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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