- active use of e-cigarettes, does not use themes proven to 

ally encourages or glamorizes e-cigarette use among youth appeal to youth and young adults, avoids media channels 

and young adults is essential. Responsible advertising by with high youth access, and does not undermine cessation 

the e-cigarette companies is needed, including adver- efforts involving traditional tobacco products. 

tising that focuses directly on established adult smokers 

Goal 6. Expand Surveillance, Research, and Evaluation Related to 

E-Cigarettes 

Tobacco control research focused on e-cigarettes has 

grown considerably in the past few years. Certainly, more 

detailed information is needed to better understand the use 

of e-cigarettes and its relationship to the use of other types of 

tobacco products. A comprehensive and evolving approach 

to research, surveillance, and evaluation is needed. 

Strategy 6A. 

Improve the quality, timeliness, and scope of e-cigarette 

surveillance, research, and evaluation. 

Present surveillance systems show that e-cigarette use is increasing rapidly and that most regular 

e-cigarette users also use conventional tobacco products 

(see Chapter 2). Thus, further study can inform strategies 

that minimize harms and maximize the potential health 

benefits of these products at the individual and population 

levels. Data should be timely and focus on the patterns of 

e-cigarette initiation and use among the general public— 

including youth, young adults, and former smokers. 

Strategic and comprehensive research and evaluation 

must further characterize the health risks of e-cigarette 

use. A comprehensive package of surveillance, research, 

and evaluation should: 

•	 Track patterns of e-cigarette use through 

cross-sectional surveys and through panels that 

follow the same people, including youth and young 

adults, over time; 

•	 Monitor trends in the e-cigarette retail market by 

type of product; 

•	 Examine the channels and messaging in the 

e-cigarette marketplace to inform proactive countermarketing strategies; 

•	 Assess the short- and medium-term health effects of 

e-cigarette use by youth and young adults and track 

long-term consequences; 

•	 Examine the risk factors and other risk behaviors 

that may be associated with using e-cigarettes; and 

•	 Create a model to develop and track the public 

health impact of e-cigarettes. 

The rapidly changing nature of the e-cigarette 

landscape calls for a comprehensive and evolving 

approach to research, surveillance, and evaluation. 

For such a package, researchers, the public health 

community, and other key stakeholders must work 

together to address and overcome many challenges: 

•	 The rapidly changing e-cigarette landscape and 

terminology; 

•	 Limited resources for collecting timely information; 
A Report of the Surgeon General

 

•	 The cross-sectional nature of existing surveys and 

their limited space for questions; 

•	 The different populations that need to be studied; 

•	 A lack of validated questions; and 

•	 Different measures and definitions across surveys. 

Strategy 6B. 

Address surveillance, research, and evaluation gaps 

related to e-cigarettes. 

Patterns of e-cigarette use are rapidly changing 

among youth and young adults, as well as among other 

groups in the population. Longitudinal data are not yet 

available to address some of the most critical issues related 

to e-cigarettes. The e-cigarette marketplace is changing so 

fast that surveillance data and research on the harms of 

e-cigarette use and the impact of these changes on traditional tobacco products are lagging behind. As they look 

to fill in gaps in scientific research, it is important for 

researchers to continue to seek more current and complete 

answers to many critical questions, such as: 

•	 What are the risks of progressing to traditional 

tobacco use among youth and young adults who 

have used e-cigarettes? 

•	 What are the health risks posed by e-cigarettes? 

•	 Are e-cigarettes safer and more effective than current 

products at helping smokers with smoking cessation? 

•	 What are the health consequences for youth and 

young adults of initiation of e-cigarettes and of dual 

use (conventional cigarettes plus e-cigarettes) compared with the health benefits of completely quitting 

smoking (or not starting at all)? 

•	 What are the health risks to former smokers who are 

exposed to nicotine from e-cigarette use? Will these 

persons be more likely to resume smoking? 

Additionally, surveillance of e-cigarette marketing 

and the advertising messages and strategies used is critical, as is the carrying out of more studies assessing the 

link between exposure to e-cigarette marketing and use 

of these products. With traditional tobacco products, 

state and local public health agencies have monitored 

retail settings, assessed outdoor advertising, and identified sponsorships of events by tobacco companies. These 

efforts should be adapted to e-cigarettes. 

The health care setting has always been an important venue for exchanging information about evidencebased approaches to smoking cessation and for protecting 

susceptible groups from exposure to secondhand smoke. 

More research is needed on the role of e-cigarettes in facilitating or hindering cessation of conventional cigarettes 

and the potential hazards of exposure to secondhand 

aerosol from e-cigarettes so that e-cigarettes can also be 

a part of this exchange. But even without this research, 

there is sufficient evidence about the dangers that nicotine-containing cigarettes pose for youth and young adults 

that health care providers and professionals can act now 

to prevent the use of such products among their young 

patients. 

Finally, existing research and surveillance efforts 

should include more detailed measures than just general 

use of e-cigarettes, including: 

•	 Frequency and patterns of e-cigarette use; 

•	 Type of e-cigarette and/or other tobacco product 

used; 

•	 The natural history of e-cigarette use, including 

initiation, co-use with other tobacco products, and 

flavoring; 

•	 Ingredients, such as nicotine and flavors; 

•	 Brand; 

•	 Reasons for using and quitting e-cigarettes; 

•	 Exposure to e-cigarette advertising; 

•	 Methods of obtaining e-cigarettes; and 

•	 Exposure to secondhand aerosol from e-cigarettes. 

Additionally, evaluation is critical to further assess 

the impact of policies on e-cigarette initiation, use, and 

other patterns of tobacco use. 

248 The Call to Action 
The Call to Action 249 

E-Cigarette Use Among Youth and Young Adults

 

Conclusions
 

E-cigarette use, particularly among youth and 

young adults, has become a public health concern that 

warrants immediate and coordinated action. The increase 

in e-cigarette use among youth and young adults in the 

past few years is cause for great concern. Many questions 

remain about e-cigarettes and their long-term impact, 

even as evidence on patterns of use and risks to health 

continue to emerge. But we know enough about these 

health risks to take action now to protect the health of our 

nation’s young people. We cannot wait. Strategies to prevent and control the harms of e-cigarettes among youth 

and young adults need to be precautionary. Therefore, 

we must take a precautionary approach by implementing 

these strategies and protecting the health of our nation’s 

young people. 

We know what works to effectively prevent tobacco use 

among young people. Now we must apply these strategies to 

e-cigarettes—and continue to apply them to other tobacco 

products. To achieve success, we must work together, 

aligning and coordinating efforts across a wide range of 

stakeholders. We must protect our nation’s young people 

from a lifetime of nicotine addiction and associated problems by immediately addressing e-cigarettes as an urgent 

public health problem. Now is the time to take action. 
A Report of the Surgeon General

 

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E-Cigarette Use Among Youth and Young Adults

List of Abbreviations 253

List of Abbreviations

α4β2 alpha 4 beta 2-nicotinic acetylcholine 

receptor subtype

α7 alpha 7 nicotinic acetylcholine 

receptor subtype

α6 alpha 6 nicotinic acetylcholine 

receptor subtype

μg microgram

5AP tLTP protocol 5 action potential timing-dependent 

long-term potentiation protocol

5-CSRTT 5-choice serial reaction time task

5-HIAA 5-hydroxyindole acetic acid, the

primary metabolite of serotonin

5-HT1AR serotonin (5-hydroxytryptamine) 

receptor 1A

5-HT2A/C serotonin (5-hydroxytryptamine) 

receptor 2 A/C

86Rb+ efflux assay measure of nicotinic acetylcholine 

receptor function via rubidium-86 

ion efflux [125-I]a-Btx binding 

measurement of binding at a7 

nAChRs using the antagonist alphabungarotoxin

[125I]α-CtxMII binding measurement of binding at a6 

nAChRs using the antagonist alphaconotoxin MII

[125I]A-85380 binding measurement of binding at a4b2 

nAChRs using the agonist A-85380

A1 primary auditory cortex

AAP American Academy of Pediatrics

ACR American Association of Cancer 

Research

AARC American Association for Respiratory 

Care

ACP American College of Physicians

ACS American Cancer Society

ADHD attention deficit hyperactivity disorder

ADI acceptable daily intake

AEMSA American E-Liquid Manufacturing 

Standards Association 

AHA American Heart Association

AMPA a-amino-3-hydroxy-5-methyl-4-

isoxazolepropionic acid

AMPAR AMPA receptor

ANHCS Annenberg National Health

Communication Survey

ANR Americans for Nonsmokers’ Rights

AOR adjusted odds ratio

AP acetyl propionyl

APA American Psychiatric Association

APV advanced personal vaporizers

arc activity-regulated cytoskeletonassociated protein

ATF U.S. Department of Justice, Bureau 

of Alcohol, Tobacco, Firearms and 

Explosives

A-V atrial-ventricular

AVA American Vaping Association 

BART Balloon Analogue Risk Task

BCAP/CAP Committees of Advertising Practice 

(UK)

BLA basolateral amygdala

BNST bed nucleus of the stria terminalis

BOP Bureau of Prisons

BP blood pressure

CAD cinnamaldehyde

CAM cell-adhesion molecule

cAMP-PKA cyclic AMP-protein kinase A, signaling 

cascade

CARDIA Coronary Artery Risk Development in 

Young Adults

CASAA Consumer Advocates for Smoke-free 

Alternatives Association 

CCTA Contraband Cigarette Trafficking Act

CDC Centers for Disease Control and 

Prevention

CDER Center for Drug Evaluation and 

Research

C-DISC-IV Diagnostic Interview for Children−

Version 4

cFos protooncogene and immediate early 

gene used as a marker of neuronal 

activity

CFR Code of Federal Regulations

CI confidence interval

CMS Centers for Medicare & Medicaid 

Services

CO2 carbon dioxide

COMDTINST Commandant Instruction

CPP conditioned place preference

CPu caudate putamen

CREB cAMP response element-binding 

protein

CRF corticotropin-releasing factor
A Report of the Surgeon General

254 List of Abbreviations

CRP C-reactive protein

CSI Child Symptom Inventory

CTA conditioned taste aversion

CTP Center for Tobacco Products

D1R dopamine D1 receptor

DA diacetyl

DA dopamine

DAT1 dopamine regulation genotype

DEHP diethylhexyl phthalate

DEP diethyl phthalate

DHS U.S. Department of Homeland 

Security

DISC-YC Diagnostic Interview Schedule for 

Children-Parent Scale-Young Child

DoD U.S. Department of Defense

DOPAC 3,4-dihydroxyphenylacetic acid, 

metabolite of dopamine

DOT U.S. Department of Transportation

DSM-III Diagnostic and Statistical Manual of 

Mental Disorders, 3rd Edition

DSM-IV Diagnostic and Statistical Manual of 

Mental Disorders, 4th Edition

EC electronic cigarette

ECIG Inc. Electronic Cigarette Industry Group, 

Inc.

ECIG Ltd. Electronic Cigarettes International 

Group, Ltd.

ED U.S. Department of Education

ENDS electronic nicotine delivery systems

ENNDS electronic non-nicotine delivery 

systems

EOP Executive Office of the President

EPA U.S. Environmental Protection Agency

ERS European Respiratory Society

EPSC excitatory postsynaptic current

EPSDT Early and Periodic Screening, 

Diagnosis and Treatment

EPSP excitatory postsynaptic potential

ESD electronic smoking device

EU European Union

F1 first filial generation (and similar)

FAA Federal Aviation Administration

FCC Federal Communications Commission

FCLAA Federal Cigarette Labeling and 

Advertising Act

FCTC Framework Convention on Tobacco 

Control

FD&C Act Federal Food, Drug, and Cosmetic Act 

FDA U.S. Food and Drug Administration

FEF forced expiratory flow

FeNO exhaled nitric oxide 

FEV1 forced expiratory volume in 1 second 

fMRI functional magnetic resonance 

imaging

FR fixed ratio

FST forced swim test

FTC U.S. Federal Trade Commission

FVC forced vital capacity

FY fiscal year

G20 gestational day 20 (and similar)

g gram

GABA gamma-aminobutyric acid

GABAergic any cell, especially any neuron, that 

releases GABA

GPCR G-protein-coupled-receptor

GSA General Services Administration

GTP guanosine triphosphate

GTPase large family of hydrolase enzymes that 

can bind and hydrolyze GTP

HONC Hooked on Nicotine Checklist

HPLC-ECD high-performance liquid 

chromatography electrochemical 

detection

HUD U.S. Department of Housing and 

Urban Development

HVA homovanillic acid

IARC International Agency for Research on 

Cancer

ICD-10 International Statistical Classification 

of Diseases and Related Health 

Problems, 10th revision

ICE Bureau of Immigration and Customs 

Enforcement

ICR mice Institute for Cancer Research strain of 

mice

ICSS intracranial self-stimulation

IOM Institute of Medicine

i.p. intraperitoneal

IQ intelligence quotient

IRC Internal Revenue Code

i.v. intravenous

kg kilogram

KO knockout

L liter

L&M Liggett & Myers

LC-MS/MS liquid chromatography-tandem mass 

spectrometry
E-Cigarette Use Among Youth and Young Adults

List of Abbreviations 255

LH lateral hypothalamus

M&As mergers, formations of partnerships, 

and acquisitions

m2 square meter

m3 cubic meter

MAOA monoamine oxidase A

MAPK mitogen-activated protein kinase

MCH melanin-concentrating hormone

mFTQ modified Fagerström Tolerance 

Questionnaire

mg milligram

mGluR2 metabotropic glutamate receptor 2

mL milliliter

mPFC medial prefrontal cortex

mRNA messenger ribonucleic acid

MSN medium spiny neuron

MTF Monitoring the Future

NAB N-nitrosoanabasine

N2 nitrogen

NAc nucleus accumbens

NACDA National Advisory Council on Drug 

Abuse

nAChR nicotinic acetylcholine receptor

NAc-shell nucleus accumbens shell

NAT N-nitrosoanatabine

NATS National Adult Tobacco Survey

NCI National Cancer Institute

NDAA National Defense Authorization Act

NDSS Nicotine Dependence Syndrome Scale

NE norepinephrine

ng nanogram

NGFI-B nerve growth factor-induced gene-B

NHANES III Third National Health and Nutrition 

Examination Survey

NHSDA National Household Survey on Drug 

Abuse

NIH National Institutes of Health

NMDAR N-methyl-d-aspartate receptor

NIDA National Institute on Drug Abuse

NIOSH National Institute for Occupational 

Safety

NJYTS New Jersey Youth Tobacco Survey

NLSY National Longitudinal Survey of Youth

nm nanometer

NNN N-nitrosonornicotine

NNK 4-(methylnitrosamino)-1-(3-pyridyl)-

1-butanone

NRT nicotine replacement therapy

NYS New York State Follow-Up

NYTS National Youth Tobacco Survey

O2 oxygen

ODD oppositional defiant disorder

OMB Office of Management and Budget

OPM Office of Personnel Management

OR odds ratio

OSH Office on Smoking and Health

OSHA U.S. Department of Labor, 

Occupational Safety and Health 

Administration

P3 (and similar) postnatal day number

PACT Prevent All Cigarette Trafficking Act

PAH polycyclic aromatic hydrocarbon

PATH Population Assessment of Tobacco and 

Health

PDAY Pathological Determinants of 

Atherosclerosis in Youth

PFC prefrontal cortex

PHS Public Health Service

PIH Public and Indian Housing

PVN paraventricular nucleus of the 

thalamus

PG propylene glycol

PM particulate matter

PM2.5 fine particulate matter

PNE prenatal nicotine exposure

p.o. per os (by mouth)

Postn periostin, osteoblast-specific factor

PR progressive ratio

PREP potential reduced-exposure product

PVN paraventricular nucleus of the 

thalamus

qRT-PCR quantitative real-time polymerase 

chain reaction

RCRA Resource Conservation and Recovery 

Act

SAC saccharin

SAMHSA Substance Abuse and Mental Health 

Services Administration

s.c. subcutaneous

SCAN Screening test for Auditory Processing 

Disorders

SD standard deviation

SE standard error

sec seconds

SEC Securities and Exchange Commission

SES socioeconomic status
A Report of the Surgeon General

256 List of Abbreviations

SFATA Smoke Free Alternatives Trade 

Association

SIDS sudden infant death syndrome

SMC serial multiple choice

SNAP Special Supplemental Nutrition 

Program

SNP single-nucleotide polymorphism

SRITA Stanford Research into the Impact of 

Tobacco Advertising

STOP Smuggled Tobacco Prevention Act

TCR trigeminocardiac reflex

TEOAEs transient evoked otoacoustic 

emissions

TH tyrosine hydroxylase

THC tetrahydrocannabinol 

TSNA tobacco-specific nitrosamine

TTB U.S. Department of Treasury, Alcohol 

and Tobacco Tax and Trade Bureau

TVECA Tobacco Vapor Electronic Cigarette 

Association

UK United Kingdom

U.S.C. U.S. Code

USDA U.S. Department of Agriculture

USDHEW U.S. Department of Health, Education, 

and Welfare

USDHHS U.S. Department of Health and Human 

Services

USP U.S. Pharmacopeia

USTR U.S. Trade Representative

V voltage

VA U.S. Department of Veterans Affairs

VG vegetable glycerin

VOC volatile organic compound

VTA ventral tegmental area

WHO World Health Organization

WIC Women, Infants, and Children

Wnt Wingless-Type MMTV Integration 

Site Family, member 1, intracellular 

signaling factors

WT wild type

w/v weight/volume

YRBSS Youth Risk Behavior Surveillance 

System
E-Cigarette Use Among Youth and Young Adults

List of Tables and Figures 257

List of Tables and Figures1

1The Executive Summary and appendixes are not a part of the main report. Instead, they are available online at 

http:/www.surgeongeneral.gov/library/reports/.

Executive Summary

Figure 1 Trends in ever e-cigarette use among U.S. middle 

and high school students; National Youth 

Tobacco Survey (NYTS) 2011–2015 1

Figure 2 Trends in past-30-day e-cigarette use among 

U.S. middle and high school students; National 

Youth Tobacco Survey (NYTS) 2011–2015 2

Figure 3 Percentage of young adults who currently 

use e-cigarettes and conventional cigarettes; 

National Adult Tobacco Survey (NATS) 

2013–2014 2

Figure 4 Diversity of e-cigarette products 3

Figure 5 Percentage of middle school students, high 

school students, young adults (18–24 years of 

age), and adults (≥25 years of age) who currently 

use e-cigarettes 6

Figure 6 Percentage of middle school students, high 

school students, young adults (18–24 years of 

age), and adults (≥25 years of age) who have ever 

used e-cigarettes 7

Figure 7 Percentage of students in grades 8, 10, and 12 

who used e-cigarettes and cigarettes in the past 

30 days; Monitoring the Future (MTF) 2015 8

Chapter 1.

Introduction, Conclusions, and Historical Background 

Relative to E-Cigarettes

Table 1.1 Multinational tobacco companies with e-cigarette 

brands 15

Figure 1.1 Diversity of e-cigarette products 3

Figure 1.2 Parts of an e-cigarette device 12

Figure 1.3 Examples of e-liquid flavors 13

Figure 1.4 E-liquids being poured into an e-cigarette

device 13

Chapter 2.

Patterns of E-Cigarette Use Among U.S. Youth and 

Young Adults

Table 2.1a Percentage of middle school students who have 

used e-cigarettes, by gender and race/ethnicity; 

National Youth Tobacco Survey (NYTS) 

2015 29

Table 2.1b Percentage of high school students who have 

used e-cigarettes, by gender and race/ethnicity; 

National Youth Tobacco Survey (NYTS) 

2015 30

Table 2.2a Percentage of middle school students who used 

e-cigarettes in the past 30 days, by gender and

race/ethnicity; National Youth Tobacco Survey

(NYTS) 2011–2015 31

Table 2.2b Percentage of high school students who used 

e-cigarettes in the past 30 days, by gender and

race/ethnicity; National Youth Tobacco Survey

(NYTS) 2011–2015 32

Table 2.3a Percentage of middle school students who 

have ever used e-cigarettes, by gender and 

race/ethnicity; National Youth Tobacco Survey 

(NYTS) 2011–2015 34

Table 2.3b Percentage of high school students who have 

ever used e-cigarettes, by gender and race/

ethnicity; National Youth Tobacco Survey 

(NYTS) 2011–2015 35

Table 2.4a Percentage of young adults (18–24 years of age) 

who have used e-cigarettes, by gender, race/

ethnicity, and education; National Adult Tobacco 

Survey (NATS) 2013–2014 38

Table 2.4b Percentage of adults (≥25 years of age) who have 

used e-cigarettes, by gender, race/ethnicity, 

and education; National Adult Tobacco Survey 

(NATS) 2013–2014 39

Table 2.5 Percentage of students in grades 8, 10, and 12 who 

used e-cigarettes, cigarettes, or both products 

in the past 30 days, by sociodemographic 

characteristics; Monitoring the Future (MTF) 

2015 41

Table 2.6a Lifetime and past-30-day e-cigarette use among 

U.S. middle school students, by other tobacco 

product use; National Youth Tobacco Survey 

(NYTS) 2015 44

Table 2.6b Lifetime and past-30-day e-cigarette use among 

U.S. high school students, by other tobacco 

product use; National Youth Tobacco Survey 

(NYTS) 2015 45

Table 2.7a Percentage of middle school students who have 

ever used tobacco, by type of product; National 

Youth Tobacco Survey (NYTS) 2011–2015 47

Table 2.7b Percentage of high school students who have 

ever used tobacco, by type of product; National 

Youth Tobacco Survey (NYTS) 2011–2015 49
A Report of the Surgeon General

258 List of Tables and Figures

Table 2.8a Percentage of young adults (18–24 years of 

age) who currently use e-cigarettes, cigarettes, 

or both products, by gender, race/ethnicity, 

and education: National Adult Tobacco Survey 

(NATS) 2013–2014 54

Table 2.8b Percentage of adults (≥25 years of age) who 

currently use e-cigarettes, cigarettes, or 

both products, by gender, race/ethnicity, and 

education: National Adult Tobacco Survey 

(NATS) 2013–2014 55

Table 2.9 Percentage of youth (middle and high school 

students), young adults (18–24 years of age), 

and adults (≥25 years of age) using tobacco 

products who reported using flavored e-cigarette 

products, by gender and race/ethnicity; National 

Youth Tobacco Survey (NYTS) and National 

Adult Tobacco Survey (NATS) 60

Table 2.10 Summary of studies on e-cigarette flavors among 

youth and young adults 61

Table 2.11 Summary of studies on perceptions of e-cigarette 

harm among youth and young adults 65

Table 2.12a Percentage of middle school and high school 

students who reported that using e-cigarettes 

on some days but not every day caused no harm, 

little/some harm, or a lot of harm, by e-cigarette 

smoking status; National Youth Tobacco Survey 

(NYTS) 2015 73

Table 2.12b Percentage of middle school students who 

reported that using e-cigarettes on some days 

but not every day caused no harm, little/some 

harm, or a lot of harm, by e-cigarette smoking 

status; National Youth Tobacco Survey (NYTS) 

2015 73

Table 2.12c Percentage of high school students who 

reported that using e-cigarettes on some days 

but not every day caused no harm, little/some 

harm, or a lot of harm, by e-cigarette smoking 

status; National Youth Tobacco Survey (NYTS) 

2015 74

Table 2.12d Percentage of young adults (18–24 years of age) 

who reported that e-cigarettes were not at all 

harmful, moderately harmful, or very harmful, 

by e-cigarette smoking status; National Adult 

Tobacco Study (NATS) 2013–2014 74

Table 2.13 Summary of studies on reasons for use and 

discontinuation of e-cigarettes among youth 

and young adults 76

Figure 2.1 Trends in ever e-cigarette use among U.S. middle 

and high school students; National Youth 

Tobacco Survey (NYTS) 2011–2015 33

Figure 2.2 Trends in past-30-day e-cigarette use among 

U.S. middle and high school students; National 

Youth Tobacco Survey (NYTS) 2011–2015 36

Figure 2.3 Trends in ever e-cigarette use among U.S. adults 

by age group; Styles 2010–2014 40

Figure 2.4 Percentage of students in grades 8, 10, and 

12 who used e-cigarettes and cigarettes in the 

past 30 days; Monitoring the Future (MTF) 

2015 40

Figure 2.5 Past-30-day use of various tobacco products 

among U.S. middle and high school students; 

National Youth Tobacco Survey (NYTS) 

2015 46

Figure 2.6 Percentage of U.S. middle school students who 

have ever used tobacco, by type of product; 

National Youth Tobacco Survey (NYTS) 

2011–2015 51

Figure 2.7 Percentage of U.S. high school students who have 

ever used tobacco, by type of product; National 

Youth Tobacco Survey (NYTS) 2011–2015 52

Figure 2.8 Percentage of young adults who currently 

use e-cigarettes and conventional cigarettes; 

National Adult Tobacco Survey (NATS) 

2013–2014 53

Appendix 2.1.

Sources of Data

Table A2.1-1 Sources of national data on e-cigarette use 

among youth and young adults A2.1-4

Appendix 2.2.

Key Measures of Use

Table A2.2-1 E-cigarette items from sources of national data 

on e-cigarette use among youth and young 

adults A2.2-5

Table A2.2-2 E-cigarette items from PATH on e-cigarette use 

among youth and young adults A2.2-10

Appendix 2.3.

Other Supporting Literature

Table A2.3-1 Summary of studies on patterns of e-cigarette 

use among youth A.2.3-6

Table A2.3-2 Summary of studies on susceptibility and 

intentions to use e-cigarettes among youth and 

young adults 2.3-20

Table A2.3-3 Summary of studies on patterns of e-cigarette 

use among young adults 2.3-23

Chapter 3.

Health Effects of E-Cigarette Use Among U.S. Youth and 

Young Adults

Table 3.1 Relevant conclusions from previous Surgeon 

General’s reports on smoking and health 98
E-Cigarette Use Among Youth and Young Adults

List of Tables and Figures 259

Figure 3.1 Plasma nicotine concentration from different 

human laboratory studies and four different 

products with blood sampled before and 

immediately after a 10-puff bout with the 

products 103

Figure 3.2 Data showing exponential increase in the 

number of cases of human exposure to 

e-cigarette products and liquid nicotine between 

2011 and 2016 121

Figure 3.3 Changes in aerosol particle PM2.5 concentrations 

during experiment of e-cigarette use and 

tobacco cigarette smoking in an exposure 

chamber 123

Appendix 3.1.

Evidence Tables

Table A3.1-1 Studies on aerosolized nicotine and dependence, 

by dependency criteria A3.1-2

Table A3.1-2 Human studies on the effects of nicotine 

exposure on adolescent users A3.1-8

Table A3.1-3 Preclinical/animal studies on adolescent 

nicotine exposure A3.1-18

Table A3.1-4 Human studies on the effects of nicotine 

exposure on fetal brain development A3.1-33

Table A3.1-5 Preclinical/animal studies on fetal nicotine 

exposure A3.1-63

Chapter 4.

Activities of the E-Cigarette Companies

Table 4.1 Estimated e-cigarette market size in 2014 

($ billion) 150

Table 4.2 Estimated e-cigarette market size in 2015 

($ billion) 150

Table 4.3 Mergers, acquisitions, partnerships, and other 

agreements in the e-cigarette industry 165

Table 4.4 Comparison of website access restrictions, 

online sales, nicotine levels, and flavors 

among e-cigarette brands with no cigarette 

manufacturer affiliation, brands acquired by 

cigarette manufacturers, and brands developed 

by cigarette manufacturers 166

Figure 4.1 E-cigarette sales in tracked channels by brand, 

2010–2014 153

Figure 4.2 E-cigarette sales in tracked channels by product 

type, 2010–2014 154

Figure 4.3 Sales volume and price of disposable e-cigarettes, 

U.S. market, 2010–2014 155

Figure 4.4 Sales volume and price of rechargeable 

e-cigarettes, U.S. market, 2010–2014 156

Figure 4.5 Quarterly promotional spending for e-cigarettes, 

2010–2014 158

Figure 4.6 E-cigarette marketing claims 160

Appendix 4.1.

Major E-Cigarette Manufacturers

Table A4.1-1 Major e-cigarette manufacturers A4.1-2

Appendix 4.2.

E-Cigarette Trade Organizations and Advocacy Groups

Table A4.2-1 E-cigarette trade organizations and advocacy 

groups A4.2-2

Appendix 4.3.

The Rapidly Changing E-Cigarette Marketplace

Figure A4.3-1 Market share of e-cigarette products A4.3-3

Appendix 4.4.

Data Points for Figure 4.1

Table A4.4-1 Data points for Figure 4.1 (e-cigarette sales in 

tracked channels by brand, 2010–2014) A4.4-2

Appendix 4.5.

Evolution of Market Share in the E-Cigarette Market

Figure A4.5-1 E-cigarette market share in tracked channels by 

brand, 2010–2014 A4.5-3

Chapter 5.

E-Cigarette Policy and Practice Implications

Table 5.1 Comparative risk assessment: Potential harms 

and benefits of e-cigarettes 186

Table 5.2 Principle federal policies and regulations of 

tobacco that emphasize e-cigarettes 189

Table 5.3 Medical organizations 207

Figure 5.1 Potential patterns of use of combustible 

products (CPs) and e-cigarettes (e-cigs) 187

E-Cigarette Use Among Youth and Young Adults

Index 261

Index1

1Note: “t” following a number refers to a table; “f” following a number refers to a figure; “n” following a number refers to a note; and “A” 

preceding a number refers to an appendix.

1964 report. See Smoking and Health: Report of the Advisory 

Committee to the Surgeon General of the Public Health Service

(1964 report)

1988 report. See The Health Consequences of Smoking–Nicotine 

Addiction (1988 report)

1994 report. See Preventing Tobacco Use Among Young People

(1994 report)

2010 report. See How Tobacco Smoke Causes Disease–The 

Biologic and Behavioral Basis for Smoking-Attributable 

Disease (2010 report)

2012 report. See Preventing Tobacco Use Among Youth and 

Young Adults (2012 report)

2014 report. See The Health Consequences of Smoking—50 Years 

of Progress (2014 report)

A

AACR (American Association for Cancer Research), 206, 

208–209t

AAP (American Academy of Pediatrics), 206, 207t

AARC (American Association for Respiratory Care), 209t

Accord cigalikes, 9

Acetaldehyde, aerosolized adulterant, 117, 118

Acetone, aerosolized toxicant, 118

Acetyl propionyl, aerosolized flavorant, 116

Acrolein

aerosolized adulterant, 117, 118

e-cigarette component, 99

Addiction

aerosolized nicotine, 102–104, 103f

fetal effects of, A3.1-40 to A3.1-48t

long-term potential, 11, 239

smoking behavior changes, with low-nicotine cigarettes, 9

Surgeon General’s report (1988), 9, 97, 98t

withdrawal symptoms (physical abstinence syndrome), 102, 

A3.1-3 to A3.1-6t

ADHD. See Attention deficit hyperactivity disorder (ADHD)

Adolescents. See also Young adults; Youth

ages of, 4

brain development, 99

nicotine and brain development, 5

nicotine, increased sensitivity to, 105

pregnancy, 109

Adulterants, aerosolized, 100, 116–117

Adults (age ≥25). See also National Adult Tobacco Survey 

(NATS); Styles Survey

current prevalence of e-cigarette use, 37, 39t

flavors in e-cigarettes, 59, 60t

poly-tobacco use, 53, 55t

survey data sources, A2.1-2 to A2.1-3, A2.2-2

trends in prevalence of e-cigarette use, 37, 40f

Ad valorem excise tax, on tobacco products, 204

Advance cigarettes, 9

Advanced personal vaporizers, 150

Advertising. See also Marketing

behavior, effect on, 170–171

Broadcast Ban, 189t

burden of proof regarding safety, 238

cigarettes, 8–9

e-cigarette companies, 14–15

exposure to, youth and young adults, 169

protections for youth, 208t

receptivity to, youth and young adults, 169–170

restrictions, 238

Surgeon General’s report (2012), 4

targeting youth and young adults, 246–247

Advertorials, 205

Advocacy groups, e-cigarette industry, 15, A4.2-2 to A42-3t

USP-grade nicotine, 114

Aerosol inhalation

adulterants, 100, 116–117

aerosolized solvents, 115

cannabis and illicit drugs, 58

e-cigarette devices, 11

flavorants, 115–116

nicotine-related compounds, 114

non-nicotine constituents, 114–118

Aerosolized nicotine

cardiovascular function, 101

clean air policies, 188

dependence, 102–104, 103f, A3.1-2 to A3.1-7t

dose and effects of, 100–101, 103f

maternal exposure, and prenatal and postnatal health 

outcomes, 108–113

secondhand exposure, 120–123, 123f, 183, 209t, 240

thirdhand exposure, 209t

toxicants in, 208t, 219t, 229

youth, effects on, 104–107

Affordable Care Act (2010), 193t

African Americans. See Race/ethnicity

flavored little cigars and cigarillos, 11

retail sales of e-cigarettes, 150

Age-of-sale laws, 208t, 238, 241, 242, 244–245

Age, of starting tobacco use, 239, 241

Alameda County, California, public health department, 224

Alcohol and Tobacco Tax and Trade Bureau (TTB), 200t

Alcohol use

e-cigarette use, with, 57–58

maternal smoking, 111
A Report of the Surgeon General

262 Index

Allergic reactions, e-cigarette aerosol exposure, 123

Altered corpus callosum, fetal effects of nicotine exposure, 

A3.1-34t

Altria Group, Inc./Nu Mark. See also MarkTen e-cigarettes

acquisition, 165t

company profile, A4.1-2t

multinational tobacco company, 15t

Aluminum, aerosolized, 119

American Academy of Pediatrics (AAP), 206, 207t

American Association for Cancer Research (AACR), 206, 208–209t

American Association for Respiratory Care (AARC), 209t

American Association of Poison Control Centers, 14

American Cancer Society (ACS), 215t

American College of Physicians, 210t

American Heart Association, 216–217t

American Legacy Foundation (Truth Initiative), 158, 159, 163

American Lung Association, 218t, 224, 225

Americans for Nonsmokers’ Rights (ANR), 219t

American Society of Clinical Oncology, 206, 208–209t

American Thoracic Society, 211–212t

American Tobacco Company, 8

American Vaping Association (AVA), A4.2-2, A4.3-2

Amino-tadalafil, aerosolized adulterant, 117

Annenberg National Health Communication Survey, 171

ANR (Americans for Nonsmokers’ Rights), 219t

Antiandrogenic activity, DEP and DEHP, 117

Anxiety disorders

adolescent smoking, 107

Netherlands Study of Depression and Anxiety Disorders, 

A3.1-14t

Apnea, SIDS and maternal smoking, 109

Appetitive behaviors, fetal effects

appetitive behaviors, defined, 110

nicotine dependence, 110–111

other substances use, 111–112, A3.1-48 to A3.1-50t

overweight and obesity, 111, A3.1-51 to A3.1-53t

smoking uptake and nicotine dependence, A3.1-40 to 1-48t

Ariva smokeless tobacco product, 9

Arousal deficits, SIDS and maternal smoking, 109

Asthma

acrolein, 117

PG inhalation, 115

ATF (Bureau of Alcohol, Tobacco, Firearms and Explosives), 

198t

Atherogenesis, 101

Atherosclerosis, 118

Attention and cognition disorders, 106–107, A3.1-56 to 1-62t

Attention deficit hyperactivity disorder (ADHD)

comorbid substance abuse, 106

nicotine dependence, A3.1-13t

nicotine exposure, A3.1-11t

prenatal nicotine exposure, 112, 113, A3.1-14t, A3.1-49t,

A3.1-56 to A3.1-59t

Attitudes, knowledge, and risk perceptions, 171

Auditory processing, deficits in

e-cigarettes use, 7

fetal exposure to nicotine, 7, A3.1-35 to 1-39t

maternal cigarette smoking, 109–110

Autonomic function and SIDS, 109

AVA (American Vaping Association), A4.2-2, A4.3-2

Aversive stimuli, enhanced sensitivity to, 107, A3.1-27t

B

Ballantyne Brands (Mistic). See Mistic e-cigarettes

Batteries for e-cigarettes

explosions and fires, 14, 119

voltage and amount of carbonyl compounds, 117, 118

Bauway Technology Limited (Shenzhen, China), A4.1-14t

Behavior, advertising, effect of, 170–171

Behavioral disorders, A3.1-56 to A3.1-62t. See also Attention 

deficit hyperactivity disorder (ADHD)

Benzene, aerosolized, 118

Blacks. See Race/ethnicity

Blu (blu) e-cigarettes

advertising expenditures, 157, 159

e-liquid manufacture, 154

magazine advertisement, 160f, 161f

manufacturer of, 15t

marketing and promotion, 152, 153f

plasma nicotine concentration, 103f

sales (2010–2014), A4.4-2 to A4.4-6t

sponsorship of events, 159, 163

website access restrictions, 166t

BOP (Bureau of Prisons), 198t

Bradycardia, SIDS and maternal smoking, 109

Brain development and nicotine exposure

prenatal, 14, 99, 104–105, 109–110, 112–113

research needed, 185

studies on, A3.1-54 to A3.1-55t

youth and young adults, 104–106

Brand preference, development of, 157

British American Tobacco (BAT), 15t, A4.1-3t

Broadcast Ban, 189t

Bronchiolitis obliterans (popcorn lung disease), 116

Brown and Williamson (Advance cigarettes), 9

Burden of proof for product safety, 238, 242

Bureau of Alcohol, Tobacco, Firearms and Explosives (ATF), 198t

Bureau of Immigration and Customs Enforcement (ICE), 196t

Bureau of Prisons (BOP), 198t

Butanol, aerosolized, 118

Buttery flavor, aerosolized flavorant in e-liquids, 116

C

CAD (cinnamaldehyde)

aerosolized flavorant, 115

cytotoxicity of, 116

Cadmium, aerosolized, 119

California

Alameda County public health department, 224

Hayward tobacco products aimed at kids, case study, 224

licensing issues, 203

Camel cigarettes, 8

Cannabinoids/cannabis. See Marijuana

Car and Driver magazine, 162f
E-Cigarette Use Among Youth and Young Adults

Index 263

Carbonyls, aerosolized, 117, 118

Carcinogens

acrolein, 118

carbonyls, 117

DEHP, 117

NNN and NNK, 116

Cardiovascular function and disease, 101, 117, 118

Case studies

Hayward, California, tobacco products for kids, 224

North Dakota, clean indoor air, 225

CDC. See Centers for Disease Control and Prevention (CDC)

Center for Devices and Radiological Health (CDRH), 16

Center for Drug Evaluation and Research (CDER), 16

Center for Tobacco Policy and Organizing, 224

Center for Tobacco Products (CTP). See U.S. Food and Drug 

Administration (FDA)

Centers for Disease Control and Prevention (CDC)

aerosolized flavorants, 115

e-cigarette use among youth, A2.3-6t, A2.3-7t, A2.3-8t, A2.3-18t

flavors in e-cigarettes, 61t

patterns of e-cigarette use among youth adults, A2.3-27t

poison centers, increase in e-cigarette-related calls, 209t

statewide tobacco control programs, 238

surveys administered or sponsored by

National Adult Tobacco Survey, A2.1-3

National Youth Tobacco Survey, A2.1-2

Styles, A2.1-3

Centers for Medicare & Medicaid Services (CMS), 193–194t

ChangeLab Solutions, 224

Chemical exposure, e-cigarettes, 7, 208t

Chesterfield cigarettes, 8

Child Nicotine Poisoning Prevention Act (2015), 14, 120, 245

Child-resistant packaging for e-liquid containers, 14, 120, 208t, 245

China

e-cigarette companies and manufacturers, 14, 152, A4.1-12 to 

A4.1-14t

e-cigarette technology, 10

products imported from, 149

CHRNA5-A3-B4 haplotypes, gene cluster in nicotine addiction, 104

Chronic obstructive pulmonary disease, acrolein associated with, 117

Cigalikes, term usage, 3

Cigarettes 

early efforts to modify, 8

exclusive use of, compared to e-cigarettes, 6

filters and tar reduction, 8–9

price of, and use of e-cigarettes, 156

reduced-harm products, 8, 185

trafficking and smuggling, 198t

Cinnamaldehyde (CAD)

aerosolized flavorant, 115

cytotoxicity of, 116

Closed-system devices, 151

Cloud Pen e-cigarettes and devices, magazine advertisement, 161f

CMS (Centers for Medicare & Medicaid Services), 193–194t

Coalition on Smoking OR Health, 9

Cocaine use and prenatal nicotine exposure, 111

Cochrane database, NRT during pregnancy, 109

Cognition

adolescent smoking, 106–107

attention and cognition disorders, 106–107, A3.1-56 to 1-62t

deficits, with maternal smoking, 110

prenatal nicotine exposure, 112–113

Combustible tobacco products

decline in rates of using, 185

e-cigarette use associated with, 6

patterns of use, 187f

Comprehensive strategy approach, prevention, 238, 244

Conduct disorders, prenatal nicotine exposure, 112–113

Consumatory behaviors, maternal smoking, 110–111

Consumer perceptions

discontinuation, reasons for, 81t, 82t, 86, 87

e-cigarette use as normative, 15

perceived harm of e-cigarettes, 59, 64–71t, 87

PREPs, safety of, 10

use, reasons for, 75–86, 76–85t, 87

Contraband Cigarette Trafficking Act, reauthorized 2005 

(CCTA), 198t

Convenience stores, 167

Corpus callosum, alteration of

e-cigarettes, 7

fetal exposure to nicotine, 7

maternal smoking, 109

Cotinine salivary levels, secondhand smoke, 108

Cotinine serum levels

e-cigarettes, 99

new e-cigarette users, 102

secondhand smoke, 122

C-reactive protein (CRP), nicotine exposure, 101

Cross-sectional studies of poly-tobacco use

adults (age ≥25), 53, 55t

young adults, 53, 53f, 54t

youth

current prevalence, 37, 40f, 41–42t, 43, 44t, 45t, 46f

trends in prevalence, 43, 47–48t, 49–50t, 51f, 52f, 53

Crotonaldehyde, aerosolized toxicant, 118

CRP (C-reactive protein) nicotine exposure, 101

CTP (Center for Tobacco Products). See U.S. Food and Drug 

Administration (FDA)

Curiosity, as reason for trying e-cigarettes, 75, 87

D

Data for report, sources for, 27

Death, from ingestion of e-liquids, 14

Deeming rule

e-liquids, free samples of, 151

FDA authority over e-cigarettes, 6

free samples, 163

Internet sales to youth under age 18, 163, 164

minimum age requirements in retail environments, 167

modified risk claims, prohibiting, 163

source and provisions of, 17

vape shops, and mixing e-liquids, 169

DEHP (diethylhexyl phthalate), aerosolized adulterant, 117

DEP (diethyl phthalate) aerosolized adulterant, 117

Dependence on nicotine

aerosolized nicotine, 102–104, 103f, A3.1-2 to A3.1-7t
A Report of the Surgeon General

264 Index

maternal smoking, 110–111

Depression, adolescent smoking, 107

Dermatitis, e-cigarette aerosol exposure, 123

Diabetes type 2, fetal effects from nicotine exposure, 111

Diacetyl (2,3-butanedione), aerosolized flavorant, 116

Diethylhexyl phthalate (DEHP), aerosolized adulterant, 117

Diethyl phthalate (DEP) aerosolized adulterant, 117

Direct-drip atomizers, carbonyls, greater exposure to, 118

Disruptive disorders, adolescent smoking, 107

Distribution channels for e-cigarettes, 149–151

Dopamine system

abused drugs, 106

fetal effects from nicotine exposure, 112, 113

Dr. Scott’s Electric Cigarettes, 8

Drugs, illicit

aerosol inhalation, 58

e-cigarette products and devices, delivery system for, 6, 13–14

Dual use

advertising and, 170–171

defined, A2.2-3

health consequences, 186

policies discouraging practice of, 244

E

E-cigarette companies

activities of, 7

advertising and marketing, 14–15, 169–171

brands, categories of, 164–165

burden of proof regarding safety, 238, 242

China based, A4.1-12 to A4.1-14t, A4.3-2

consolidation of companies, A4.3-2

distribution and purchase channels, 149–150

e-cigarette market in the U.S., 149–154, 150t, 153f, 154f

e-liquids, production of, 154

FDA registration and disclosures, 242

independent private companies, A4.1-6 to A4.1-11t, A4.3-2

independent public companies, A4.1-4 to A4.1-6t, A4.3-2

marketing expenditures, 157–167, 158f, 160–162f, 165t, 166t

market share of products, 152

mergers, acquisitions, partnerships, and agreements, 165t

multinational companies, 15t

other product-related companies, A4.1-11 to A4.1-12t, A4.3-2

packaging, 242, 245

product evolution, 151–152

product standards, 242

retail outlets, 150t, 152–154, 153f, 154f, 167–169

sales projections, 14

sales volume and prices, 155–157, 155f, 156f

tobacco industry, A4.1-2 to A4.1-3t

visitors to websites, recruitment of, 14

websites, 165–166, 166f

E-cigarette policy and practice implications

agencies addressing specific populations, 243

case studies, 224–225

changing landscape, 184

clean indoor air, 188

comprehensive strategy relating to adverse consequences, 238

control measures, 184

educational initiatives, 206

future research, 185–186

health care practice, implications for, 203

licensing, 203

marketing restrictions, 205–206

overview, 7

pricing measures, 204–205, 238

public policy approaches, 187–188

risk tradeoffs, 184–185, 186t

taxation, 204–205, 238

tobacco-free spaces, 240

youth access and prevention, 203, 243–245

E-cigarette-related exposures, 14, 209t, 245

E-cigarettes

bridge to greater tobacco product use, 11

controversy over, 183

countries that have banned e-cigarettes/ENDS, 223t

discontinuation, reasons for, 81t, 82t, 86, 87

disposable, and prices, 3f, 152, 154, 154f, 155, 155f

federal regulation of, 15–18, 187–188

growth in awareness and use, 149

health effects

fetal brain development from nicotine exposure, A3.1-33 

to A3.1-62t

fetal nicotine exposure, preclinical/animal studies, A3.1-63 

to A3.1-79t

nicotine exposure effects, human studies, A3.1-8 to A3.1-17t

nicotine exposure effects, on fetal brain development, 

A3.1-33 to A3.1-62t

nicotine exposure effects, preclinical/animal studies, 

A3.1-18 to A3.1-32t

overview of, 6–7

historical background, 8–10

intentions to use summary data, A2.3-20 to A2.3-22t

invention of, 10–11

marketplace changes

market share of products, A4.3-3f, A4.5-2, A4.5-3 to A4.5-5f

tobacco industry, A4.1-2 to A4.1-3t

tracking of, 238

trade organizations and partnerships, A4.3-2

names used for, 5, A2.2-2

patterns of use, 6, 186, 187f, A2.3-6 to A2.3-19t, A2.3-23 to 

A2.3-37t

persistent use despite harmful consequences, A3.1-7t

physiological withdrawal state, A3.1-3t, A3.1-3 to A3.1-6t

potential harms and benefits, 185–186, 186t

preoccupation with, A3.1-7t

prevalence of use, 204, A2.3-2 to A2.3-3

price and sales volume, 7

products and devices

additional functions, 152

candy and menthol flavored, 211t

components of, 11, 12f

disposable, 3f

dose of inhaled nicotine, 100, 103f

evolution of, 151–152

illicit drugs, delivery system for, 6, 216t

modification of, 11
E-Cigarette Use Among Youth and Young Adults

Index 265

rechargeable, 3f

risks, 13–14

substances found in, 216t

types of, 3, 3f

public health concerns, 183

reasons for using, 6

rechargeable, and sales volume and price, 3f, 155–156, 156f

sales, tracked retail outlets, A4.4-2 to A4.4-6t

surveys

key measures, A2.2-2 to A2.2-4

methodologic information, A2.2-2

sources of data, A2.2-5 to A2.2-15t

susceptibility summary data, A2.3-20 to A2.3-22t

susceptibility to use, and advertising, 170

tolerance to effects, A3.1-6t

use, reasons for, 75–86, 76–85t, 87

use with other tobacco products (See Poly use)

without nicotine, health effects of, 17

E-cigars, appearance of, 3f

E-cigs (brand), 15

Eclipse cigalikes, 9

Educational attainment

adults (age ≥25), 39t

young adults, and e-cigarette use, 37, 38t

Educational initiatives

e-cigarette policies, 206

on ENDS products, 210t

health care professionals, 217t, 226, 241

media campaigns, 238

responsibility for, 239–241

United Nations organization on, 183

Educational plans of youth, 37, 41t

Electronic Cigarette Industry Group, Inc. (ECIG Inc.), A4.3-2

Electronic cigarettes. See entries beginning with E-cigarette

Electronic nicotine delivery systems (ENDS), 27. See also

E-cigarettes

Alcohol and Tobacco Tax and Trade Bureau, 200t

American Association for Cancer Research, 208–209t

American College of Physicians, 210t

Forum of International Respiratory Societies, 214t

International Union Against Tuberculosis and Lung Cancer, 223t

term usage, 27

World Health Organization, 219–220t

Elektro e-cigarettes, sales (2010–2014), 153f, A4.4-2 to A4.4-6t

E-liquids

adulterants, 100

child-resistant packaging, 14, 208t

concentration, and dose of inhaled nicotine, 100, 103f

devices, filling, 11, 13f

free samples, 151

ingestion of or exposure to, and health effects, 7, 119–120, 

121f, 184

nut allergy, and e-cigarette aerosol exposure, 123

production of, 154

refills, sales of, 154, 154f

taxation of, 204

vape shops, mixing in, 169

Employers, rewards or penalties for tobacco use, 194t

Ending the Tobacco Problem: A Blueprint for the Nation (IOM), 16

ENDS (electronic nicotine delivery systems), 27. See also

E-cigarettes

E-pipes, appearance of, 3f

Esquire magazine, 160f

Estrogenic activity, DEP and DEHP, 117

Ethnicity. See Race/ethnicity

European Commission, Tobacco Products Directive, 213t

European Medicines Agency, 117

European Respiratory Society (ERS), 213t

European Union (EU)

indoor air quality, 122

position on e-cigarettes and ENDS, 221t

Evaluation, policy impacts, 248

Ever (lifetime) use, defined, A2.2-2. See also High school 

students; Middle school students; National Youth Tobacco 

Survey (NYTS); Youth

EVIC tank device, 103f

Evod heating element, 103f

Exalt smokeless tobacco product, 9

Excise tax, on tobacco products, 204

Explosions caused by e-cigarette batteries, 14, 119

F

Facebook

advertising, 157

coupons and discounts, 163

distribution and purchase channels, 150

e-cigarettes, 15

Family Smoking Prevention and Tobacco Control Act of 2009, iii, 

9, 16, 18, 58, 183, 210t, 241

Favor cigarettes, 10

FDA. See U.S. Food and Drug Administration (FDA)

Fear responses, and adolescent smoking, 107

Federal Communications Commission (FCC), 189t

Federal Food, Drug, and Cosmetic Act, 16–17, 183, 241

Federal regulation of e-cigarettes. See also specific agencies by name

approach to, 15–18

policies of federal agencies, 189–202t

Tobacco Control Act, 187–188

Fetal effects of nicotine exposure. See also Pregnancy; Prenatal 

nicotine exposure

altered corpus callosum, 7, A3.1-34t

appetitive behaviors, A3.1-40 to 1-55t

attention and cognition, behavioral disorders, A3.1-56 to 

A3.1-62t

attention deficit hyperactivity disorder (ADHD), 112, 113, 

A3.1-14t, A3.1-49t, A3.1-56 to A3.1-59t

auditory processing defects, 7, A3.1-35 to 1-39t

brain development, 14, 99, 104–105, 109–110, 112–113

brain reward systems changes, A3.1-54 to A3.1-55t

cognition disorders, 112–113

conduct disorders, 112–113

obesity, 7

preclinical/animal studies, A3.1-63 to A3.1-79t

sudden infant death syndrome (SIDS), 7, 109, A3.1-33t

Filters, health, effects on, 8
A Report of the Surgeon General

266 Index

FIN e-cigarettes

magazine advertisement, 162f

television advertising, 159

website access restrictions, 166t

Fires caused by e-cigarette batteries, 14, 119

Flavors for e-cigarettes

addiction and use of conventional tobacco products, 11

aerosol inhalation, 115–116

flavors appealing to minors, California prohibiting, 151

Internet sales, 164

licensing requirements, 203

restrictions on, 242

safety of inhaling, 13, 184, 186

sales, growth of, 154

studies on, 58–59, 60t, 61–63t

sweet flavors, 11, 13f, 211t

youth and young adults, 6, 11

Food and Drug Administration (FDA). See U. S. Food and Drug 

Administration (FDA)

Food and Nutrition Act (2008), 190t

Formaldehyde

aerosolized adulterant, 117, 118

e-cigarettes, 99

higher temperature of e-cigarettes, 13

Forum of International Respiratory Societies, ENDS devices, 214t

4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK), 

aerosolized adulterant, 116

Free samples; restrictions, 242

Frequent use, defined, A2.2-3. See also High school students; 

Middle school students; National Youth Tobacco Survey 

(NYTS); Youth

FTC. See U.S. Federal Trade Commission (FTC)

Future regulatory actions, 242

Future research initiatives, 185–186, 226

G

Gamucci e-cigarettes

company profile, A4.1-8t

market share (2010–2014), A4.5-3f

sales (2010–2014), 153f, A4.4-2 to A4.4-6t

Gender differences

e-cigarette use

adults (age ≥25), 39t

high school, 28, 30t, 32t, 33, 35t, 37

middle school, 28, 29t, 31t, 33, 34t, 36

young adults, 37, 38t

flavors in e-cigarettes, 59, 60t

myelination gene expression with maternal smoking, 109

poly-tobacco use

adults (age ≥25), 55t

young adults, 53, 54t

youth, 37, 41t, 43

General Services Administration (GSA)

agency description, 190t

e-cigarette regulations, 188

smoking regulations, 190t

Genetics

gene expression alterations with maternal smoking, 109

genetically modified nontobacco plants, 17

genetically sensitive research designs, 112, 112n

nicotine addiction, 104

Glycidol, e-cigarette aerosol, 99

Glyoxal, aerosolized toxicant, 118

Green Smoke e-cigarettes

manufacturer, 15t

website information, 166, 166t

H

Halco, e-cigarettes, A4.1-8t

Halo Companies, Inc., A4.1-10t

Harm

reduced-harm products, 8, 185

reduction with e-cigarettes, and advertising, 171

strategies to prevent, 237–238

Haus e-cigarettes, sales (2010–2014), 153f, A4.4-2 to A4.4-6t

Health Belief Model, tobacco use, and perception of harm, 64

Health care practice, implications for, 203

Health care professionals, as education channel, 217t, 226, 241

The Health Consequences of Smoking—50 Years of Progress

(2014 report)

conceptual modeling, 186

conclusions from, 97, 99t

maternal cigarette use and disruptive-behavior disorders, 112, 113

passive use effects for pregnant women, 14

relevance of conclusions to e-cigarettes, 225

sensitivity of youth to nicotine effects, 99

The Health Consequences of Smoking–Nicotine Addiction (1988 

report)

conclusions from, 97, 98t

nicotine addiction, 9

Health effects

e-cigarette potential harms and benefits, 185–186, 186t

e-liquids, ingestion of, 7, 184, 245

nicotine and tar reduction, 8–9

risk tradeoffs and, 184–185

HealthStyles Survey, A2.1-3, A2.1-4 to A2.1-5t

Heat-not-burn products, 15t

Heavy metals, aerosolized, 119

High school students. See also Youth

current prevalence of e-cigarette use

ever use, 28, 30t

frequency of use, 28, 30t

past-30-day use, 28, 32t

susceptibility to use, 28, 30t

trends in prevalence of e-cigarette use

ever use, 33, 33f, 35t

past-30-day use, 32t, 36–37, 36f

Hill, Sir Austin Bradford, 186

Hippocampal function, adolescent smoking, 107

Hispanic population, retail sales of e-cigarettes, 150, 168

Hispanics. See Race/ethnicity

Hon Lik, 10

Hookah bars and lounges, 203
E-Cigarette Use Among Youth and Young Adults

Index 267

How Tobacco Smoke Causes Disease–The Biologic and 

Behavioral Basis for Smoking-Attributable Disease (2010 

report)

aerosols in e-cigarettes, 99

conclusions from, 97, 98t

Hypotension, SIDS and maternal smoking, 109

I

ICE (Bureau of Immigration and Customs Enforcement), 196t

Illicit uses. See also Marijuana

cocaine use and prenatal nicotine exposure, 111

European regulations, 213t

hashish oil, 14

methamphetamine, 111

Imperial Tobacco Group (Fontem Ventures)

acquisitions, 165t

advertising expenditures for blu, 157

company profile, A4.1-2t

Lorillard, 152

multinational tobacco company, 15t

Ruyan e-cigarettes, 10

sales (2010–2014), 153f, A4.4-2 to A4.4-6t

Impulsivity in adulthood, adolescent smoking, 107

Indoor air policies, 122, 188, 225, 238, 243–244

Inflammatory mediators, nicotine exposure, 101

Ingredient disclosures, 17, 64, 215, 242

Instagram

advertising, 157

e-cigarette promotion, 166

e-cigarettes, 15

Institute of Medicine (IOM)

comprehensive tobacco control, 16

potentially reduced-exposure products, 9

Insurance coverage, rates for tobacco users, 194t. See also

Medicaid; Medicare

International cooperation

ENDS products, 209t

Tobacco Tax and Trade Bureau, 209t

International Union Against Tuberculosis and Lung Cancer, 223t

International Vapor Group (IVG), A4.1-7t

Internet

advertising, 157, 158f

age verification, 208t, 242

distribution and purchase channels, 150

e-cigarette companies, 14, 15

e-cigarette marketing, 10

e-cigarette promotion, 163

websites selling e-cigarettes, 163–164

IOM (Institute of Medicine)

comprehensive tobacco control, 16

potentially reduced-exposure products, 9

IQOS e-cigarettes, 15t

Iron, aerosolized, 119

J

Japan Tobacco International (JTI)

acquisition and partnership, 165t

company profile, A4.1-3t

multinational tobacco company, 15t

JieShiBo Technology (Shenzhen, China), A4.1-14t

Johnson Creek Vapor Company, 154, A4.1-11t

Joyetech Co., Ltd. (Shenzhen, China), 152, A4.1-12t

K

Kantar Media, 157, 159

Knowledge, attitudes, and risk perceptions, 171

Koop, C. Everett, 97

Korean Youth Risk Behavior Web-Based Survey (2011), A2.3-5

Krave e-cigarettes, sales (2010–2014), 153f, A4.4-2 to A4.4-6t

L

Labels

ingredients, 17, 64, 215

warning, 206, 211t, 213t, 216t, 240–241

Latinos. See Race/ethnicity

Lead, aerosolized, 119

Legislation to curb tobacco sales

Hayward, California, case study, 224

North Dakota, case study, 225

Licensing

e-cigarette policies, 203

retailers, 245

Lifetime (ever) use, defined, A2.2-2. See also High school 

students; Middle school students; National Youth Tobacco 

Survey (NYTS); Youth

Liggett & Myers (L&M), 8

Limbic system, long-term changes with nicotine exposure, 106

Literature search for report, 27

Litigation

FDA regulation of e-cigarettes, 187–188, 241

violations of existing local rules, 205

Local government, tobacco control, 16, 18. See also State, local, 

tribal, and territorial governments

Logic e-cigarettes

company profile, A4.1-8t

market share, (2012–2014), A4.5-4 to A4.5-5f

sales (2010–2014), 153f, A4.4-2 to A4.4-6t

website information, 166, 166t

Longitudinal studies

data for report, source for, 27

poly-tobacco use, 53, 56–57

Lorillard (Lorillard Vapor Company)

acquisition, 165t

advertising expenditures for blu, 157, 159

blu, marketing of, 152, 153f

company profile, A4.1-3t

multinational tobacco company, 15t
A Report of the Surgeon General

268 Index

Lucky Strike cigarettes, 8

Lung cancer, and acrolein, 117

M

Machine testing of tar and nicotine yields, 8, 9

Magazines/print media, and advertising, 158–159, 158f, 160–162f

Mail-order sales, age verification, 208t

Manufacturers. See E-cigarette companies

Marijuana

aerosol inhalation, 58

e-cigarette devices used for, 6, 14, 58, 203, 241

e-cigarette use with, 57–58

open systems, 152

Ploom PAX e-cigarettes, 15t

poly-tobacco use, 57

tank devices, 14

“wax” marijuana resin, 14

Market for e-cigarettes in the U.S. See also Vape shops

distribution and purchase channels, 149–151, 154f

e-liquid production, 154

market share, evolution of, 152

product evolution, 151–152

sales in retail outlets, 150t, 152–154, 153f, 154f, 167–169

value of, 149, 150t

Marketing. See also Advertising

burden of proof regarding safety, 238

channels, 7

e-cigarette companies, 14–15

e-cigarettes, 7, 185

effect of advertising on behavior, 170–171

exposure and receptivity to advertising, 169–170

Internet, 10, 163

marketing expenditures, 157–167, 158f, 160–162f, 165t, 166t

restriction policies, 205–206, 208t, 238

retail environment, 167–169

self-service displays, 17, 203, 224, 242, 244

Surgeon General’s report (2012), 4

targeting youth and young adults, 246–247

themes, 7

MarkTen e-cigarettes. See also Altria Group, Inc./Nu Mark

distribution and purchase channels, 150

e-liquid manufacturers, 154

manufacturer, 15t

market share (2014), A4.5-5f

promotion of, 158

sales (2010–2014), 153f, A4.4-2 to A4.4-6t

website information, 165, 166, 166t

Master Settlement Agreement (1998)

Hayward, California, case study, 224

marketing surveillance, 205

placement of e-cigarette advertisement, 168

point-of-sale advertising, 168

tobacco product sponsorship of events, 15, 159, 240

Maternal nicotine consumption. See Prenatal nicotine exposure

Maxim magazine, 160f

Medicaid

Incentives for Chronic Disease Prevention Program, 193t

prescription drug benefits, 193t

tobacco screening and cessation, 193–194t

Medical organizations

government health, 221–223t

professional organizations, 207–214t

voluntary health organizations, 215–219t

World Health Organization, 219–220t

Medicare, tobacco screening and cessation, 194t

Memory, adolescent smoking, 107. See also Cognition

Men’s Journal magazine, 160f

Metals, found in e-cigarettes, 216t

Methamphetamine use, fetal effects from nicotine exposure, 111

Methylglyoxal, aerosolized toxicant, 118

Middle school students. See also Youth

current prevalence of e-cigarette use

ever use, 28, 29t

frequency of use, 28, 29t

past-30-day use, 28, 31t

susceptibility to use, 28, 29t

trends in prevalence of e-cigarette use

ever use, 33, 33f, 34t

past-30-day use, 31t, 36, 36f

Minnesota Adult Tobacco Survey, A2.2-2

Mistic e-cigarettes

company profile, A4.1-6t

magazine advertisement, 161f

market share, (2012), A4.5-4f

sales (2010–2014), 153f, A4.4-2 to A4.4-6t

website access restrictions, 166t

“Mods.” See Tank devices (“mods”)

Monitoring the Future Survey (MTF)

data for report, source for, 27

e-cigarette use

items from sources of national data, A2.2-5 to A2.2-9t

sources of national data, A2.1-4 to A2.1-5t

e-cigarette use, current prevalence, 28

flavors in e-cigarettes, 59

poly-tobacco use, 37, 40f, 41–42t

profile of, A2.1-2

Monoamine oxidase A, fetal effects from nicotine exposure, 113

Mood disorders, adolescent smoking, 107. See also Anxiety disorders

Moratoriums, on vape shops, 203

MTF. See Monitoring the Future Survey (MTF)

Myelination

gene expression alterations with maternal smoking, 109

nicotine exposure, 104–105

N

NAB (N-nitrosoanabasine), aerosolized adulterant, 116

NACDA (National Advisory Council on Drug Abuse), 195t

NAChRs. See Nicotinic acetylcholine receptors (nAChRs)

NAT (N-nitrosoanatabine), aerosolized adulterant, 116

National Adult Tobacco Survey (NATS)

comparison to 2013–2014 survey, A2.3-3

data for report, source for, 27, A2.1-3, A2.1-4 to A2.1-5t

e-cigarette use data, A2.2-5 to A2.2-9t

flavors in e-cigarettes, 59, 60t
E-Cigarette Use Among Youth and Young Adults

Index 269

poly-tobacco use, 53, 53f, 54t, 55t

prevalence of e-cigarette use, 37, 38t, 39t

young adults

e-cigarette use, A2.3-3

perceived harm of e-cigarettes, 64, 74t, 75

National Center for Health Statistics, 27

National Comorbidity Survey—Adolescent dataset, 102

National Defense Authorization Act (2015), 191t

National Health Interview Survey (NHIS), A2.1-4 to A2.1-5t, A2.3-3

National Institute for Occupational Safety (NIOSH), 116

National Institute on Drug Abuse (NIDA)

Monitoring the Future Survey, A2.1-2

Population Assessment of Tobacco and Health Study, A2.1-3

tobacco industry-supported research and funding, 195t

National Institutes of Health (NIH)

supporting e-cigarette research, 186

tobacco-free initiative, 195t

National Library of Medicine, 27

National Park Service

e-cigarette regulations, 188

role in implementing strategies, 243

National Tobacco Company, 165t

National Youth Tobacco Survey (NYTS)

advertising

effect on behavior, 170

exposure to e-cigarette, 169

current e-cigarette use by youth, increase of, 10

current prevalence of e-cigarette use

ever use, 28, 29t, 30t

frequency of use, 28, 29t, 30t

past-30-day use, 28, 31t, 32t

susceptibility to use, 28, 29t, 30t

data for report, source for, 27

e-cigarette use data

items from sources of national data, A2.2-5 to A2.2-9t

measures used, A2.2-4

patterns of use, 2015 survey, A2.3-2

sources of national data, A2.1-4 to A2.1-5t

survey description, A2.1-2

flavors in e-cigarettes, 59, 60t

perceived harm of e-cigarettes, 64, 73t, 74t

poly-tobacco use

current prevalence, 43, 44t, 45t, 46f

trends in prevalence, 43, 47–48t, 49–50t, 51f, 52f, 53

survey profile, A2.1-2

trends in prevalence of e-cigarette use

ever use, 28, 33, 33f, 34t, 35t

past-30-day use, 31t, 32t, 36–37, 36f

NATS. See National Adult Tobacco Survey (NATS)

Netherlands Study of Depression and Anxiety Disorders, A3.1-14t

Netherlands Twin Registry, 106

Neurobehavioral disorders of childhood, A3.1-56 to A3.1-62t

Neurobiological development, 104–106

Neuroteratogens, 14

New Jersey Youth Tobacco Survey (NJYTS), 33, A2.2-4

NHALE, Inc., A4.1-6t

Nickel, aerosolized, 119

Nicolites e-cigarettes, 15t

Nicorette inhalators, 116

Nicotek e-cigarettes

sales (2010–2014), 153f, A4.4-2 to A4.4-6t

website access restrictions, 166t

Nicotek LLC, A4.1-9t

Nicotine

addiction and fetal effects, A3.1-40 to A3.1-48t

adverse effects during pregnancy, 208t

Camel cigarettes, and high nicotine content, 8

genetically modified nontobacco plants, 17

higher temperature of e-cigarettes, 13

poisoning, with ingestion of e-liquids, 119–120, 121f

reduction of content, health effects of, 8–9

role of, and nicotine delivery, 9

secondhand exposure, and California level standards, 123

Nicotine-related compounds, aerosol inhalation of, 114

Nicotine replacement therapy (NRT)

cardiovascular risk, 101

Nicorette inhalators, 116

pregnancy, 108–109

Nicotinic acetylcholine receptors (nAChRs)

adolescence, 105

e-cigarette addiction, 102

fetal development, 108, 110

NicSelect, A4.1-11t

NIDA. See National Institute on Drug Abuse (NIDA)

NIH. See National Institutes of Health (NIH)

NIOSH (National Institute for Occupational Safety), 116

Nitric oxide, aerosol inhalation, 114

NJOY cigalikes

company profile, A4.1-7t

e-liquid manufacture, 154

funding for study on flavors in e-cigarettes, 59

magazine advertisement, 161f

market share (2010–2014), A4.5-2 to A4.5-5f

product evolution, 151

sales (2010–2014), 153f, A4.4-2 to A4.4-6t

television advertising, 159

website access restrictions, 166t

N-nitrosoanabasine (NAB), aerosolized adulterant, 116

N-nitrosoanatabine (NAT), aerosolized adulterant, 116

N-nitrosonornicotine (NNN), 116

NNK (4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone), 116

NNN (N-nitrosonornicotine), 116

Nonusers. See Environmental exposure

North America Tobacco Regulatory Laboratory Network, 200t

North Dakota Center for Tobacco Prevention and Control Policy, 225

NRT (nicotine replacement therapy)

cardiovascular risk, 101

Nicorette inhalators, 116

pregnancy, 108–109

NuMark. See Altria Group, Inc./Nu Mark

Nut allergy, and e-cigarette aerosol exposure, 123

NYTS. See National Youth Tobacco Survey (NYTS)

O

Obesity. See Overweight and obesity

Occupational Safety and Health Administration (OSHA), 199t
A Report of the Surgeon General

270 Index

Ocular irritation, acrolein, 117

Office of Management and Budget (OMB), 189t

Office of Personnel Management (OPM), 190t

Old Gold cigarettes, 8

OMB (Office of Management and Budget), 189t

Omni cigarettes, 9

Open system devices, 151–152

OPM (Office of Personnel Management), 190t

Oppositional defiant disorder (ODD), 107

OSHA (Occupational Safety and Health Administration), 199t

Overweight and obesity

e-cigarettes, 7

fetal effects from nicotine exposure, 7, 111, A3.1-51 to A3.1-53t

P

Particulate matter 2.5 (PM2.5), secondhand smoke measure, 122, 123f

Past-30-day use, defined, A2.2-2. See also High school students; 

Middle school students; National Youth Tobacco Survey 

(NYTS); Youth

PATH study. See Population Assessment of Tobacco and Health 

(PATH) study

Patient Protection and Affordable Care Act of 2010 (PPACA), 193t

PG. See Propylene glycol (PG)

Philip Morris International (PMI), 15t, A4.1-2t

Physical abstinence syndrome (withdrawal symptoms), 102, 

A3.1-3 to A3.1-6t

Physiological withdrawal state, electronic cigarettes, A3.1-3t

Pipeline and Hazardous Materials Safety Administration, 199t

Plasma nicotine concentration, 103f

Plasticity of the brain, 104–105, 113

Ploom e-cigarettes, 15t

Ploom vaporizers, 15t, 165t

PM2.5 (particulate matter 2.5), secondhand smoke measure, 122, 123f

PMI (Philip Morris International), 15t, A4.1-2t

Poison control centers, e-cigarette-related exposures, 14, 209t, 245

Poly use

adults, cross-sectional studies, 53, 55t

defined, A2.2-3

educational plans of youth, 37, 41t

gender differences

adults (age ≥25), 55t

young adults, 53, 54t

youth, 37, 41t, 43

longitudinal studies, 56–57

marijuana, 57

race/ethnicity

adults (age ≥25), 55t

young adults, 53, 54t

youth, 37, 41t

young adults, cross-sectional studies, 53, 53f, 54t

youth

current prevalence, 37, 40f, 41–42t, 43, 44t, 45t, 46f

educational plans of, 37, 41t

trends in prevalence, 43, 47–48t, 49–50t, 51f, 52f, 53

Popcorn lung disease (bronchiolitis obliterans), 116

Population Assessment of Tobacco and Health (PATH) Study

e-cigarette use

items from sources of national data, A2.2-2 to A2.2-15t

patterns of use, 2013–2014 study, A2.3-2

sources of national data, A2.1-4 to A2.1-5t

flavors in e-cigarettes, 59

overview, A2.1-2

profile of, A2.1-3

Population-level strategies, 243

Porter Novelli (public relations firm), A2.1-3

Potentially reduced-exposure products (PREPs), 9–10

Precautionary approach strategy, 238

Precautionary principle

appropriate use of, 183

as guide for decision makers, 188

as guide to address e-cigarette use, 4

Prefrontal cortex, development of, in adolescents and young 

adults, 105

Pregnancy. See also Fetal effects of nicotine exposure; Prenatal 

nicotine exposure

adverse effects of nicotine, 7, 208t, 239

e-cigarettes as tobacco cessation option, 206

nicotine exposure, 14

nicotine use, 5, 7, 14

tobacco screening cessation services, 193–194t

Premarket reviews, 242

Premier, smokeless cigarette product, 9

Prenatal nicotine exposure. See also Fetal effects of nicotine 

exposure; Pregnancy

appetitive and consumatory behaviors, 110–112

attention and cognition, 112–113

auditory processing deficits, 109–110

cocaine use, 111

corpus callosum, altered development of, 109

discordant sibling pair design studies, 111

e-cigarettes, 14

nicotine, 5, 7

nicotine concentrations in fetal fluid, 108

prenatal and postnatal outcomes, 108–113

sudden infant death syndrome (SIDS), 109

toxicants and, 108, 109

PREPs (potentially reduced-exposure products), 9–10

Prevent All Cigarette Trafficking Act (2009), 164

Preventing Tobacco Use Among Young People (1994 report), 4

Preventing Tobacco Use Among Youth and Young Adults (2012 

report)

conclusions from, 97, 98t

educational initiatives, 206

marketing influence in tobacco use behaviors, 157

release of, 4

sensitivity of youth to, 99

Pricing of e-cigarettes

disposable e-cigarettes, 155, 155f

Internet coupons and discounts, 163

policies, 7, 204–205, 238

sales, impact on, 155–157, 155f, 156f

Primacy, defined, A2.2-4

Print media/magazines, and advertising, 158–159, 158f, 160–162f

Processed tobacco, defined, 200t
E-Cigarette Use Among Youth and Young Adults

Index 271

Pro-Children Act of (2001), 192t

Product placements, e-cigarettes, 15

Promotion or promotional activities. See Marketing

Propanol, aerosolized toxicant, 118

Propylene glycol (PG)

aerosol inhalation, 115

inhalation toxicity, 114

secondhand exposure, and California level standards, 123

Pruning of unnecessary synapses, and nicotine exposure, 104–105

Psychiatric events, and rimonabant, 117

Public and Indian Housing (PIH), 197t

Public health

agencies role in assisting state attorney general or FTC, 206

e-cigarettes policy, 7

e-cigarette use, 10–11

FDA regulatory authority, 16

future regulatory options, 17–18

precautionary strategies to protect youth and young adults, 226

Public Health England (UK), 222t

Public policy

cigarette restrictions, 149

e-cigarettes, 7, 187–188, 205

magazine advertisement, 161f, 162f

retail sales of e-cigarettes, 168

“Puff topography,” dose and effects of inhaled nicotine, 100–101

Puff volumes, dose and effects of inhaled nicotine, 101

Purchase channels for e-cigarettes, 149–151

R

Race/ethnicity

e-cigarette advertising, exposure to, 169

e-cigarette use

current prevalence, 28, 29t, 30t, 31t, 32t

trends in prevalence, 28, 33–37, 34t, 35t

flavored little cigars and cigarillos, 11

flavors in e-cigarettes, 59, 60t

poly-tobacco use

adults (age ≥25), 55t

young adults, 53, 54t

youth, 37, 41t

retail sales of e-cigarettes, 150, 168

Regulation of e-cigarettes. See also specific agencies by name

federal

approach to, 15–18

policies of federal agencies, 189–202t

Tobacco Control Act, 187–188

state, local, tribal, and territorial governments

clean air policies, 188

control measures, 184

interventions policies, 188

Tobacco Control Act, 16

Research

suggestions for future research, 185–186, 226, 247–248

tobacco control and prevention, 238

tobacco industry-supported, 195t

Respiratory irritation, acrolein, 117

Retail environment

e-cigarette sales, 14

U.S. market, 150t, 152–154, 153f, 154f, 167–169

Revel smokeless tobacco product, 9

Reward-seeking behavior

adolescent smoking and long-term changes in reward system, 106

nicotine, increased sensitivity to, in adolescents, 105

Reynolds American Inc. (RAI) (R.J. Reynolds Vapor Company)

American manufacturing, 152

company profile, A4.1-3t

multinational tobacco company, 15t

Premier “smokeless cigarette product,” 9

VUSE, 150, 152, 158

Rimonabant (Zimulti), aerosolized adulterant, 117

Risk assessments, 186t

Risk perceptions, knowledge and attitudes, 171

Risk tradeoffs, 184–185

Risky behaviors, and e-cigarette use, 57–58

R.J. Reynolds. See Reynolds American Inc. (RAI)

Rolling Stone magazine, 159, 161f

Ruyan e-cigarettes

introduction of, 10

manufacturer, 15t

S

Safe and Drug-Free Schools and Communities Act (1994), 192t

Safety

battery explosions and fires, 14, 119

burden of proof, responsibility for, 238, 242

cigarette marketing, 8

e-cigarette products and components, 13–14

SAMHSA (Substance Abuse and Mental Health Services 

Administration), 196t

Satisficing, defined, A2.2-4

Schools, proximity to, and e-cigarette availability, 168

Secondhand exposure 

aerosolized e-cigarette constituents, 120–123, 123f, 183, 209t, 240

e-cigarettes, 14

nicotine from e-cigarettes, compared to conventional 

cigarettes, 97

nonusers of nicotine, exposure to, 120

teratogenic effects, 108

Seizures, 117

Sensory deficits, with maternal smoking, 109–110

SFATA (Smoke Free Alternatives Trade Association), A4.2-2, 

A4.3-2

SIDS. See Sudden infant death syndrome (SIDS)

Silicates, aerosolized, 119

Silver, aerosolized, 119

Smoke Free Alternatives Trade Association (SFATA), A4.2-2, A4.3-2

Smokefree policies, 188, 243–244

Smoker Friendly International, LLC, A4.1-10t

Smoker’s One Choice e-cigarettes

market share, (2011), A4.5-3f

sales (2010-2014), 153f, A4.4-2 to A4.4-6t
A Report of the Surgeon General

272 Index

Smoking and Health: Report of the Advisory Committee to the 

Surgeon General of the Public Health Service (1964 report)

mortality contribution results, 8

release of, 4

Smoking behavior

changes, with low-nicotine cigarettes, 9

dose and effects of inhaled nicotine, 100–101

Smoking cessation

in clinical care setting, 206

e-cigarettes as cessation option, 183, 184, 186, 206

magazine advertisement, 161f

reason for trying e-cigarettes, 75

screening and cessation services, 193–194t

studies showing inconsistent results, 214t

Smuggled Tobacco Prevention (STOP) Act (proposed), 198t

SNAP program, 190t

Snus

cardiovascular risk, 101

modified tobacco product, 9

Soap Opera Digest, 161f

Social media. See also Facebook; Twitter; YouTube

advertising, 157

distribution and purchase channels, 150

e-cigarette marketing, 10, 15

e-cigarette promotion, 166–167

Social Security Act (2010 amendments to), 193t

Socioeconomic status, and price of e-cigarettes, 157

Solvents, and aerosol inhalation, 115

Sottera, Inc. See NJOY

Sottera, Inc. v. U.S. Food and Drug Administration (2010), 16, 

241, A4.2-2

Spin magazine, 162f

Sponsorship of events by e-cigarette companies, 15, 159, 163, 240

Sports Illustrated magazine, 160f

Stanford Research into the Impact of Tobacco Advertising 

research group, 158

Starfire e-cigarettes, television advertising, 159

State, local, tribal, and territorial governments

best practices of, 245

e-cigarette taxation policies, 204

ENDS regulations, 209t

existing rules that constrain marketing, 205

licensing, 203

population-level strategies, 243

Tobacco Control Act, 188

tobacco control strategies, 16, 18, 226, 238, 242

Stimulus-response-discrimination-learning processes, 107

Studies. See Surveys

Styles (HealthStyles, Summer Styles) Survey

e-cigarette use data

items from sources of national data, A2.2-5 to A2.2-9t

sources of national data, A2.1-4 to A2.1-5t

prevalence of e-cigarette use, 37, 40f

profile of, A2.1-3

Styrene, aerosolized, 118

Substance Abuse Prevention and Treatment Block Grant, 196t, 203

Substance use and abuse

adolescent smoking as “gateway” for, 106

comorbid, with adolescent smoking, 106

e-cigarette use with, 57–58

fetal effects from nicotine exposure, 111–112

Sudden infant death syndrome (SIDS)

e-cigarettes, 7

fetal effects of nicotine exposure, A3.1-33t

fetal exposure to nicotine, 7

maternal smoking, 109

Surgeon General Call to Action

curb advertising and marketing, 246–247

do no harm, 237–239

expand surveillance, research and evaluations, 247–248

prevention programs and policies, 243–245

provide information about dangers, 239–241

regulate e-cigarettes at federal level, 241–243

stakeholders, 237

Surgeon General’s reports, health risks outlined in previous 

reports, 97–99, 98–99t. See also individual reports by name

Surveillance

proposals, 205, 226, 247–248

studies, 27

Surveys. See also specific survey or study by name

data analysis instruments, A2.2-4

e-cigarette and other tobacco product use, A2.3-4

future research, 185–186

measurement factors, special issues, A2.2-4

modeling concepts, 186

prevalence estimates, 204, A2.3-2 to A2.3-3

Susceptibility to use

advertising and, 170

current prevalence of high school students, 28, 30t

current prevalence of middle school students, 28, 29t

defined, A2.2-3

intentions to use, A2.3-20t

survey summary data, A2.3-20 to A2.3-22t

Synar Amendment, 196t, 203

T

Tank devices (“mods”)

appearance of, 3f, 11

components of, 12f

increasing role in e-cigarette market, 150

plasma nicotine concentration, 103f

product evolution, 151, 152

Tar reduction, health effects of, 8–9

Taxation

e-cigarette policies, 188, 204–205, 238

ENDS, 209t, 210t

Tobacco Tax and Trade Bureau, 200t

Television advertising, 157, 158f, 159

Temperature of e-cigarettes

aerosolized carbonyls, 117, 118

higher, and increased nicotine and toxicant release, 13

toxicants, 118

Tetrahydrocannabinol (THC)

aerosol inhalation, 58

tank devices, 14

Theory of Reasoned Action, tobacco use, and perception of harm, 64
E-Cigarette Use Among Youth and Young Adults

Index 273

Thermal metered-dose cannabis inhalers for medical applications, 58

Third-hand smoke

described, 120, 121

exposure, 209t

Tiered tax rate systems, 204

Tin, aerosolized, 119

Tobacco Control Act (2009)

deeming rule, 17

e-cigarette regulation relating to youth and young adults, 18

federal authority to regulate tobacco products, 9, 15, 16, 183, 

187–188, 241

flavor ban for cigarettes, 11

flavors in cigarettes, 58

state, local, tribal, and territorial government authority, 16

vape shops, mixing e-liquids, 169

youth tobacco access control regulations, 203

Tobacco Control Legal Consortium, 204, 225

Tobacco Free North Dakota, 225

Tobacco-free policies, 240

Tobacco industry companies, A4.1-2 to A4.1-3t

Tobacco industry-supported research and funding, 195t

Tobacco Laboratory Network, 200t

Tobacco Product Directive (TPD), 222t

Tobacco products. See also Aerosol inhalation; Aerosolized 

nicotine; Cigarettes; E-cigarettes

combustible, 6

e-cigarettes regulated as, legal basis for, 16–17

FDA regulation of, 9–10, 15–17

smokeless, 9

sponsorship of events, 15, 159, 163, 240

Tobacco Products and Risk Perceptions Survey (2014), A2.3-3

Tobacco Products Directive, European Commission, 213t

Tobacco-specific nitrosamines (TSNAs), 99, 116

Toluene, aerosolized, 118–119

Toxicants

aerosolization process, 114, 118–119

aerosolized adulterants, 100, 116–117

fetal development, 108, 109

flavorants, 116

prenatal exposure, 108, 109

TPD (Tobacco Product Directive), 222t

Trade organizations and partnerships, e-cigarettes, A4.3-2

Trigeminocardiac reflex, SIDS and maternal smoking, 109

Trinkets & Trash archive, 158

TruNic, A4.1-12t

Truth Initiative (American Legacy Foundation), 158, 159, 163

TSNAs (tobacco-specific nitrosamines), 99, 116

21st Century Smoke e-cigarettes

market share, (2010–2014), A4.5-2 to A4.5-5f

sales (2010–2014), 153f, A4.4-2 to A4.4-6t

website access restrictions, 166t

Twitter

advertising, 157

coupons and discounts, 163

distribution and purchase channels, 150

e-cigarette promotion, 166, 167

e-cigarettes, 15

2-methoxycinnamaldehyde, cytotoxicity of, 116

2,3-butanedione (diacetyl), aerosolized flavorant, 116

U

Uniform tax rate systems, 204

United Nations Educational, Scientific and Cultural Organization 

(2005), 183

USA Liquid Nicotine/USA Laboratories, A4.1-12t

U.S. Coast Guard, 196t

U.S. Department of Agriculture (USDA), 190t

U.S. Department of Defense (DoD), 188, 191t

U.S. Department of Education, 192t

U.S. Department of Health and Human Services (USDHHS)

National Advisory Council on Drug Abuse, 195t

National Institute on Drug Abuse, 195t

National Institutes of Health, 195t

preparation of Surgeon General’s report (2016), 4–5

Substance Abuse and Mental Health Services Administration, 196t

tobacco screening and cessation, 193–194t

U.S. Department of Homeland Security (DHS)

Bureau of Immigration and Customs Enforcement, 196t

Coast Guard, 196t

U.S. Department of Housing and Urban Development (HUD), 197t

U.S. Department of Justice

Bureau of Alcohol, Tobacco, Firearms and Explosives, 198t

Bureau of Prisons, 198t

U.S. Department of Labor, 199t

U.S. Department of Transportation (DOT)

e-cigarette regulations, 188

Pipeline and Hazardous Materials Safety Administration, 199t

tobacco use on aircraft, 199t

U.S. Department of Treasury, 200t

U.S. Department of Veterans Affairs, 188, 201t

U.S. Environmental Protection Agency (EPA)

e-cigarette regulations, 188, 201t

formaldehyde as carcinogenic, 117

U.S. Federal Trade Commission (FTC)

agency profile and policies, 189t

description and authority of, 201t

monitoring advertising, 246

public health agency interaction, 206

source disclosure of advertorials, 205–206

tar and nicotine content in advertising, 9

U.S. Fire Administration, 119

U.S. Food and Drug Administration (FDA)

areas not authorized to regulate, 242

authority to regulate tobacco products, 9, 238

Center for Devices and Radiological Health (CDRH), 16

Center for Drug Evaluation and Research (CDER), 16

Center for Tobacco Products (CTP), 17, A2.1-3

deeming rule, 6, 17

e-cigarette regulation as tobacco products, 16–17

e-cigarette rules, 241–242

e-cigarette shipments, denying entry to, 16

future regulatory options, 17–18

litigation against, 187, A4.2-2

minimum age requirements in retail environments, 167

nicotine regulation, 9–10, 183, 187–188
A Report of the Surgeon General

274 Index

PATH study. See Population Assessment of Tobacco and 

Health (PATH) study

product warnings, 206, 211t, 213t, 216t, 240–241

Sottera, Inc. v. U.S. Food and Drug Administration, 16, 241, 

A4.2-2

tobacco product regulation, 9–10, 15–16

U.S. Pharmacopeia (USP), 114

U.S. Preventive Services Task Force, 206

U.S. Supreme Court, 9

U.S. Trade Representative (USTR), 189t

Us Weekly magazine, 159

V

V2cigs

plasma nicotine concentration, 103f

sales (2010–2014), 153f, A4.4-2 to A4.4-6t

Vape Holdings, Inc., A4.1-6t

Vape pens

components of, 12f

term usage, 3

Vape shops

clean indoor air, legislation, 225

e-cigarette sales, 14, 203

e-liquid mixing, 120

market for e-cigarettes in the U.S., 149, 150–151, 150t, 168–169

Vape tanks, components of, 12f. See also Tank devices (“mods”)

Vegetable glycerin (VG)

aerosol inhalation, 115

nose-only exposure to, 114

Vending machine sales, regulation, 203, 242

Visual processing, deficits in, with maternal smoking, 110

Volatile organic compounds (VOCs), 118–119

VUSE e-cigarettes

distribution and purchase channels, 150

manufacturer, 15t

market share (2014), A4.5-5f

promotion of, 152, 153f, 158

website information, 165, 166, 166t

W

Warning labels

on e-cigarettes, 206, 211t, 213t

on refill bottles, 216t

on tobacco products, 240–241

Whites. See Race/ethnicity

WIC program, 190t

Withdrawal symptoms (physical abstinence syndrome)

conventional cigarettes, 102

e-cigarettes, A3.1-3 to A3.1-6t

Workplace exposure, e-cigarette aerosol, 123

World Health Organization (WHO)

indoor air quality, 122

position on ENDS, 219–220t

Tobacco Laboratory Network, 200t

X

Xylenes, aerosolized, 118–119

Y

Young adolescents, ages of, 4

Young adults. See also Surgeon General Call to Action

ages of, 4

awareness of consequences of e-cigarettes, 240

current prevalence of e-cigarette use, 37, 38t

e-cigarette use

intentions to use summary data, A2.3-20 to A2.3-22t

items from PATH, A2.2-10 to A2.2-15t

items from sources of national data, A2.2-5 to A2.2-19t

patterns of use summary data, A2.3-5, A2.3-23 to A2.3-37t

survey data sources, A2.1-4 to A2.1-5t

surveys, A2.1-3

susceptibility summary data, A2.3-20 to A2.3-22t

flavors in e-cigarettes, 59, 60t

perceived harm of e-cigarettes, 64, 74t, 75

poly-tobacco use, 53, 53f, 54t

prevalence of e-cigarette use, 204, A2.3-3

Surgeon General’s reports focusing on, 4

trends in prevalence of e-cigarette use, 37, 40f

Youth. See also High school students; Surgeon General Call to 

Action

access prevention policies, 203

advertising and marketing restrictions, 208t

ages of, 4

attention and cognition with nicotine exposure, 106

awareness of consequences of e-cigarettes, 240

current e-cigarette use, increase of, 10

current prevalence of e-cigarette use

ever use, 28, 29t, 30t

frequency of use, 28, 29t, 30t

past-30-day use, 28, 31t, 32t

susceptibility to use, 28, 29t, 30t

e-cigarettes, as most commonly used tobacco product, 5

e-cigarette use

higher than other tobacco products, 211t

intentions to use summary data, A2.3-20 to A2.3-22t

items from PATH, A2.2-10 to A2.2-15t

items from sources of national data, A2.2-5 to A2.2-9t

nicotine exposure effects, human studies, A3.1-8 to A3.1-17t

nicotine exposure effects, preclinical/animal studies, 

A3.1-18 to A3.1-32t

patterns of use summary data, A2.3-4, A2.3-6 to A2.3-19t

survey data sources, A2.1-4 to A2.1-5t

survey descriptions, A2.1-2

susceptibility summary data, A2.3-20 to A2.3-22t

flavored little cigars and cigarillos, 11

flavors in e-cigarettes, 59, 60t

legislation to curb tobacco sales, 224

mood disorders with nicotine exposure, 107

nicotine, effects of, 104–107

perceived harm of e-cigarettes, 64, 73t, 74t
E-Cigarette Use Among Youth and Young Adults

Index 275

poly-tobacco use, cross-sectional studies of

current prevalence, 37, 40f, 41–42t, 43, 44t, 45t, 46f

trends in prevalence, 43, 47–48t, 49–50t, 51f, 52f, 53

prevalence of e-cigarette use, 204–205, A2.3-2 to A2.3-3

restricting access to e-cigarettes, 244–245

reward-seeking behaviors, 106

Surgeon General’s reports focusing on, 4

tobacco cessation services, 193t

trends in prevalence of e-cigarette use

ever use, 28, 33, 33f, 34t, 35t

past-30-day use, 31t, 32t, 36–37, 36f

Youth Risk Behavior Surveillance System (YRBSS)

overview and methods, A2.1-4 to A2.1-5

data for report, source for, 27

e-cigarette use

current prevalence, 28

patterns of use, 2015 survey, A2.3-2

sources of national data, A2.1-4 to A2.1-5t

YouTube

distribution and purchase channels, 150, 151

e-cigarette promotion, 166–167

e-cigarettes, 15