Regulating E-Cigarettes

Non-combustible tobacco and nicotine products—electronic cigarettes, or e-cigarettes, being by far the most common—have become increasingly popular around the world, particularly among youth, but too many countries have yet to regulate them. In 2022, 121 countries regulated these products, while 74 did not. Of the 121, 34 countries banned their sale and 87 countries—with a total of 3.3 billion people—adopted either full or partial regulations. Moreover, nearly half of countries (47 percent) are not monitoring e-cigarette use among adolescents, and 67 percent (122 countries) have no data on adult use, which highlights a significant lapse in surveillance. The rapidly growing and evolving markets for both e-cigarettes and heated tobacco products (HTPs) demand immediate and effective action by governments.

The governments that have acted—mostly high- and middle-income countries—have implemented a variety of policies ranging from sales bans on e-cigarettes to subjecting them to some or all the country’s tobacco control regulations. For HTPs, which heat sticks of tobacco just short of combustion to produce a harmful aerosol, though clearly subject to FCTC provisions as tobacco products, many countries are not yet implementing these provisions for them. Additionally, authorities have to be vigilant as the tobacco industry attempts to blur the distinctions between HTPs and electronic cigarettes. Through these efforts, the industry seeks to exploit legal loopholes that allow for commercialization of these products under e-cigarettes’ typically lighter regulatory frameworks.

A relative consensus about how to regulate e-cigarettes is emerging. For countries that have not opted to ban e-cigarette sales, implementation of a package of regulations similar to those proven effective to curb smoking is most promising. Such regulatory packages include:

• Apply and regularly raise taxes to make these products less affordable to prevent initiation, particularly among the youth (though synchronizing them with cigarette taxes to avoid substitution).
• Ban use of these products in public places and never exempt them from indoor smoke-free places to protect non-users from exposure to the products’ harmful emissions.
• Ban advertising, promotion, and sponsorship of these products to prevent companies from making them attractive to children and non-tobacco users.
• Require mandatory graphic health warnings in line with regulations applied to combustible tobacco products.
• Ban flavours because they are largely used to attract children.
• Implement minimum age restrictions in line with cigarettes (e.g., 21 years).
• Expand tobacco surveillance systems to monitor use of these products, both among adults and adolescents.
• Offer evidence-based cessation strategies for users who want to quit.

While this consensus was already reached among WHO FCTC Parties in 2016 and reaffirmed in 2018, the global regulatory panorama for electronic cigarettes remains disappointing.

Against this background, in most countries tobacco and related nicotine industries remain free to carry out aggressive marketing of these products—particularly targeting young people through their modern designs, use of flavors, and endorsement by social media influencers, among other strategies. In some countries the tobacco industry claims they are a cessation tool, but in very few are they marketed—or regulated—this way. Unless government action is taken, commercialization and consumption of novel products is likely to grow around the world.

A total of 121 countries have acted, with 34 of them banning sales of electronic cigarettes and 87 allowing their sale while applying at least one major tobacco control regulation (not including excise tax).

The global regulatory panorama is not static, mainly due to the tobacco and related nicotine industries consistently pressuring governments to approve authorizations for the commercialization of these products, pushing for reversing sales bans where they exist, and asking for these products to be exempt from existing or potential regulations (particularly marketing bans, taxation, and smoke-free laws). As almost all major multinational tobacco corporations—such as British American Tobacco, Philip Morris International, and Japan Tobacco International—have developed their own non-combustible tobacco products and/or purchased large shares of existing e-cigarette companies, these corporations seek to muddy the debate about regulating these products by propagating false and misleading claims about their health effects.

Countries that have not yet acted should consider the decisions by the FCTC Conference of the Parties. In deciding the best policy path, these decisions compel Parties to consider:

• their tobacco control goals;
• the size of the market/level of consumption of e-cigarettes;
• availability of illegal distribution networks;
• capacity to enforce regulations including curbing illicit trade; and
• compliance of existing tobacco control measures with the FCTC, particularly those related to marketing.

Countries should also note that where these products are available, experimentation by adolescents and young adults is a challenge, even in countries with sales bans, which are circumvented among other ways by internet sales targeted at youth. Countries should regularly collect data on the uptake of these products by their population, particularly among youth, regardless of regulatory status. Moreover, experiences in countries with sales bans illustrate the importance of accompanying them with:

• regulations banning their use in public places by extending smoke-free laws to these products;
• close surveillance in schools; and
• effective action to eliminate illegal sales with special attention to those through internet.

Even in the United Kingdom (UK), which has an active program to move cigarette smokers to electronic cigarettes, the government recently released a report that includes their concerns on rapid youth uptake. The UK government has realized that it needs to pay significantly more attention to what has been and is happening among youth on this issue.

Heated tobacco products

Regulation of HTPs varies considerably across the world. In 2023, at least 18 countries banned HTPs. Being tobacco products, they should at a minimum be regulated as any other tobacco products and in no case be excepted from tobacco regulation. Many countries are generally behind in tobacco product regulation, which means that where HTPs are not banned, they can be marketed easily to young populations.

Conclusion

There are three decisions by recent FCTC Conferences of Parties explicitly addressing electronic cigarette or HTP regulation, and there is consensus that Parties should regulate these products within the Framework. Therefore, countries have both an obligation and a clear policy framework for achieving this important public health goal.