TECHNICAL NOTE ON

Call to action on
electronic cigarettes
Why is there a need for a call to action?
WHO works with numerous independent experts, and is continuously reviewing the latest empirical
scientific evidence, on electronic cigarettes through its technical advisory groups on product regulation.
As part of this, the WHO Study Group on Tobacco Regulation (TobReg) has published a number of reports
which contain evidence-based recommendations on electronic nicotine delivery systems and electronic
non-nicotine delivery systems (ENDS and ENNDS), colloquially referred to as e-cigarettes. Policy options
guided by evidence have also been articulated in the reports and decisions of the Conference of the
Parties to the WHO Framework Convention on Tobacco Control (WHO FCTC). Although there are still
several unknowns, including the precise quantification of risk of these products, the uptake of these
products by children and adolescents, and other non-smokers has increased rapidly in many countries.
Some of this uptake is potentially occurring as an attempt to stop smoking, but the evidence does
not support the conclusion that e-cigarettes as actually used as consumer (non-therapeutic) products
under real world conditions, are effective for cessation at the population level. Urgent and strong action
is thus necessary to reduce the risk of uptake, and the following factors underpin the call to action.

The global market for electronic cigarettes is Marketing of e-cigarettes usually relies heavily on social
growing rapidly. Since 2018, there has been a large media and influencers, rapidly expanding their reach
increase in the global e-cigarette market size, from (3,11). Studies illustrate the impact on adolescents;
7,806 million USD in 2015 to 22,349 million USD one study showed that daily use of one social media
in 2022 (1). In the last five years, between 2018 and platform among middle school students was associated
2022, there has been a market increase of 116% for with a 3.8% increase in risk of current e-cigarette usage
disposable e-cigarettes (2), with over 550,000 different and an associated 6.1% increase among high school
products,1 and accounting for 22% of the total global students (12). Another found that each additional
e-cigarette market (2). hour per day spent on the platform among first-year
university students was associated with a 4.6% in-
Electronic cigarettes come in thousands of crease in the probability of lifetime e-cigarette use (13).
flavours, which are particularly attractive to Even brief exposure to e-cigarette content on social
children and young people. E-cigarettes offer, media was associated with greater intention to use
by far, the largest number of flavours of all nicotine these products, as well as more positive attitudes
and tobacco products (3). There were approximately toward e-cigarettes (14). These products are por-
16,000 unique flavours identified for e-cigarettes in trayed as cool, with attractive colours and appealing
2017, more than double those in 2014 (4). Many of the names. For example, one major brand advertises “big
flavours appeal to young people and some mask the vapour clouds” and contains a patent that provides
harshness of nicotine (5). E-cigarette flavours are clas- for connectivity to a smartphone that would allow
sified in various categories, including tobacco, men- the user to control the size of the cloud (15). Once
thol, fruit, dessert, alcohol, nut, spices, confectionery, the information is on a smartphone, it could become
coffee/tea, beverages and sweet-like flavours (5). accessible and potentially be transmitted to the pro-
Flavours play a key role in product use initiation, as ducer for marketing purposes. Many e-cigarettes
they are often cited as the one of the reasons for youth are also designed to allow discreet use, marketed
trying e-cigarettes (as with other nicotine and tobacco as such, and some can be integrated into hoodies,
products), serving as a path from experimentation or resemble lipsticks and watches, so they can be
to regular use, and perpetuating the global tobacco hidden, especially from teachers and parents (16).
epidemic (6–10). E-cigarettes are particularly marketed in ways that
are inconsistent with public health goals, leading to
Children and young people are aggressively marked increases in their use among adolescents in
targeted in marketing of electronic cigarettes. many countries that often exceed adult use (5,17).
1 WHO-commissioned paper on disposable electronic cigarettes

2
There is an increased uptake of electronic studies consistently demonstrate that e-cigarettes use
cigarettes among young people. Young people increases conventional cigarette uptake, particularly
in many countries are increasingly taking up the use among non-smoking youth, by nearly three times (27).
of e-cigarettes and this trend has been reported to be
of great public health concern by several countries Disposable electronic cigarettes, particularly
(9,10,18–20). The number of 16–19-year-olds who popular among youth, have increased in size,
currently use e-cigarettes in Canada has doubled from contain much more nicotine than before and are
2017 to 2022 (20), and in England (United Kingdom), increasingly cheaper and accessible. ‘Disposable’
the number has tripled in the past three years (21). (non-rechargeable and non-refillable) e-cigarettes sold
Across Canada, England (United Kingdom) and the in the USA have nearly tripled in nicotine strength
United States, between 40% and 50% of those that use (dubbed as the “nicotine strength arms race”), quin-
e-cigarettes reported use within 30 minutes of wak- tupled in e-liquid capacity, and dropped in price by
ing (20). Further, 56- 64% of the 16-19-year-olds that nearly 70% between 2017 and 2022 (28). The current
reported using e-cigarettes across the three countries generation of disposable e-cigarettes in the USA con-
considered themselves to be addicted (either ‘a little’ tain nicotine levels comparable to several cartons of
or ‘very’) to e-cigarettes (20). Evaluation of available cigarettes (28,29). In contrast to 2017, in which nearly
information from the Global Tobacco Surveillance no disposable e-cigarettes contained among the high-
System reveals that current use of e-cigarettes by est levels of nicotine (at least 5% nicotine strength), by
school-aged children 13–15-year-olds often exceeds 2022, more than 95% of disposable e-cigarettes sold in
those of the older age groups (≥ 15 years) (22). For the USA did (28). Additionally, with the plummeting
example, in the Philippines, Romania, Ukraine and of prices the purchasing power for price sensitive
Uruguay, comparisons within a similar time period youth has nearly tripled in the USA (28). A review of
shows a range of 0.2-3.4% of adults currently us- global sales data between 2019 and 2022 in the major
ing e-cigarettes, in comparison to 8.2-18.4% in the markets similarly show increases in tank capacity,
young (22). Additionally, in many countries and areas, particularly within non-EU markets, as well as price
such as Albania, Belarus, the Dominican Republic, decreases, by 30–50% (2).
Guam, Morocco, Niue, Oman, the Russian Federation
and Ukraine, the current use of e-cigarettes among Electronic cigarettes are harmful. E-cigarettes
13–15-year-olds is 2–3 times more prevalent than heat a liquid to create aerosols that are inhaled by the
those currently smoking conventional cigarettes, and user (30). E-liquids may or may not contain nicotine
in Paraguay, it is four-fold (22). Similarly, in England and other additives, flavours and chemicals – many
(United Kingdom), more children now “vape” than of which are toxic to people’s health (30). E-cigarettes
smoke (23). In an additional cross-country analysis generate substances some of which are known to cause
among 13–15-year-olds, which examined data from cancer and, on their own, they are associated with
75 countries globally, prevalence of current dual use increased risk of lung disorders, poisoning, injuries
(simultaneous use of e-cigarettes and conventional and burns and immediate nicotine toxicity through
cigarettes) ranged from 0.1% in Cambodia to 10.0% inhalation (5,27). E-cigarettes can have negative ef-
in Italy and 13.6% in Poland (24). Current dual use fects on cardiovascular health, including increased
was fivefold higher among boys compared to girls heart rate and blood pressure. Exposure to emissions
(24). Further, a study among 15–16-year-olds across from e-cigarettes also poses risks to bystanders (5).
32 countries in Europe shows 6.4% overall current All e-cigarettes emit toxic chemicals, often including
dual use (25). Within a smaller subset, of six Nordic nicotine, the highly addictive substance in tobacco
countries and jurisdictions, prevalence of current that can adversely affect the development of the fetus
dual use ranged from 23% to 31% (26). The co-use in a pregnant woman and can affect the develop-
of cigarettes and e-cigarettes is the most common ment of children’s and adolescents’ brain (5,27). These
pattern of current dual use in the majority of these age groups are highly susceptible to nicotine addic-
countries (26). In all six countries studied, triple use tion (31). Additional concerns arise regarding custom-
(e-cigarettes plus conventional cigarettes plus snus) izable electronic cigarettes that allow the user to in-
varies between 3% to 13% among current e-cigarette crease nicotine uptake, as well as newer disposable and
users (26). Additionally, high quality epidemiology pod systems that have higher nicotine delivery (27).

3
Dual use, which is common, is at least as dangerous under national law requiring evidence of their efficacy
and likely more dangerous than smoking conven- and safety, with authorities attaching any necessary
tional cigarettes or using e-cigarettes alone (32). conditions to authorization, taking account of the risk
of uptake, and whether products should be available
Electronic cigarettes as actually used in the on a prescription-only or over the counter basis.
population as consumer products have not
been proven to be effective for cessation at There is a wide diversity of electronic cigarettes,
the population level and may lead to ongoing many of which allow the user to customise the
nicotine dependence. One of the reasons given products, including increasing nicotine uptake,
for use of e-cigarettes is to quit smoking (33,34). and/or the level of toxicants. E-cigarettes vary
Despite being promoted for this purpose, e-cigarettes greatly and are evolving rapidly, even within the broad
as used in the real-world, have not been proven to categories of open systems (refillable tanks and cus-
be effective for smoking cessation at the population tomizable), and closed systems (pre-filled cartridges
level (35,36). While there is some evidence from or pods and disposables that are not meant to be
randomized controlled trials that nicotine contain- modified) (5). The extent of the delivery of nicotine
ing e-cigarettes, as medical interventions in clinical depends both on the concentration of nicotine in
settings and when used daily, can assist in stopping the e-liquid itself and a variety of factors of which
smoking cigarettes (37), a meta-analysis examining the user of an open-system system or manufacturer
nicotine abstinence found that randomization to of a closed system could manipulate (5). Devices
e-cigarettes was associated with significantly lower can be manipulated to produce a satisfactory expe-
odds of being nicotine free than nicotine replacement rience in terms of the speedy delivery of sufficient
therapy (38) and others reported high continuing nicotine to mimic the sensory feel of smoking (43).
use of e-cigarettes among people who had stopped By controlling the desired delivery of nicotine, the
cigarettes (39,40), suggesting that e-cigarettes may user of an open system can also often unknowingly
lead to ongoing dependence on nicotine. The lack of negatively influence the extent to which e-cigarettes
evidence on the safety of e-cigarettes for major health emit non-nicotine toxicants (3), as well as emissions
outcomes combined with the risk of ongoing depen- to which bystanders are exposed (5). The levels of
dence limits any conclusions regarding the overall toxicants can vary enormously across and within
balance of benefits and harms of using e-cigarettes brands and sometimes reach higher levels than in
to quit smoking, as compared with other approaches. tobacco smoke (44,45).
For a product to be appropriate for cessation, it must
demonstrate both efficacy and safety. • Device characteristics – battery power and customiz-
Currently, the evidence does not support a gen- able wattage. The voltage of the battery and default
eralizable conclusion that commercialization of e- power settings differ widely among models, and
cigarettes as consumer products will improve popula- more advanced devices often allow the user to adjust
tion health by supporting tobacco use cessation. Use the power settings (5). The electrical power gener-
of e-cigarettes as consumer products has not proven ated in the device can determine the amount of
effective for cessation at the population level, as actu- nicotine and toxicants to which the user is exposed.
ally used in the real world (5,27,41,42). Given the risk Increasing the device power increases nicotine
of uptake, it is not recommended that governments yields, with one study finding that increasing the
permit sale of e-cigarettes as consumer products in power output from 3 to 7.5 W increased the nicotine
pursuit of a cessation objective. Recognizing that there yield by four or five times (3). However, increas-
is emerging evidence of some e-cigarettes potentially ing the power from 4.1 to 8.8 W approximately
playing a role in supporting cessation under con- tripled volatile aldehyde emissions; increasing the
trolled medical conditions, it is recommended that power from 6 to 13 W increased emissions of the
any cessation objective governments may have utiliz- carcinogen benzene 100 times (44). While earlier
ing e-cigarettes, be pursued by regulating e-cigarettes models were powered at about 10 W, some mod-
as medicines - with a comprehensive tobacco control els have increased to more than 250 W, thereby
strategy. This means subjecting specific products to increasing the risk of users’ exposure to harmful
marketing authorization procedures for medicines and potentially harmful constituents (5,44).

4
 • Liquid constituents – choice of e-liquid. The nico- products, and now with new and emerging tobacco
tine content of e-liquids in pre-filled devices can and nicotine products. This means that research and
contain very high levels of nicotine of > 60 mg/ advocacy funded by tobacco companies and their front
mL (3,27), and “do-it-yourself ” liquids can reach groups cannot be accepted at face value. The sixth
levels of nicotine of about 130 mg/mL (3). In ad- session of the Conference of the Parties to the WHO
dition to nicotine, e-cigarette emissions contain Framework Convention on Tobacco Control (WHO
other toxicants, which are either present in the FCTC) stressed the critical need to protect public
liquid or are formed by thermal breakdown of the health from the interests of “all commercial and other
liquid’s ingredients (44). Flavours in e-cigarettes vested interests related to ENDS/ENNDS, including
can increase the general toxicity of the aerosols (3). interests of the tobacco industry” (51). In a review of
Several flavourings have raised health concerns (44). 105 studies analysing the composition of liquids and
Fourth generation e-cigarettes (pods, pod mods emissions, 30% had authors that had received funding
and disposables) almost exclusively contain high from ENDS/ENNDS interests – including the tobacco
concentration nicotine salt e-liquid, which makes industry and related industries (43).
the nicotine easier to inhale and increases delivered
dosage, creating greater dependence potential than Insufficient country level action. Very few coun-
other products (27). In addition, open systems al- tries have measures in place to protect children from
low the users to fill the tank of their device with e-cigarettes (30). E-cigarettes also carry the additional
the mixtures they want (5). Users commonly mix risk of renormalizing smoking behaviour, particularly
and match flavours in refillable systems, and “do- among younger populations. 88 countries, covering
it-yourself ” is a common practice, sometimes with a population of 2.3 billion people, have no minimum
the addition of illicit substances (3). age at which these products can be bought and 74
countries, with over 2 billion people, have no regu-
• User behaviour – user’s puffing style. Increasing lations in place addressing e-cigarettes (30). These
puffing intensity can generate more nicotine in products are regulated in some way in 121 countries,
the smoke (7). By puffing more intensely, some including 34 countries that have banned their sale
users of e-liquids with low nicotine strength can and 4 that ban all flavours (30).
also achieve the same amount of nicotine per puff
as high nicotine liquid users (3). More intensive A comprehensive approach to tobacco control.
puffing patterns can also expose users to higher Countries should implement a comprehensive ap-
amounts of toxicants, including an increase of the proach to tobacco control, which includes raising
production of carbonyls, which have been cor- tobacco excise taxes, bans on tobacco advertising, pro-
related with pulmonary disease in smokers (3). motion and sponsorship, health warnings, smoke-free
areas, and mass-media campaigns. This call to action
Labelling is not always accurate. Much remains is intended to prompt action in parallel with WHO
unknown about all the contents of the wide variance FCTC implementation for Parties, which in addition
in e-liquids, as well as their emissions (45). These to stipulating that Parties develop appropriate policies
products are not routinely tested by governments, for preventing and reducing tobacco consumption,
mainly due to lack of capacity, and people are not as well as exposure to tobacco smoke, requires Par-
aware of what they are ingesting (46). Further, studies ties to adopt policies to prevent and reduce nicotine
have found that labelling is not consistently a reliable addiction. Therefore, the measures recommended
indicator of nicotine content and mislabelling is a above to strengthen action on e-cigarettes should
common issue (47,48). form part of a comprehensive approach to tobacco
control and should be implemented in line with
Commercial and other vested interests related to national circumstances, including existing tobacco
e-cigarettes harm public health. There is a “funda- control measures. Accordingly, the approach that a
mental conflict of interest between the tobacco indus- government takes to regulation of e-cigarettes (such
try and public health” (49). The tobacco industry and as whether to ban sale or permit commercialization
its front groups (50) have a long history of misleading as consumer products) should be considered in light
the public about the risks associated with tobacco of national circumstances.

5
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