smoking cigarettes thesis statement

235 Smoking Essay Topics & Examples

Looking for smoking essay topics? Being one of the most serious psychological and social issues, smoking is definitely worth writing about.

🏆 Best Smoking Essay Examples & Topic Ideas

🥇 good titles for smoking essay, 👍 best titles for research paper about smoking, ⭐ simple & easy health essay titles, 💡 interesting topics to write about health, ❓ essay questions about smoking.

In your essay about smoking, you might want to focus on its causes and effects or discuss why smoking is a dangerous habit. Other options are to talk about smoking prevention or to concentrate on the reasons why it is so difficult to stop smoking. Here we’ve gathered a range of catchy titles for research papers about smoking together with smoking essay examples. Get inspired with us!

Smoking is a well-known source of harm yet popular regardless, and so smoking essays should cover various aspects of the topic to identify the reasons behind the trend.

You will want to discuss the causes and effects of smoking and how they contributed to the persistent refusal of large parts of the population to abandon the habit, even if they are aware of the dangers of cigarettes. You should provide examples of how one may become addicted to tobacco and give the rationales for smokers.

You should also discuss the various consequences of cigarette use, such as lung cancer, and identify their relationship with the habit. By discussing both sides of the issue, you will be able to write an excellent essay.

Reasons why one may begin smoking, are among the most prominent smoking essay topics. It is not easy to begin to enjoy the habit, as the act of smoke inhalation can be difficult to control due to a lack of experience and unfamiliarity with the concept.

As such, people have to be convinced that the habit deserves consideration by various ideas or influences. The notion that “smoking is cool” among teenagers can contribute to the adoption of the trait, as can peer pressure.

If you can find polls and statistics on the primary factors that lead people to tweet, they will be helpful to your point. Factual data will identify the importance of each cause clearly, although you should be careful about bias.

The harmful effects of tobacco have been researched considerably more, with a large body of medical studies investigating the issue available to anyone.

Lung cancer is the foremost issue in the public mind because of the general worry associated with the condition and its often incurable nature, but smoking can lead to other severe illnesses.

Heart conditions remain a prominent consideration due to their lethal effects, and strokes or asthma deserve significant consideration, as well. Overall, smoking has few to no beneficial health effects but puts the user at risk of a variety of concerns.

As such, people should eventually quit once their health declines, but their refusal to do so deserves a separate investigation and can provide many interesting smoking essay titles.

One of the most prominent reasons why a person would continue smoking despite all the evidence of its dangers and the informational campaigns carried out to inform consumers is nicotine addiction.

The substance is capable of causing dependency, a trait that has led to numerous discussions of the lawfulness of the current state of cigarettes.

It is also among the most dangerous aspects of smoking, a fact you should mention.

Lastly, you can discuss the topics of alternatives to smoking in your smoking essay bodies, such as e-cigarettes, hookahs, and vapes, all of which still contain nicotine and can, therefore, lead to considerable harm. You may also want to discuss safe cigarette avoidance options and their issues.

Here are some additional tips for your essay:

• Dependency is not the sole factor in cigarette consumption, and many make the choice that you should respect consciously.
• Cite the latest medical research titles, as some past claims have been debunked and are no longer valid.
• Mortality is not the sole indicator of the issues associated with smoking, and you should take chronic conditions into consideration.

Find smoking essay samples and other useful paper samples on IvyPanda, where we have a collection of professionally written materials!

• How Smoking Is Harmful to Your Health The primary purpose of the present speech is to inform the audience about the detrimental effects of smoking. The first system of the human body that suffers from cigarettes is the cardiovascular system.
• Smoking: Problems and Solutions To solve the problem, I would impose laws that restrict adults from smoking in the presence of children. In recognition of the problems that tobacco causes in the country, The Canadian government has taken steps […]
• Conclusion of Smoking Should Be Banned on College Campuses Essay However, it is hard to impose such a ban in some colleges because of the mixed reactions that are held by different stakeholders about the issue of smoking, and the existing campus policies which give […]
• Should Smoking Be Banned in Public Places? Besides, smoking is an environmental hazard as much of the content in the cigarette contains chemicals and hydrocarbons that are considered to be dangerous to both life and environment.
• Smoking Cigarette Should Be Banned Ban on tobacco smoking has resulted to a decline in the number of smokers as the world is sensitized on the consequences incurred on 31st May.
• Causes and Effects of Smoking Some people continue smoking as a result of the psychological addiction that is associated with nicotine that is present in cigarettes.
• Should Cigarettes Be Banned? Essay Banning cigarette smoking would be of great benefit to the young people. Banning of cigarette smoking would therefore reduce stress levels in people.
• Advertisements on the Effect of Smoking Do not Smoke” the campaign was meant to discourage the act of smoking among the youngsters, and to encourage them to think beyond and see the repercussions of smoking.
• Smoking Cessation Programs Through the Wheel of Community Organizing The first step of the wheel is to listen to the community’s members and trying to understand their needs. After the organizer and the person receiving treatment make the connection, they need to understand how […]
• Smoking: Effects, Reasons and Solutions This presentation provides harmful health effects of smoking, reasons for smoking, and solutions to smoking. Combination therapy that engages the drug Zyban, the concurrent using of NRT and counseling of smokers under smoking cessation program […]
• On Why One Should Stop Smoking Thesis and preview: today I am privileged to have your audience and I intend to talk to you about the effects of smoking, and also I propose to give a talk on how to solve […]
• Tobacco Smoking and Its Dangers Sufficient evidence also indicates that smoking is correlated with alcohol use and that it is capable of affecting one’s mental state to the point of heightening the risks of development of disorders.
• Smoking and Its Negative Effects on Human Beings Therefore, people need to be made aware of dental and other health problems they are likely to experience as a result of smoking.
• Smoking and Its Effects on Human Body The investigators explain the effects of smoking on the breath as follows: the rapid pulse rate of smokers decreases the stroke volume during rest since the venous return is not affected and the ventricles lose […]
• Smoking Among Teenagers as Highlighted in Articles The use of tobacco through smoking is a trend among adolescents and teenagers with the number of young people who involve themselves in smoking is growing each day.
• Quitting Smoking: Strategies and Consequences Thus, for the world to realize a common positive improvement in population health, people must know the consequences of smoking not only for the smoker but also the society. The first step towards quitting smoking […]
• “Thank You For Smoking” by Jason Reitman Film Analysis Despite the fact that by the end of the film the character changes his job, his nature remains the same: he believes himself to be born to talk and convince people.
• Hookah Smoking and Its Risks The third component of a hookah is the hose. This is located at the bottom of the hookah and acts as a base.
• Teenage Smoking and Solution to This Problem Overall, the attempts made by anti-smoking campaigners hardly yield any results, because they mostly focus on harmfulness of tobacco smoking and the publics’ awareness of the problem, itself, but they do not eradicate the underlying […]
• Social Marketing: The Truth Anti-Smoking Campaign The agreement of November 1998 between 46 states, five territories of the United States, the District of Columbia, and representatives of the tobacco industry gave start to the introduction of the Truth campaign.
• Cigarette Smoking in Public Places Those who argue against the idea of banning the smoking are of the opinion that some of them opt to smoke due to the stress that they acquire at their work places.
• Ban of Tobacco Smoking in Jamaica The first part of the paper will address effects of tobacco smoking on personal health and the economy. Cognizant of its international obligation and the aforementioned health effects of tobacco smoke, Jamaica enacted a law […]
• Should Smoking Tobacco Be Classified As an Illegal Drug? Although this is the case, the tobacco industry is one of the most profitable industries, a fact that has made it very hard for the government to illegalize the use of tobacco products.
• A Peer Intervention Program to Reduce Smoking Rates Among LGBTQ Therefore, the presumed results of the project are its introduction into the health care system, which will promote a healthy lifestyle and diminish the level of smoking among LGBTQ people in the SESLHD.
• Health Promotion for Smokers The purpose of this paper is to show the negative health complications that stem from tobacco use, more specifically coronary heart disease, and how the health belief model can help healthcare professionals emphasize the importance […]
• Gender-Based Assessment of Cigarette Smoking Harm Thus, the following hypothesis is tested: Women are more likely than men to believe that smoking is more harmful to health.
• Hazards of Smoking and Benefits of Cessation Prabhat Jha is the author of the article “The Hazards of Smoking and the Benefits of Cessation,” published in a not-for-profit scientific journal, eLife, in 2020.
• The Impact of Warning Labels on Cigarette Smoking The regulations requiring tobacco companies to include warning labels are founded on the need to reduce nicotine intake, limit cigarette dependence, and mitigate the adverse effects associated with addiction to smoking.
• Psilocybin as a Smoking Addiction Remedy Additionally, the biotech company hopes to seek approval from FDA for psilocybin-based therapy treatment as a cigarette smoking addiction long-term remedy.
• Investing Savings from Quitting Smoking: A Financial Analysis The progression of interest is approximately $50 per year, and if we assume n equal to 45 using the formula of the first n-terms of the arithmetic progression, then it comes out to about 105 […]
• Smoking as a Community Issue: The Influence of Smoking A review of the literature shows the use of tobacco declined between 1980 and 2012, but the number of people using tobacco in the world is increasing because of the rise in the global population.
• Smoking Public Education Campaign Assessment The major influence of the real cost campaign was to prevent the initiation of smoking among the youth and prevent the prevalence of lifelong smokers.
• Quitting Smoking and Related Health Benefits The regeneration of the lungs will begin: the process will touch the cells called acini, from which the mucous membrane is built. Therefore, quitting the habit of smoking a person can radically change his life […]
• Smoking and Stress Among Veterans The topic is significant to explore because of the misconception that smoking can alleviate the emotional burden of stress and anxiety when in reality, it has an exacerbating effect on emotional stress.
• Smoking as a Predictor of Underachievement By comparing two groups smoking and non-smoking adolescents through a parametric t-test, it is possible to examine this assumption and draw conclusions based on the resulting p-value.
• Smoking and the Pandemic in West Virginia In this case, the use of the income variable is an additional facet of the hypothesis described, allowing us to evaluate whether there is any divergence in trends between the rich and the poor.
• Anti-Smoking Policy in Australia and the US The anti-smoking policy is to discourage people from smoking through various means and promotion of a healthy lifestyle, as well as to prevent the spread of the desire to smoke.
• Smoking Prevalence in Bankstown, Australia The secondary objective of the project was to gather and analyze a sufficient amount of auxiliary scholarly sources on smoking cessation initiatives and smoking prevalence in Australia.
• Drug Addiction in Teenagers: Smoking and Other Lifestyles In the first part of this assignment, the health problem of drug addiction was considered among teens and the most vulnerable group was established.
• Aspects of Anti-Smoking Advertising Thus, it is safe to say that the authors’ main and intended audience is the creators of anti-smoking public health advertisements.
• Anti-Smoking Communication Campaign’s Analysis Defining the target audience for an anti-smoking campaign is complicated by the different layers of adherence to the issue of the general audience of young adults.
• Smoking Cessation Project Implementation In addition, the review will include the strengths and weaknesses of the evidence presented in the literature while identifying gaps and limitations.
• Smoking Cessation and Health Promotion Plan Patients addicted to tobacco are one of the major concerns of up-to-date medicine as constant nicotine intake leads to various disorders and worsens the health state and life quality of the users.
• Maternal and Infant Health: Smoking Prevention Strategies It is known that many women know the dangers of smoking when pregnant and they always try to quit smoking to protect the lives of themselves and the child.
• Peer Pressure and Smoking Influence on Teenagers The study results indicate that teenagers understand the health and social implications of smoking, but peer pressure contributes to the activity’s uptake.
• Smoking: Benefits or Harms? Hundreds of smokers every day are looking for a way to get rid of the noose, which is a yoke around the neck, a cigarette.
• The Culture of Smoking Changed in Poland In the 1980-90s, Poland faced the challenge of being a country with the highest rates of smoking, associated lung cancer, and premature mortality in the world.
• The Stop Smoking Movement Analysis The paper discusses the ideology, objective, characteristics, context, special techniques, organization culture, target audience, media strategies, audience reaction, counter-propaganda and the effectiveness of the “Stop Smoking” Movement.”The Stop Smoking” campaign is a prevalent example of […]
• Health Promotion Plan: Smokers in Mississippi The main strategies of the training session are to reduce the number of smokers in Mississippi, conduct a training program on the dangers of smoking and work with tobacco producers.
• Smoking Health Problem Assessment The effects of smoking correlate starkly with the symptoms and diseases in the nursing practice, working as evidence of the smoking’s impact on human health.
• Integration of Smoking Cessation Into Daily Nursing Practice Generally, smoking cessation refers to a process structured to help a person to discontinue inhaling smoked substances. It can also be referred to as quitting smoking.
• E-Cigarettes and Smoking Cessation Many people argue that e-cigarettes do not produce secondhand smoke. They believe that the e-fluids contained in such cigarettes produce vapor and not smoke.
• Introducing Smoking Cessation Program: 5 A’s Intervention Plan The second problem arises in an attempt to solve the issue of the lack of counseling in the unit by referring patients to the outpatient counseling center post-hospital discharge to continue the cessation program.
• Outdoor Smoking Ban in Public Areas of the Community These statistics have contributed to the widespread efforts to educate the public regarding the need to quit smoking. However, most of the chronic smokers ignore the ramifications of the habit despite the deterioration of their […]
• Nicotine Replacement Therapy for Adult Smokers With a Psychiatric Disorder The qualitative research methodology underlines the issue of the lack of relevant findings in the field of nicotine replacement therapy in people and the necessity of treatment, especially in the early stages of implementation.
• Smoking and Drinking: Age Factor in the US As smoking and drinking behavior were both strongly related to age, it could be the case that the observed relationship is due to the fact that older pupils were more likely to smoke and drink […]
• Smoking Cessation Clinic Analysis The main aim of this project is to establish a smoking cessation clinic that will guide smoker through the process of quitting smoking.
• Cigarette Smoking Among Teenagers in the Baltimore Community, Maryland The paper uses the Baltimore community in Maryland as the area to focus the event of creating awareness of cigarette smoking among the teens of this community.
• Advocating for Smoking Cessation: Health Professional Role Health professionals can contribute significantly to tobacco control in Australia and the health of the community by providing opportunities for smoking patients to quit smoking.
• Lifestyle Management While Quitting Smoking Realistically, not all of the set goals can be achieved; this is due to laxity in implementing them and the associated difficulty in letting go of the past lifestyle.
• Smoking in the Actuality The current use of aggressive marketing and advertising strategies has continued to support the smoking of e-cigarettes. The study has also indicated that “the use of such e-cigarettes may contribute to the normalization of smoking”.
• Analysis of the Family Smoking Prevention and Tobacco Control Act The law ensures that the FDA has the power to tackle issues of interest to the public such as the use of tobacco by minors.
• “50-Year Trends in Smoking-Related Mortality in the United States” by Thun et al. Thun is affiliated with the American Cancer Society, but his research interests cover several areas. Carter is affiliated with the American Cancer Society, Epidemiology Research Program.
• Pulmonology: Emphysema Caused by Smoking The further development of emphysema in CH can lead to such complications caused by described pathological processes as pneumothorax that is associated with the air surrounding the lungs.
• Smoking and Lung Cancer Among African Americans Primarily, the research paper provides insight on the significance of the issue to the African Americans and the community health nurses.
• Health Promotion and Smoking Cessation I will also complete a wide range of activities in an attempt to support the agency’s goals. As well, new studies will be conducted in order to support the proposed programs.
• Maternal Mental Health and Prenatal Smoking It was important to determine the variables that may lead to postpartum relapse or a relapse during the period of pregnancy. It is important to note that the findings are also consistent with the popular […]
• Nursing Interventions for Smoking Cessation For instance, the authors are able to recognize the need to classify the level of intensity in respect to the intervention that is employed by nurses towards smoking cessation.
• Smoking and Cancer in the United States In this research study, data on tobacco smoking and cancer prevalence in the United States was used to determine whether cancer in the United States is related to tobacco smoking tobacco.
• Marketing Plan: Creating a Smoking Cessation Program for Newton Healthcare Center The fourth objective is to integrate a smoking cessation program that covers the diagnosis of smoking, counseling of smokers, and patient care system to help the smokers quit their smoking habits. The comprehensive healthcare needs […]
• Risks of Smoking Cigarettes Among Preteens Despite the good news that the number of preteen smokers has been significantly reducing since the 1990s, there is still much to be done as the effects of smoking are increasingly building an unhealthy population […]
• Public Health Education: Anti-smoking Project The workshop initiative aimed to achieve the following objectives: To assess the issues related to smoking and tobacco use. To enhance the health advantages of clean air spaces.
• Healthy People Program: Smoking Issue in Wisconsin That is why to respond to the program’s effective realization, it is important to discuss the particular features of the target population in the definite community of Wisconsin; to focus on the community-based response to […]
• Health Campaign: Smoking in the USA and How to Reduce It That is why, the government is oriented to complete such objectives associated with the tobacco use within the nation as the reduction of tobacco use by adults and adolescents, reduction of initiation of tobacco use […]
• Smoking Differentials Across Social Classes The author inferred her affirmations from the participant’s words and therefore came to the right conclusion; that low income workers had the least justification for smoking and therefore took on a passive approach to their […]
• Cigarette Smoking Side Effects Nicotine is a highly venomous and addictive substance absorbed through the mucous membrane in the mouth as well as alveoli in the lungs.
• Long-Term Effects of Smoking The difference between passive smoking and active smoking lies in the fact that, the former involves the exposure of people to environmental tobacco smoke while the latter involves people who smoke directly.
• Smoking Cessation Program Evaluation in Dubai The most important program of this campaign is the Quit and Win campaign, which is a unique idea, launched by the DHCC and is in the form of an open contest.
• Preterm Birth and Maternal Smoking in Pregnancy The major finding of the discussed research is that both preterm birth and maternal smoking during pregnancy contribute, although independently, to the aortic narrowing of adolescents.
• Enforcement of Michigan’s Non-Smoking Law This paper is aimed at identifying a plan and strategy for the enforcement of the Michigan non-smoking law that has recently been signed by the governor of this state.
• Smoking Cessation for Patients With Cardio Disorders It highlights the key role of nurses in the success of such programs and the importance of their awareness and initiative in determining prognosis.
• Legalizing Electronic Vaping as the Means of Curbing the Rates of Smoking However, due to significantly less harmful effects that vaping produces on health and physical development, I can be considered a legitimate solution to reducing the levels of smoking, which is why it needs to be […]
• Inequality and Discrimination: Impact on LGBTQ+ High School Students Consequently, the inequality and discrimination against LGBTQ + students in high school harm their mental, emotional, and physical health due to the high level of stress and abuse of various substances that it causes.
• Self-Efficacy and Smoking Urges in Homeless Individuals Pinsker et al.point out that the levels of self-efficacy and the severity of smoking urges change significantly during the smoking cessation treatment.
• “Cigarette Smoking: An Overview” by Ellen Bailey and Nancy Sprague The authors of the article mentioned above have presented a fair argument about the effects of cigarette smoking and debate on banning the production and use of tobacco in America.
• “The Smoking Plant” Project: Artist Statement It is the case when the art is used to pass the important message to the observer. The live cigarette may symbolize the smokers while the plant is used to denote those who do not […]
• Dangers of Smoking While Pregnant In this respect, T-test results show that mean birthweight of baby of the non-smoking mother is 3647 grams, while the birthweight of smoking mother is 3373 grams. Results show that gestation value and smoking habit […]
• The Cultural Differences of the Tobacco Smoking The Middle East culture is connected to the hookah, the Native American cultures use pipes, and the Canadian culture is linked to cigarettes.
• Ban on Smoking in Enclosed Public Places in Scotland The theory of externality explains the benefit or cost incurred by a third party who was not a party to the reasoning behind the benefit or cost. This will also lead to offer of a […]
• How Smoking Cigarettes Effects Your Health Cigarette smoking largely aggravates the condition of the heart and the lung. In addition, the presence of nicotine makes the blood to be sticky and thick leading to damage to the lining of the blood […]
• Alcohol and Smoking Abuse: Negative Physical and Mental Effects The following is a range of effects of heavy alcohol intake as shown by Lacoste, they include: Neuropsychiatric or neurological impairment, cardiovascular, disease, liver disease, and neoplasm that is malevolent.
• Smoking Prohibition: Local Issues, Personal Views This is due to the weakening of blood vessels in the penis. For example, death rate due to smoking is higher in Kentucky than in other parts of the country.
• Tobacco Smoking: Bootleggers and Baptists Legislation or Regulation The issue is based on the fact that tobacco smoking also reduces the quality of life and ruins the body in numerous ways.
• Ban Smoking in Cars Out of this need, several regulations have been put in place to ensure children’s safety in vehicles is guaranteed; thus, protection from second-hand smoke is an obvious measure that is directed towards the overall safety […]
• Smoking: Causes and Effects Considering the peculiarities of a habit and of a disease, smoking can be considered as a habit rather than a disease.
• Smoking and Its Effect on the Brain Since the output of the brain is behavior and thoughts, dysfunction of the brain may result in highly complex behavioral symptoms. The work of neurons is to transmit information and coordinate messengers in the brain […]
• Smoking Causes and Plausible Arguments In writing on the cause and effect of smoking we will examine the issue from the point of view of temporal precedence, covariation of the cause and effect and the explanations in regard to no […]
• Summary of “Smokers Get a Raw Deal” by Stanley Scott Lafayette explains that people who make laws and influence other people to exercise these laws are obviously at the top of the ladder and should be able to understand the difference between the harm sugar […]
• Smoking Qualitative Research: Critical Analysis Qualitative research allows researchers to explore a wide array of dimensions of the social world, including the texture and weave of everyday life, the understandings, experiences and imaginings of our research participants, the way that […]
• Motivational Interviewing as a Smoking Cessation Intervention for Patients With Cancer The dependent variable is the cessation of smoking in 3 months of the interventions. The study is based on the author’s belief that cessation of smoking influences cancer-treated patients by improving the efficacy of treatment.
• Factors Affecting the Success in Quitting Smoking of Smokers in West Perth, WA Australia Causing a wide array of diseases, health smoking is the second cause of death in the world. In Australia, the problem of smoking is extremely burning due to the high rates of diseases and deaths […]
• Media Effects on Teen Smoking But that is not how an adult human brain works, let alone the young and impressionable minds of teenagers, usually the ads targeted at the youth always play upon elements that are familiar and appealing […]
• Partnership in Working About Smoking and Tobacco Use The study related to smoking and tobacco use, which is one of the problematic areas in terms of the health of the population.
• Causes and Effects of Smoking in Public The research has further indicated that the carcinogens are in higher concentrations in the second hand smoke rather than in the mainstream smoke which makes it more harmful for people to smoke publicly.
• Quitting Smoking: Motivation and Brain As these are some of the observed motivations for smoking, quitting smoking is actually very easy in the sense that you just have to set your mind on quitting smoking.
• Health Effects of Tobacco Smoking in Hispanic Men The Health Effects of Tobacco Smoking can be attributed to active tobacco smoking rather than inhalation of tobacco smoke from environment and passive smoking.
• Smoking in Adolescents: A New Threat to the Society Of the newer concerns about the risks of smoking and the increase in its prevalence, the most disturbing is the increase in the incidences of smoking among the adolescents around the world.
• Smoking and Youth Culture in Germany The report also assailed the Federal Government for siding the interest of the cigarette industry instead of the health of the citizens.
• New Jersey Legislation on Smoking The advantages and disadvantages of the legislation were discussed in this case because of the complexity of the topic at hand as well as the potential effects of the solution on the sphere of public […]
• Environmental Health: Tabaco Smoking and an Increased Concentration of Carbon Monoxide The small size of the town, which is around 225000 people, is one of the reasons for high statistics in diseases of heart rate.
• Advanced Pharmacology: Birth Control for Smokers The rationale for IUD is the possibility to control birth without the partner’s participation and the necessity to visit a doctor just once for the device to be implanted.
• Legislation Reform of Public Smoking Therefore, the benefit of the bill is that the health hazard will be decreased using banning smoking in public parks and beaches.
• Smoking Bans: Protecting the Public and the Children of Smokers The purpose of the article is to show why smoking bans aim at protecting the public and the children of smokers.
• Clinical Effects of Cigarette Smoking Smoking is a practice that should be avoided or controlled rigorously since it is a risk factor for diseases such as cancer, affects the health outcomes of direct and passive cigarette users, children, and pregnant […]
• Public Health and Smoking Prevention Smoking among adults over 18 years old is a public health issue that requires intervention due to statistical evidence of its effects over the past decades.
• Smoking Should Be Banned Internationally The questions refer to the knowledge concerning the consequences of smoking and the opinions on smoking bans. 80 % of respondents agree that smoking is among the leading causes of death and 63, 3 % […]
• Microeconomics: Cigarette Taxes and Public Smoking Ban The problem of passive smoking will be minimized when the number of smokers decreases. It is agreeable that the meager incomes of such families will be used to purchase cigarettes.
• Tobacco Debates in “Thank You for Smoking” The advantage of Nick’s strategy is that it offers the consumer a role model to follow: if smoking is considered to be ‘cool’, more people, especially young ones, will try to become ‘cool’ using cigarettes.
• Alcohol and Smoking Impact on Cancer Risk The research question is to determine the quantity of the impact that different levels of alcohol ingestion combined with smoking behavioral patterns make on men and women in terms of the risks of cancer.
• Indoor Smoking Restriction Effects at the Workplace Regrettably, they have neglected research on the effect of the legislation on the employees and employers. In this research, the target population will be the employees and employers of various companies.
• Hypnotherapy Session for Smoking Cessation When I reached the age of sixty, I realized that I no longer wanted to be a smoker who was unable to take control of one’s lifestyle.
• Vancouver Coastal Health Smoking Cessation Program The present paper provides an evaluation of the Vancouver Coastal Health smoking cessation program from the viewpoint of the social cognitive theory and the theory of planned behavior.
• Smoking Experience and Hidden Dangers When my best college friend Jane started smoking, my eyes opened on the complex nature of the problem and on the multiple negative effects of smoking both on the smoker and on the surrounding society.
• South Illinois University’s Smoking Ban Benefits The purpose of this letter is to assess the possible benefits of the plan and provide an analysis of the costs and consequences of the smoking ban introduction.
• Smoking Cessation in Patients With COPD The strategy of assessing these papers to determine their usefulness in EBP should include these characteristics, the overall quality of the findings, and their applicability in a particular situation. The following article is a study […]
• Smoking Bans: Preventive Measures There have been several public smoking bans that have proved to be promising since the issue of smoking prohibits smoking in all public places. This means it is a way of reducing the exposure to […]
• Ban Smoking Near the Child: Issues of Morality The decision to ban smoking near the child on father’s request is one of the demonstrative examples. The father’s appeal to the Supreme Court of California with the requirement to prohibit his ex-wife from smoking […]
• The Smoking Ban: Arguments Comparison The first argument against banning smoking employs the idea that smoking in specially designated areas cannot do harm to the health of non-smokers as the latter are supposed to avoid these areas.
• Smoking Cessation and Patient Education in Nursing Pack-years are the concept that is used to determine the health risks of a smoking patient. The most important step in the management plan is to determine a date when the man should quit smoking.
• Philip Morris Company’s Smoking Prevention Activity Philip Morris admits the existence of scientific proof that smoking leads to lung cancer in addition to other severe illnesses even after years of disputing such findings from health professionals.
• Virginia Slims’ Impact on Female Smokers’ Number Considering this, through the investigation of Philip Morris’ mission which it pursued during the launch of the Virginia Slims campaign in 1968-1970 and the main regulatory actions undertaken by the Congress during this period, the […]
• Cigarette Smoking and Parkinson’s Disease Risk Therefore, given the knowledge that cigarette smoking protects against the disease, it is necessary to determine the validity of these observations by finding the precise relationship between nicotine and PD.
• Tuberculosis Statistics Among Cigarette Smokers The proposal outlines the statistical applications of one-way ANOVA, the study participants, the variables, study methods, expected results and biases, and the practical significance of the expected results.
• Smoking Habit, Its Causes and Effects Smoking is one of the factors that are considered the leading causes of several health problems in the current society. Smoking is a habit that may be easy to start, but getting out of this […]
• Smoking Ban and UK’s Beer Industry However, there is an intricate type of relationship between the UK beer sector, the smoking ban, and the authorities that one can only understand by going through the study in detail The history of smoking […]
• Status of Smoking around the World Economic factors and level of education have contributed a lot to the shift of balance in the status of smoking in the world.
• Redwood Associates Company’s Smoking Ethical Issues Although employees are expected to know what morally they are supposed to undertake at their work place, it is the responsibility of the management and generally the Redwood’s hiring authority to give direction to its […]
• Smokers’ Campaign: Finding a Home for Ciggy Butts When carrying out the campaign, it is important to know what the situation on the ground is to be able to address the root cause of the problem facing the population.
• Mobile Applications to Quit Smoking A critical insight that can be gleaned from the said report is that one of the major factors linked to failure is the fact that smokers were unable to quit the habit on their own […]
• Behavior Modification Technique: Smoking Cessation Some of its advantages include: its mode of application is in a way similar to the act of smoking and it has very few side effects.
• Effects of Thought Suppression on Smoking Behavior In the article under analysis called I suppress, Therefore I smoke: Effects of Thought Suppression on Smoking Behavior, the authors dedicate their study to the evaluation of human behavior as well as the influence of […]
• Suppressing Smoking Behavior and Its Effects The researchers observed that during the first and the second weeks of the suppressed behavior, the participants successfully managed to reduce their intake of cigarettes.
• Smoking Cessation Methods These methods are a part of NRT or nicotine replacement therapy, they work according to the principle of providing the smoker with small portions of nicotine to minimize the addiction gradually and at the same […]
• Understanding Advertising: Second-Hand Smoking The image of the boy caught by the smoke is in the center of the picture, and it is in contrast with the deep black background.
• People Should Quit Smoking Other counseling strategies such as telephone calls and social support also serves the ultimate goal of providing a modern approach in which counseling can be tailored to suit the counseling needs of an individual smoker. […]
• Importance of Quitting Smoking As such, quitting smoking is important since it helps relief the worry and the fear associated with possibility of developing cancer among other smoking-related illnesses. It is therefore important to quit smoking if the problems […]
• Anti-Smoking Campaign in Canada This is not the first attempt that the federal government of Canada intends to make in reducing the prevalence of smoking in the country.
• Electronic Cigarettes: Could They Help University Students Give Smoking Up? Electronic Cigarettes An electronic cigarette is an electronic device that simulates the act of smoking by producing a mist which gives the physical sensation and often the flavor and the nicotine just as the analog […]
• The Change of my Smoking Behavior With the above understanding of my social class and peer friends, I was able to create a plan to avoid them in the instances that they were smoking.
• Psychosocial Smoking Rehabilitation According to Getsios and Marton most of the economic models that evaluate the effects of smoke quitting rehabilitation consider the influence of a single quit attempt.
• The Program on Smoking Cessation for Employees Due to the fact that the main purpose of the program on smoking cessation consisted in improving healthy lifestyles of their employees, the focus on cost reduction and insurance seems to be irrelevant.
• Tips From Former Smokers (Campaign) Over the years, the campaigns have led to both the increase and the decrease of smoking all over the world. The second type of anti-smoking campaign employed was the use of celebrities to encourage people […]
• Combating Smoking: Taxation Policies vs. Education Policies This is a considerable provision in the realms of health; hence, the efforts created by the government to curb this trend should be supported fully. In this regard, there is need to reduce the mentioned […]
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How To Create A Thesis Statement For An Academic Essay About Smoking In The Us

August 10, 2017

A thesis statement is not supposed to be something that you have to worry about. This is actually one of the easiest things that you need to think about. There are a number of students who struggle to learn how to frame a really good statement, and bearing that in mind, it will be important to at least try and make sure that you are in a good position to address the issue at hand, and then from there you can think about how to frame this and make a really good paper in the process.

The following are some ideas that you need to think about when you are looking to write the thesis statement for your essay on smoking in the US:

• What do you want to tell the reader?

What idea do you want the reader to have?

How do your ideas fit in with the topic.

If at all there is something that you need to know when working on this particular idea for your research essay , it is the fact that you need to figure out beforehand the message that you want to share with the reader of your paper. This is one of the most important things that will help you determine how to frame this statement the way you want it to come out.

If you can do this well, rest assured that your statement will blend in perfectly with the reader, and you will have the best experience so far when you are working on this.

Other than what you want to tell the audience, you also need to think in terms of the perception that you want them to have of your topic . You should think about how you would want them to react when you are discussing your ideas on smoking within the US, and then frame your statement based on the same concept.

A good thesis statement has to blend in well with the topic of your essay .

This is mandatory. Someone should read it and see the connection between it and your topic and nod in appreciation. If you are able to do this, you will have made the first and most important step towards writing one of the best papers ever.

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Essay on Smoking

500 words essay on  smoking.

One of the most common problems we are facing in today’s world which is killing people is smoking. A lot of people pick up this habit because of stress , personal issues and more. In fact, some even begin showing it off. When someone smokes a cigarette, they not only hurt themselves but everyone around them. It has many ill-effects on the human body which we will go through in the essay on smoking.

Ill-Effects of Smoking

Tobacco can have a disastrous impact on our health. Nonetheless, people consume it daily for a long period of time till it’s too late. Nearly one billion people in the whole world smoke. It is a shocking figure as that 1 billion puts millions of people at risk along with themselves.

Cigarettes have a major impact on the lungs. Around a third of all cancer cases happen due to smoking. For instance, it can affect breathing and causes shortness of breath and coughing. Further, it also increases the risk of respiratory tract infection which ultimately reduces the quality of life.

In addition to these serious health consequences, smoking impacts the well-being of a person as well. It alters the sense of smell and taste. Further, it also reduces the ability to perform physical exercises.

It also hampers your physical appearances like giving yellow teeth and aged skin. You also get a greater risk of depression or anxiety . Smoking also affects our relationship with our family, friends and colleagues.

Most importantly, it is also an expensive habit. In other words, it entails heavy financial costs. Even though some people don’t have money to get by, they waste it on cigarettes because of their addiction.

How to Quit Smoking?

There are many ways through which one can quit smoking. The first one is preparing for the day when you will quit. It is not easy to quit a habit abruptly, so set a date to give yourself time to prepare mentally.

Further, you can also use NRTs for your nicotine dependence. They can reduce your craving and withdrawal symptoms. NRTs like skin patches, chewing gums, lozenges, nasal spray and inhalers can help greatly.

Moreover, you can also consider non-nicotine medications. They require a prescription so it is essential to talk to your doctor to get access to it. Most importantly, seek behavioural support. To tackle your dependence on nicotine, it is essential to get counselling services, self-materials or more to get through this phase.

One can also try alternative therapies if they want to try them. There is no harm in trying as long as you are determined to quit smoking. For instance, filters, smoking deterrents, e-cigarettes, acupuncture, cold laser therapy, yoga and more can work for some people.

Always remember that you cannot quit smoking instantly as it will be bad for you as well. Try cutting down on it and then slowly and steadily give it up altogether.

Get the huge list of more than 500 Essay Topics and Ideas

Conclusion of the Essay on Smoking

Thus, if anyone is a slave to cigarettes, it is essential for them to understand that it is never too late to stop smoking. With the help and a good action plan, anyone can quit it for good. Moreover, the benefits will be evident within a few days of quitting.

FAQ of Essay on Smoking

Question 1: What are the effects of smoking?

Answer 1: Smoking has major effects like cancer, heart disease, stroke, lung diseases, diabetes, and more. It also increases the risk for tuberculosis, certain eye diseases, and problems with the immune system .

Question 2: Why should we avoid smoking?

Answer 2: We must avoid smoking as it can lengthen your life expectancy. Moreover, by not smoking, you decrease your risk of disease which includes lung cancer, throat cancer, heart disease, high blood pressure, and more.

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• Open access
• Published: 04 July 2024

Impact of global smoking prevalence on mortality: a study across income groups

• Roshinie De Silva 1 ,
• Disuri Silva 1 ,
• Lakindu Piumika 1 ,
• Isuri Abeysekera 1 ,
• Ruwan Jayathilaka 1 ,
• Lochana Rajamanthri 1 &
• Colinie Wickramaarachchi 1  

BMC Public Health volume  24 , Article number:  1786 ( 2024 ) Cite this article

274 Accesses

Metrics details

Smoking significantly contributes to the mortality rates worldwide, particularly in non-communicable and preventable diseases such as cardiovascular ailments, respiratory conditions, stroke, and lung cancer. This study aims to analyse the impact of smoking on global deaths, and its association with mortality across the main income groups.

The comprehensive analysis spans 199 countries and territories from 1990 to 2019. The study categorises countries into four income groups: high income, upper middle income, lower middle income, and low income.

The findings underscore the profound impact of global tobacco smoking on mortality. Notably, cardiovascular disease mortality is notably affected in both upper-middle-income and high-income groups. Chronic respiratory disease mortality rates show a significant impact across all income groups. Moreover, stroke-related mortality is observed in the lower-middle, upper-middle, and high-income groups. These results highlight the pervasive influence of smoking prevalence on global mortality, affecting individuals across various socioeconomic levels.

The study underscores the critical implications of smoking on mortality rates, particularly in high-income countries. It emphasises the urgency of targeted interventions in these regions to address the specific challenges posed by tobacco smoking on public health. Policy recommendations include implementing prohibitive measures extending to indoor public areas such as workplaces and public transportation services. Furthermore, allocating funds for research on tobacco and health, is imperative to ensure policymakers are consistently informed about emerging facts and trends in this complex domain.

Peer Review reports

In recent years, the prevalence of smoking has emerged as a significant contributor to global mortality rates. By 2020, smoking was reported to have contributed to 22.3% of worldwide deaths annually due to excessive tobacco use [ 1 ]. Cardiovascular diseases are known to be the leading cause of death globally posing a threat to 182 countries and responsible for 90% of chronic respiratory deaths [ 2 , 3 , 4 , 5 ]. Despite economic differences, the majority of smokers succumb to cardiovascular disease [ 6 , 7 , 8 ], highlighting the severe impact of tobacco usage on one in ten adults [ 6 , 7 ] and their quality of life [ 9 ].

However, these diseases are more prevalent in Low Income (LI) and Lower Middle Income (LMI) countries [ 4 , 10 , 11 , 12 ], accounting for a significant share of all cardiovascular mortality rates globally [ 13 ] and leading to high economic and social burden [ 14 , 15 ]. Studies conducted in North Africa, the Middle East and South Africa reveal that chronic respiratory deaths occur predominantly due to smoking [ 16 , 17 ]. Results show that women have a lower prevalence of smoking than men, particularly among youth and adults [ 7 ]. Respiratory diseases, tuberculosis, and ischaemic heart diseases act as leading risk factors for smoking, further increasing the risk of stroke [ 18 ]. In Indonesia, the majority of deaths are due to cardiovascular diseases, with a significant proportion related to smoking [ 19 ], attributed to unhealthy lifestyles [ 20 ]. Earlier econometric studies have concluded that increased smoking over the years has led to rises in cardiovascular diseases and premature deaths [ 21 , 22 ].

Furthermore, studies incorporating both Cardiovascular Disease Death Rates (CDDR) and Stroke Death Rates (SDR) revealed that current smokers display symptoms of both stroke and vascular-related symptoms irrespective of their educational level and financial state [ 23 , 24 ]. Another study investigated more than 52 countries in the LMI and Upper Middle Income (UMI) brackets in relation to Chronic Respiratory Disease Death Rates (CRDDR), revealing that over half of the country’s population shows symptoms of respiratory diseases and addicted to tobacco-related products [ 25 , 26 ]. The study predicts that by 2030, 80% of all global deaths will be due to chronic respiratory diseases among both income groups. These studies often focus on specific time periods, resulting in gaps in literature.

Additionally, concerning lung cancer-related deaths, researchers identified high-risk increase in smoking in LMI countries, emphasising the importance of early detection to support preventive measures [ 27 ]. Statistical methodologies used in previous studies are often outdated. Ethnic-related studies in China revealed that certain ethnic populations [ 28 , 29 , 30 , 31 ] such as the ‘Han’ have a lower prevalence of cardiovascular diseases despite high smoking prevalence. However, smoking prevalence among the ‘Han’ remains high. In Mexico, the highest risk from smoking is associated with cardiovascular diseases and related deaths [ 8 ], although these studies have not incorporated more than two dependent variables.

Regarding CRDDR, a study found that smoking is widespread among Chinese men in the middle-income category, with similar trends observed in East Asian and Pacific region countries with a high tendency towards respiratory disease-related deaths [ 32 ]. However, many studies interpret mortality rate results compared to vascular and respiratory diseases through simplistic data analysis. Empirical gender-related studies have highlighted higher chronic respiratory disease cases and smoking incidences in males than females [ 33 ].

Concerning SDR, a study conducted in Cuba, portrays 786.6 deaths per 100,000 people due to stroke-related deaths [ 34 ]. Stroke-related deaths have significantly increased among male smokers. Smoking cessation among the Chinese does not appear to reduce risk of stroke deaths [ 35 ]. Finally, Lung Cancer Death Rates (LCDR) are highlighted in a study conducted in Shanghai, indicating a change in serum miRNAs as potential biomarkers for different cancers, including lung cancer, associated with cigarette smoking [ 36 ]. Another study identified the prevalence of lung cancers among smokers in Shanghai from 2016 to 2017 showing an increased proportion of lung cancer deaths due to excessive smoking [ 37 ].

Results of studies considering ‘time’ and the risk of Cardiovascular Diseases (CVDs) due to smoking prevalence indicate a higher susceptibility to CVDs among the young population and women [ 38 , 39 ]. Even smoking one cigarette per day could significantly increase the risk of cardiovascular diseases, serving as a vital independent risk factor for cardiovascular disease-related deaths [ 40 , 41 ]. Researchers concluded that smokers have a higher risk of cardiovascular diseases compared to non-smokers [ 42 ].

Moreover, a study on chronic respiratory diseases and lung cancer identified patients continued smoking habits, even after as the main cause [ 43 ]. Those diagnosed with these conditions showed a lower rate of engaging with smoking cessation agents to prevent disease severity.

A strong nexus between stroke and smoking in middle-aged men in Norway indicates increased risk of cardiovascular diseases and cancer [ 44 ]. A study in New Zealand identified a relatively high risk of acute stroke associated with exposure to environmental tobacco smoke and passive smoking [ 45 ]. Compared to non-smokers, there is a higher risk of SDR in men and women who smoke one cigarette a day. Gender differences are thoroughly assessed interpreting the findings of both research studies.

The risk of lung cancer increases with the number of cigarettes smoked daily [ 46 ]. Studies form Finland [ 47 ], Japan [ 48 ] and the US [ 49 ] reviewed the relationship between smoking prevalence and the risk of lung cancer and respiratory diseases. They concluded that there is a strong association between smoking prevalence and the occurrence of lung cancer and respiratory diseases. Smoking cessation is recommended tom minimise lung cancer risk.

However, in high-income countries a strong association exists between smoking prevalence and CDDR, CRDDR, SDR, and lung cancer death rates. High-income countries may have better access to smoking prevalence data compared to UMI, LMI, and LI countries.

Despite systematic efforts to alleviate death rates through nicotine treatment, trigger avoidance, physical activities, and preventative measures, outcomes might be slow. Empirical studies have consistently associated cigarette smoking with a significantly higher risk of dying from chronic respiratory diseases [ 33 , 50 ]. However, these studies often focus solely on chronic respiratory and cardiovascular death rates and are limited to specific countries [ 24 , 51 ]. A comprehensive global study capturing the impact of Global Tobacco Smoking Prevalence (GSP) on CDDR, CRDDR, SDR, and LCDR over time, considering different income levels in 199 countries, remains unexplored. Hence, there is a visible gap in the existing literature that requires attention.

This paper aims to determine the impact of global smoking prevalence on worldwide mortality rates due to cardiovascular diseases, chronic respiratory diseases, stroke, and lung cancer. The study seeks to contribute to the existing literature in three ways:

First, this research fills a gap by conducting, to the authors’ knowledge, the first quantitative study incorporating four dependent variables in a global mortality analysis, cross-referencing with the GSP as the independent variable, with all variables age-standardised.

Second, the study methodology differs from previous literature by employing a panel data regression model covering thirty years from 1990 to 2019 for 199 countries, categorised into four primary income levels.

Third, the research aims to explore and prioritise age-standardised death rates for cardiovascular diseases globally, comparing countries across income groups and offering diverse perspectives on the findings.

This section presents the samples and observations derived from data spanning from 1990 to 2019, covering a 30-year period for 199 countries, excluding five countries not assigned an income group by the World Bank. Age-standardised rates were utilised in this study’s analysis to ensure that the statistical results for the income groups were not influenced by variations in age distributions across different countries. The dataset is divided into four income group classifications as defined by the World Bank [ 52 ]. The independent variable in this study is GSP, and the dependent variables are CDDR, CRDDR, SDR, and LCDR. The data file used in this study is attached in S1 Appendix.

This study uses secondary data sources with the data file presented in S1 Appendix. Data were collected from three databases to obtain health outcome data for the five variables, detailed in Table  1 .

Statistical analysis

Descriptive statistics were used to summarise and explore the data. Figure  1 presents a summary of descriptive statistics using a violin plot combined with a box plot, according to the data in Table  2 . The violin plot provides a comprehensive visualisation of data density and range, including the five-number summary and outliers graphically represented through the box plot [ 53 ].

Summary of descriptive statistics illustrated as a violin plot by critical variables

Source: Authors’ illustrations based on data

The panel regression model for time variation data to identify the impact of GSP on CDDR, CRDDR, SDR and LCDR is given below. Four separate equations are regressed for the \(i\) th cross section (income group) units at time t (years), with ε accounting for standard errors:

Where \({\alpha }_{1}\) represents the estimated increase in CDDR per 100,000 people over the change in global smoking prevalence and \({\alpha }_{0}\) is the intercept.

Similarly, \({\beta }_{1}\) represents the positive increase in CRDDR over the change in global smoking prevalence, with \({\beta }_{0}\) as the intercept.

In this equation, \({\gamma }_{1}\) associates SDR with smoking prevalence, while \({\gamma }_{0}\) is the intercept.

Here, \({\delta }_{1}\) reflects the effect of GSP on LCDR, with \({\delta }_{0}\) as the intercept. Through the incorporation of the co-efficient, α 1 , β 1 , γ 1 and δ 1 , this study attempts to test the hypothesis that the independent variable significantly affects the dependent variables, offering a thorough insight into the impact on each dependent variable through the panel regression model. For the regression models concerning CDDR, CRDDR, SDR, and LCDR, we formulated the following hypotheses:

CDDR [ \({\alpha }_{1}\) > 0]: Higher GSP levels would be linked to higher rates of chronic disease-related mortality. This hypothesis was grounded in literature suggesting that increased economic development improves healthcare infrastructure and overall public health.

CRDDR [ \({\beta }_{1}\) > 0]: Higher GSP would impact higher mortality rates from chronic respiratory diseases, supported by previous research indicating the association of economic development with improved respiratory health outcomes.

SDR [ \({{\gamma }_{1}}_{1}\) > 0]: Higher GSP levels would influence overall higher mortality rates across various causes, based on the premise that economic development facilitates improvements in healthcare provision and disease prevention measures.

LCDR [ \({\delta }_{1}\) > 0]: Higher GSP would result in higher mortality rates from lung cancer, informed by studies that highlight the relationship between economic development, lifestyle factors, and access to healthcare resources, all of which influence lung cancer incidence and mortality rates.

Moreover, this study computes three potentially stabilised models in consideration to the literature such as Pooled Ordinary Least Squares (POLS) to focus on dependencies between individuals [ 54 ], the Fixed Effects (FE) model to determine individual unobserved effects and the Random Effects (RE) model [ 55 , 56 ] to focus on both dependencies between and within individuals [ 57 ] in analysing the balanced panel data regression. On the other hand, the specification tests F-Test, Breusch-Pagan [ 58 , 59 ] and Hausman test [ 60 , 61 ] were applied to select the appropriate estimator from the results generated. Furthermore, the issue of multicollinearity is exempted as this study comprises only one independent variable, aligning with the methodology [ 62 ]. Finally, statistical data analysis was conducted using Stata and R Studio software.

The descriptive statistics for the critical variables used in this study are summarized in Table  2 . For example, the highest GSP value was 521 per 100,000 people in Kiribati in 2004, while the highest mean GSP was 258 per 100,000 people in the high-income (HI) group. The LMI group represents the highest mean values for CDDR, CRDDR, and SDR. The most significant occurrence of CDDR was 1156 per 100,000 people in Uzbekistan in 2005. The highest mean CRDDR was observed in the LMI group, while the highest mean SDR was 140 per 100,000 people in the LMI group.

Figure  1 portrays violin plot diagrams for five variables categorised into four major income groups. This plot highlights the relationship between income groups and global deaths per 100,000 people. The box plot elements show the lower and median fatalities in the HI group for SDR and LCDR, respectively. Both CDDR and CRDDR have a long-tail distribution for the LMI group. LCDR does not show wide area dispersions for all income levels as no frequent values are exposed. In the case of LI countries, all variables except LCDR show higher probabilities. Narrow spread plots are visible in CRDDR and LCDR for the LMI group. GSP and SDR variables visualise wider dispersions compared to the other variables. The data regarding the independent variable show multiple mode values under all four income groups. In comparison, the variables GSP and SDR portray higher dispersions.

Further elaborating on the plots, it is evident that CDDR and CRDDR have the highest outliers for the LMI group compared to the other variables and stratums. On the other hand, the UMI group shows no outliers for the variables GSP, CDDR and LCDR. Moreover, GSP has no outliers in the HI group, and LCDR has zero outliers for the LI stratum. The side flip of this plot depicts a mixture of a histogram and a density plot. The box plot diagram is attached to S2 Appendix for further clarification..

Figure  2 depicts line charts symbolising the mean disparity over the years from 1990 to 2019, reflecting the income groups in the research study. Examination of GSP, presented in Fig.  2 A, shows that the LI group indicated the lowest rate and the HI group the highest rate of mean GSP per 100,000 people in 1990. A continuous decline of 0.44%, 0.49%, 0.47% and 0.91% on average per year can be observed for LI, LMI, UMI, and HI countries, respectively, resulting in the lines for the HI and UMI groups covering around the year 2016.

Income group-wise averaged variables from 1990–2019

Likewise, Fig.  2 B represents the mean variations of CDDR per 100,000 people. Accordingly, the mean death rates from cardiovascular diseases for all four income groups were 350–410 per 100,000 people in 1990. The line plotted for HI and LI countries shows a decline of 2.08% and 0.44% on average per year, respectively. The UMI countries ranked first from 1990 to 1997 and fell to third place in 2009, preceded by the LMI and LI groups, respectively. The UMI group has shown a drop of 23.11% overall from 1990 to 2019, intercepting the LMI and LI group lines in 1998 and 2007, respectively.

Figure  2 C shows a drop of 1.20%, 1.21%, 1.71% and 1.47% per year in LI, LMI, UMI and HI groups for the mean CRDDR per 100,000 people. At the same time, LI and HI groups continue to have the highest and the lowest mean deaths per 100,000 people, respectively.

Figure  2 D portrays a drastic decline of 51.46% for the mean SDR per 100,000 people in the HI group. Furthermore, the HI group, which had a difference of around 33 mean SDR per 100,000 people compared to the other three income groups in 1990, increased the contrast to at least 50 per 100,000 people by 2019. The LMI group, which was in second place in 1990, surpassed the LI group by 2000 to take first place. Subsequently, the LMI group shows a slight decrease from 2005 and intersects with LI group by 2015.

Figure  2 E presents the line plot for mean LCDR per 100,000 people according to income groups. The HI group remains the highest from 1990 to 2019, with a decline of 0.98% on average per year. Unfortunately, the line plot of the LI group does not provide a factual illustration due to insufficient data.

Panel regression analysis

Results from the panel data regression conducted for the LI and LMI groups are portrayed in Table  3 . The outcome suggests that for the LI group, the RE model was suitable for the variables CDDR, CRDDR and SDR, except for LCDR due to insufficient data. Likewise, for the LMI group, the RE model is suggested for all four dependent variables. For the LI group, the RE model estimates that GSP has a positive influence on CRDDR at a 5% significance level, whereby when GSP increases by one per 100,000 people, CRDDR has shown an increase across time by an average of 18%. For the LMI group, the RE estimates show a positive influence of GSP on CRDDR at a 1% significance level, with an increase of GSP by 1 per 100,000 people affecting CRDDR by 19% on average. Furthermore, GSP indicates a positive and statistically significant effect of 10% on SDR, whereby SDR increases by 17% whenever GSP increase by one per 100,000 people.

The statistical results for the UMI and HI groups are represented in Table  4 . For the UMI group, the RE model was deemed appropriate for the variables CDDR, CRDDR, and SDR, but not for LCDR. Conversely, for the HI group, the RE model was more suitable for CRDDR and LCDR, while the FE model was preferred for CDDR and SDR. Consequently, both the FE and RE models were separately applied to all dependent variables within the UMI and HI groups. The RE estimates for the UMI group indicated that GSP has a highly significant positive effect on CDDR and SDR at the 1% level, suggesting that an increase in GSP by one per 100,000 people will result in an average increase of 72% in CDDR and 27% in SDR over time.

It also shows a statistically significant positive effect for CRDDR at 5%, with GSP increasing CRDDR by 13%. Likewise, the estimates for the HI group imply that GSP positively influences CDDR, CRDDR, SDR, and LCDR at a 1% significance level. The model coefficients for CDDR, CRDDR, SDR, and LCDR show increases of 126%, 8%, 40% and 13% on average, respectively.

In examining the LI group, it is evident that GSP has a positive but insignificant impact on CDDR and SDR variables. However, a contradictory finding revealed that tobacco use was linked to a reduced risk of cardiovascular-related diseases and was identified as the most crucial risk factor for stroke [ 6 ]. Moreover, the study indicated that GSP influences death rates from chronic respiratory diseases only within the LI group. Additionally, smoking was found to be a primary risk factor for chronic respiratory diseases, making CRDDR the leading cause of mortality in the countries studied [ 16 ]. Due to limited data on the LCDR variable, relevant results could not be obtained for the LI group. Nonetheless, it was found that higher smoking rates correlate with an increased mortality burden from lung cancer [ 14 ].

For the LMI group, the investigation suggested that despite a positive relationship between GSP and CDDR, the effect is not significant. Supporting this, the study discovered that while there is no significant relationship between tobacco smoking and cardiovascular disease deaths, smoking does increase the risk of death from ischemic heart diseases [ 12 ]. Furthermore, the study showed that GSP significantly impacts only CRDDR and SDR. Current smokers had a higher risk of all-cause mortality, including deaths from cardiovascular diseases and stroke, compared to non-smokers [ 19 ].

The analysis in the UMI stratum, revealed that CDDR, CRDDR, and SDR significantly impact GSP. There is a positive relationship between deaths caused by stroke and daily smoking prevalence among both females and males [ 35 ]. This finding aligns with existing literature, which indicates that smoking prevalence among both genders contributes significantly to mortality rates from cardiovascular diseases and stroke [ 7 , 33 ]. Studies have consistently shown a significant association between smoking status and cardiovascular mortality rates [ 63 ]. Previous research suggests that although smoking rates among males have historically been higher, the prevalence of smoking among females has been increasing, leading to a narrowing gender gap in smoking-related mortality [ 34 , 38 ]. Our results underscore the importance of considering gender-specific factors in mortality analysis, as smoking behaviours and their associated health risks may vary between genders. For instance, while males may have higher overall smoking rates, females may be more susceptible to certain smoking-related health outcomes, such as lung cancer [ 44 ]. However, our study was limited by the unavailability of gender-specific data, preventing us from conducting a gender-stratified analysis to explore potential differences in smoking prevalence and its impact on mortality rates between males and females. At the HI level, the research showed that GSP substantially impacts CDDR, CRDDR, SDR, and LCDR, with a significant association between smoking status and cardiovascular mortality rates. Supported studies explicitly show a significant association between smoking status and cardiovascular mortality rates [ 40 , 64 ].

Vertical analysis of the results, comparing the RE and FE coefficients for the UMI and HI groups by the dependent variable CDDR, suggests that GSP has a more significant effect on CDDR for HI countries than UMI countries. Similarly, RE coefficients for CRDDR across all four income groups imply that GSP has the highest impact on CRDDR in LMI countries and the lowest impact in HI countries. In the context of SDR, it is more affected by GSP in HI countries and least affected in LMI countries. Within the LMI group, CRDDR and SDR are more significantly affected by GSP, while in UMI countries, CDDR experiences the highest impact from GSP. In HI countries, CDDR, SDR, LCDR, and CRDDR experience varying degrees of impact from GSP, with CRDDR being the most affected in LI and LMI groups from 1990 to 2019, but in contradiction, almost all income groups show a high tendency in CRDDR [ 65 ].

Previous studies have examined the impact of GSP on CVD, chronic respiratory diseases, stroke, and lung cancer, considering factors other than a country’s income level. A study on the burden of CVD attributable to smoking during the same period found a reduction in CVD-related deaths from 1990 to 2019, with the lowest mortality rates in high socio-economic regions in 2019 [ 66 ]. Similarly, research on risk factors for chronic respiratory diseases and cancer from 1990 to 2019 supports that smoking remains a high-risk factor for these health issues despite lower incident rates [ 67 , 68 ].

Despite the extensive literature on global smoking prevalence and death rates, this study stands out by examining a combination of quadruple variables: CDDR, CRDDR, SDR, and LCDR across different income strata, rendering it unique. Tobacco smoking prevalence correlates directly with increased global deaths from cardiovascular diseases, respiratory diseases, stroke, and lung cancer among populations worldwide, primarily segmented by four income levels. However, the violin plot demonstrates minimal variations in LCDR, contrasting with noticeable variations in GSP and SDR across all income groups. A line graph illustrates a significant decline in mean death rates, particularly in the HI stratum from 1990 to 2019, with fluctuations in death rates among other income groups. Regression results indicate that a higher proportion of smoking prevalence deaths is attributable to cardiovascular diseases, particularly in the HI group. Variations are also observed in age-standardised prevalence death rates across different income levels and dependent variables, with chronic respiratory diseases and stroke deaths being predominant in UMI and LMI groups, respectively.

Nonetheless, this study has limitations, including the inability to consider data from 2020 to 2022 due to unavailability, lack of data on the LCDR variable, and reliance solely on deaths caused by specific diseases due to data constraints. However, it underscores the impact of global tobacco smoking on death rates from cardiovascular diseases, chronic respiratory diseases, stroke, and lung cancer.

Moreover, a pertinent limitation of this analysis is the absence of consideration towards the aspect of gender due to the insufficient availability of secondary data. As a consequence of this restriction, this study falls short in analysing the differences in the impact of GSP on mortality with respect to gender. By examining factors such as the age at which a person starts smoking regularly, gender differences in the duration and daily intake of smoking, and variations in environmental and occupational exposures related to age and gender, the study could offer a clearer understanding of how GSP affects mortality.

As a factor influencing CDDR, CRDDR, SDR, and LCDR rates, the socioeconomic burden of GSP is substantial, necessitating pragmatic policy implications. Implementing higher taxes on tobacco products and stringent regulations can effectively reduce GSP, especially among vulnerable groups like the youth. Additionally, revenue from increased tobacco taxes can be reinvested by governments into healthcare costs for treating tobacco-related illnesses.

Future research directions could focus on addressing critical gaps in understanding socioeconomic influences on health outcomes. Refining deprivation indices and studying their applicability across diverse populations could enhance health assessments [ 69 , 70 ]. Studies could also investigate gender differences in the impact of smoking on mortality rates and track the effectiveness of health interventions over time, particularly in mitigating health disparities among low-income groups. Comparative studies across countries could shed light on how evolving socioeconomic conditions and health behaviours affect cardiovascular risk globally. Furthermore, future research could evaluate the efficacy of tobacco control programs across different socioeconomic strata to determine the most effective approaches to reduce tobacco-related mortality.

Moreover, longitudinal studies can track the impact of socioeconomic status cardiovascular risk factors and other diseases, assessing the effectiveness of health interventions in reducing disparities among low-income groups over the time [ 71 ]. Additionally, comparative data from studies conducted across different countries can analyse how evolving socioeconomic conditions and health behaviours influence cardiovascular risk in various global contexts [ 72 ]. Lastly, future research should investigate the efficacy of tobacco control programs across different socioeconomic strata, aiming to identify the most effective approaches to reducing tobacco-related mortality across diverse demographic segments [ 73 ].

Furthermore, awareness regarding the dangers of smoking and the benefits of quitting can be highlighted through investments in public education campaigns targeted primarily at towards those who are more vulnerable to the adverse health effects of smoking. To safeguard the health of non-smokers and deter smoking habits, the implementation of smoke-free policies is highly recommended, including smoking bans in public indoor places such as workplaces and public transport services.

Lastly, by investing in tobacco and health related research, policymakers can stay updated and informed about timely facts and trends, enabling them to generate new policies and health initiatives worldwide more practically and conveniently.

Data availability

The datasets generated and analysed during the current study are publicly available at Our World in Data database: https://ourworldindata.org/ and Institute for Health Metrics and Evaluation (IHME) database: https://www.healthdata.org/ .

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• Cigarette smoking decline among US young adults from 2000 to 2019, in relation to state-level cigarette price and tobacco control expenditure
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• Karen Messer 1 ,
• http://orcid.org/0000-0002-0075-7471 John P Pierce 1 ,
• Jiayu Chen 2 ,
• Man Luo 2 ,
• http://orcid.org/0000-0002-1152-0621 Matthew D Stone 3 ,
• http://orcid.org/0000-0001-9221-0336 Eric C Leas 3 ,
• http://orcid.org/0000-0001-9293-0659 Yuyan Shi 3 ,
• David R Strong 3 ,
• Dennis R Trinidad 3 ,
• Sara B McMenamin 3
• 1 Moores Cancer Center , Univeristy of California , San Diego , California , USA
• 2 Division of Biostatistics, Herbert Wertheim School of Public Health , University of California , San Diego , California , USA
• 3 Herbert Werthiem School of Public Health , Univeristy of Califronia , San Diego , California , USA
• Correspondence to Dr John P Pierce, Cancer Centre, University of California, San Diego, California, USA; jppierce{at}ucsd.edu

Objective To investigate the association of state-level cigarette price and tobacco control expenditure with the large 2000–2019 decline in cigarette smoking among US 18–24 year-olds.

Methods Smoking behaviour was assessed in the 24 most populous US states using the 1992–2019 Tobacco Use Supplements to the Current Population Survey; association with price and expenditure was tested using adjusted logistic regression. States were ranked by inflation-adjusted average price and tobacco control expenditure and grouped into tertiles. State-specific time trends were estimated, with slope changes in 2001/2002 and 2010/2011.

Results Between 2000 and 2010, the odds of smoking among US young adults decreased by a third (adjusted OR, AOR 0.68, 95% CI 0.56 to 0.84). By 2019, these odds were one-quarter of their 2000 level (AOR 0.24, 95% CI 0.19 to 0.31). Among states in the lowest tertile of price/expenditure tobacco control activity, initially higher young adult smoking decreased by 13 percentage points from 2010 to 2018–2019, to a prevalence of 5.6% (95% CI 4.5% to 6.8%), equal to that in the highest tobacco-control tertile of states (6.5%, 95% CI 5.2% to 7.8%). Neither state tobacco control spending (AOR 1.0, 95% CI 0.999 to 1.002) nor cigarette price (AOR 0.96, 95% CI: 0.92 to 1.01) were associated with young adult smoking in statistical models. In 2019, seven states had prevalence over 3 SDs higher than the 24-state mean.

Conclusion National programmes may have filled a gap in state-level interventions, helping drive down the social acceptability of cigarette smoking among young adults across all states. Additional interventions are needed to assist high-prevalence states to further reduce smoking.

• Public policy
• Denormalization
• Surveillance and monitoring

Data availability statement

Data are available in a public, open access repository. The TUS-CPS data are publicly available from reference 26.

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/ .

https://doi.org/10.1136/tc-2023-058483

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WHAT IS ALREADY KNOWN ON THIS TOPIC

Tobacco control expenditures and increased cigarette prices are effective state- and national-level strategies which reduce cigarette smoking. US states varied considerably in implementation of these price/expenditure strategies. There was a major decline in cigarette smoking among US 18–24 year-olds, 2000–2019.

WHAT THIS STUDY ADDS

The 24 most populous states were ranked by price/expenditure activity level. Young adult smoking declined substantially across all states, and then decreased dramatically among the lowest price/expenditure states. 2019 prevalence was equal for the top and bottom tertile of states.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

There was a nationwide trend in the decline of US young adult smoking, including in states with both high and low tobacco control activity. National programs may have helped fill in gaps in state-level tobacco control activity.

Introduction

A major public health goal is to reduce the proportion of young people who become newly dependent cigarette smokers. 1 In the USA, cigarette smoking uptake has generally occurred between ages 12 and 24 years 2 and can be monitored using current smoking prevalence among young adults ages 18–24 years. Between 1998 and 2020, cigarette smoking declined by over 75% among both US adolescent 3 and young adult age groups. 4 E-cigarette use rose rapidly among adolescents between 2017 and 2019, but this was independent of the decrease in cigarette smoking. 4 Prior studies have shown that state-level interventions on cigarette price and tobacco control expenditures were associated with decreases in smoking among US adolescents ages 12–17 years. 5 6 However, the recent rapid decline in prevalence also suggests the possibility of a nationwide effect where cigarette smoking is no longer an acceptable or normative behaviour among US young people. Such a nationwide effect might overwhelm the expected effect from state-level tobacco control interventions. 7

All US states had started taxing cigarettes by 1966 and these taxes have generally increased over time. 8 However, there are large differences across US states in the implementation of cigarette excise taxes, which increase price of cigarettes. There is a substantial health economics literature demonstrating that increases in cigarette taxes are associated with reductions in adult cigarette smoking prevalence. 9–11 Studies have differed on whether the effect on youth is greater than for adults. 12 13 US states also differ in their tobacco control expenditure. The first statewide comprehensive tobacco control programme in the USA started with a dedicated excise tax in California in 1988. 14 A major focus of the California campaign was de-normalising cigarette smoking among youth 15 16 ; in the first decade, the proportion of 12–13 years who had even puffed on a cigarette declined by 70%. 17 Florida started an adolescent campaign in 1997, again focused on denormalising tobacco 18 and this also was associated with a substantial decline in adolescent smoking. 19 20

In 1998, the Master Settlement Agreement (MSA) between the tobacco industry and state attorneys general related to lawsuits on smoking-related healthcare costs provided (a) about US$10 billion/year in unrestricted continuing payments to the states (which led to the tobacco industry increasing cigarette prices); (b) restrictions on advertising targeting minors and (c) funding for a foundation to run nationwide antismoking campaigns. 21 Particularly in the early years, some states expended a portion of the unrestricted monies from the MSA on tobacco control programmes. However, on the 25th anniversary of the MSA, it was noted that most states had chronically underfunded their tobacco prevention and cessation programmes. 22 A decade later, in 2009, the USA enacted into law the Family Smoking Prevention and Tobacco Control Act which increased federal cigarette taxes and gave the Food and Drug Administration (FDA) authority to regulate tobacco products. 23 One result of this was that the FDA launching a nationwide media campaign to reduce youth smoking. 24

In this paper, we use the state and nationally representative Tobacco Use Supplements (TUS) to the Current Population Survey (CPS) to model the association of state-level cigarette price and tobacco control expenditures with the probability of smoking among young adults aged 18–24 years, 2000–2019, for the 24 most populous US states. We describe the heterogeneity across these states in both cigarette prices (1992–2019) and tobacco control expenditures (available 2000–2019), using publicly available data. We rank states on their average level of cigarette prices and tobacco control expenditure 2000–2019 and group them into tertiles of price/expenditure tobacco control activity. We estimate the change in prevalence by state and group for the periods 2000–2010 and 2010–2019.

Data sources

The CPS is a rolling monthly survey of ~54 000 households that serves as the US labour force survey. Its design is state based and incorporates both national-level and state-level reliability requirements. 25 The TUS has been sponsored by the National Cancer Institute every 3–4 years since 1992. Each TUS consists of three independent monthly CPS samples at 4-month intervals, typically spanning 2 calendar years. Following enumeration, about one-third of TUS respondents are interviewed in person with the remainder surveyed by telephone. Response rates ranged from 62% (2007) to 75% (2019). We analysed the US population aged 18–24 years using the harmonised datafile of surveys from 1992/1993 to 2018/2019. 26 To ensure stable estimates, we restricted consideration to US states with a 2020 population >5 million. 24 states met this criterion, covering 82% of the US population. The combined 1992–2019 analytical sample was 90 313 respondents ages 18–24 and the 2000–2019 subsample was 54 408 respondents ( online supplemental eTable 1 ). TUS-CPS documentation notes that the person-level survey weights are designed to account for missing data and provide representative state and national estimates. 26 Cigarette price data for each state in each year from 1991 to 2020 were obtained from the Tax Burden of Tobacco. 8 Annual state expenditures on tobacco control and recommended funding levels, adjusted for state population demographics, were taken from tabulated data provided by the Centers for Disease Control and Prevention (CDC) since 2000 22

Supplemental material

Cigarette smoking.

Each TUS-CPS asked respondents if they had smoked 100 cigarettes in their lifetime and, if so, whether they now smoked every day, some days or not at all. Current established smokers are those who reported having smoked at least 100 cigarettes in their lifetime and currently smoked either every day or some days at the time of the survey.

Tobacco control expenditures

From the available tables, 22 we use the per cent of CDC recommended expenditure for each state and year. 27 For graphical presentation, we averaged the expenditure data over 4-year intervals ( online supplemental eTable 3 ), In the statistical models, we used individual-year data.

State cigarette prices

Price data came from tobacco industry surveys and are reported as weighted state-specific averages for a pack of 20 cigarettes (including generic brands) as of 1 November each year. 8 Price was expressed in constant 2020 dollars for each year 1992–2019 using the Consumer Price Index 28 within each state. For graphical presentation, we computed the change in the average inflation-adjusted price across 4-year periods, however, statistical models used individual-year data ( online supplemental eTable 4 ).

Sociodemographic covariates

There are known sociodemographic differences in smoking behaviour 29 30 and TUS-CPS uses standard questions to identify respondent sex, educational level and race ethnicity. Population distributions on these variables are in online supplemental eTable 1 .

Data analysis

To visualise cigarette prices and tobacco control expenditures over time for the 24 US states, we present heatmaps 31 using a red-green spectrum, where red represents the least and green the most favourable tobacco control option. We ranked states on (a) the per cent increase in state price, adjusted to 2020 dollars and (b) the average proportion of CDC-recommended tobacco control spending over the study period and then summed these two ranks to provide an overall ranking of average state-level price/expenditure tobacco control activity. States were grouped into tertiles on this rank.

We investigated the association of individual smoking status with the state-level predictors (annual inflation-adjusted cigarette price and per cent of CDC recommended tobacco control expenditure) 2000–2019, which is the period of available expenditure data. All models were adjusted for individual-level confounders (sex, race/ethnicity and educational attainment). Price and expenditure were screened for statistical significance, and then indicators for state of residence and year were included in the model. State indicators were modelled as both fixed and random effects; with both linear and categorical time modelled as fixed effects. We selected the model with the lowest Akaike information criterion (AIC) ( online supplemental eTable 5 ), which assesses both lack of fit and model complexity. 32 As sensitivity analyses, we also present the next-best competitor model ( online supplemental eTable 6 ). We also estimated post hoc modifications of the main model where we varied the inclusion of state, price, expenditure and time to address confounding ( online supplemental eTable 7 ) and another model which allowed the effects of price and expenditure to differ pre and post 2010 ( online supplemental eTable 8 ).

For each state and for the US as a whole, we display time trends in young adult smoking prevalence graphically from 1992 to 2019, using a piecewise linear model estimated by first-degree regression splines fitted to the aggregate prevalence for each state in each survey year. 33 We allowed two changes of slope: the first at 2001/2002 (previously identified start of the prevalence decline in 18–24 years 4 ), and the second at 2010/2011 (midpoint of the ongoing decline). We grouped the states by tertiles of their average price/expenditure tobacco control activity and summarise the change in prevalence for each group of states.

Results are presented as proportions or ORs with 95% confidence limits and p values. All estimates are weighted by the survey weights, and p values and CIs used the published replicate weights. 26 We use non-overlapping CIs as a conservative measure of statistically significant differences. Analyses were carried out in R statistical software.

State-level average cigarette price, 1992–2019

In 1992, across the 24 most populous US states, there was a 40% difference between the highest and lowest average cigarette price (range in 2020 dollars: US$3.04–US$4.27) ( figure 1 , column 1, online supplemental eTable 4 ). Changes in price over time tended to be synchronised across states, as indicated by the colours of the heatmap. Considering the 24 states, from 1998 to 2001, 17 states had increases of at least 40% ( figure 1 , column 4), with a 43.3% increase in average prices; from 2006 to 2010 prices increased by 30.3% on average ( figure 1 , column 7). In other time periods, prices were relatively stable, with a few outliers. By 2019, prices varied across states from a low of US$5.68/pack in Missouri to a high of US$11.48/pack in New York. Over the study period, the largest overall price increases occurred in Massachusetts (+197%) and New York (+184%); there were six states with less than half that level of increase: Virginia (+90%), South Carolina (+86%), Missouri (+82%), Alabama (+81%), Tennessee (+79%), Georgia (+76%) and Texas (+74%).

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Per cent changes in inflation-adjusted cigarette price for the 24 most populous US states, 1992–2019, with time periods matching the TUS-CPS survey periods. Heatmap using a red-green palette where dark red represents a price decrease and dark green a price increase. Data are presented in online supplemental eTable 4 . Adapted from Orzechowski W, et al . 8 TUS-CPS, Tobacco Use Supplement to the Current Population Survey.

State expenditure on tobacco control programmes, 2000–2019

In the early years following the MSA, from 2000 to 2003, the 24 most populous states spent an average of 44.4% of CDC recommended tobacco control expenditures ( figure 2 column 1 and online supplemental eTable 3 ). There was heterogeneity across states: five states spent more than 90% of recommended levels, and five states spent less than 10%. In 2004–2007, average expenditure was 34.8% of recommended levels, but then after 2012 expenditure was about half of that level. Across the period 2000–2019, the top four states averaged more than 40% of CDC recommended expenditures: Minnesota (62%), Arizona (58%), Colorado (47%) and California (41%). The lowest ranked states had expenditures which averaged 7% or less of CDC recommended expenditure across the period (South Carolina (7%), Texas (6%), Alabama (4%), Tennessee (3%), Michigan (1%), Missouri (<1%)).

Per cent of CDC-recommended state expenditures on tobacco prevention programmes over consecutive 4-year periods in the 24 most populous US states. Heatmap using a red-green palette where dark red is zero expenditure and dark green 80% of recommended expenditure level. Data are presented in online supplemental eTable 3 Adapted from Campaign for Tobacco Free Kids 22 Recommended levels from CDC recommends best practices for tobacco control expenditure. CDC, Centers for Disease Control and Prevention.

Association of 18–24 years cigarette smoking with state-level price and expenditure, 2000–2019

We used weighted logistic regression to model the probability of smoking among US 18–24 years who were residents of one of the 24 most populous states, adjusting for gender, education and race/ethnicity. Predictors included state, survey year (2000 to 2019), state-level tobacco control expenditure and average state cigarette price; the best-fitting model was chosen by AIC, considering either fixed (selected) or random effects for state and linear or categorical (selected) time and interaction terms (excluded) ( online supplemental eTable 5 ). In the final model ( table 1 ), neither state-level tobacco control expenditure (adjusted OR AOR 1.00, 95% CI 0.999 to 1.002, p=0.64) nor cigarette price (AOR 0.96, 95% CI 0.92 to 1.01, p=0.12) added significant information to smoking prevalence over and above the main effects of the time and state indicators. Time had a strong effect: with each successive year, the odds of cigarette smoking decreased from the reference year (2000, 18–24 years smoking prevalence: 25.8%, 95% CI 24.5% to 27.0%). By 2010, the odds of smoking were reduced by a third from 2000 (AOR 0.68, 95% CI 0.56 to 0.84). By 2019, these odds were one-quarter of the 2000 level (AOR 0.24, 95% CI 0.19 to 0.31). With Indiana chosen as the reference state, eight states had an average prevalence significantly lower than this state. Sex, race ethnicity and education had significant effects in the expected direction. We also present the best model (chosen by AIC) which incorporated the state indicators as a random effect ( online supplemental eTable 6 ). Effect size estimates were very similar, although price was nominally statistically significant in this model. However, it did not use survey weights or replicate weights due to a limitation of the software so should be interpreted with caution.

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Logistic regression model* with outcome current smoking, for respondents aged 18–24 years in the 24 most populous US states:2000–2018/2019: data from TUS-CPS

We used several sensitivity analyses to explore the confounding of the state-level price and expenditure data with the state and time indicators ( online supplemental eTable 7 ). In many models, the effect of price was significant and in the expected direction. However, the effect of price was sensitive to the inclusion of both time and state, indicating confounding with these factors. State tobacco control expenditure was associated with an increased likelihood of young adult smoking in most but not all models, again indicating confounding. We also added a post hoc term to the final model ( table 1 ) which allowed the effects of price and expenditure to differ before and after the year 2010 ( online supplemental eTable 8 ). While neither variable was significant, results are consistent with a larger effect of price in the earlier period (p=0.07), with no evidence of an effect after 2010.

Smoking prevalence among 18–24 years in 24 US states, 1992–2019, ranked by average price/expenditure levels

For each state, we estimated a linear trend over time in young adult smoking prevalence, allowing for a change in slope at 2001/2002 and at 2010/2011 ( figure 3 ). States are grouped into tertiles of average price plus expenditure levels (panel A: highest; panel B: middle, panel C: lowest price/expenditure tobacco control activity group). The heavy line represents prevalence for the state; the dotted line is the average prevalence across all 50 states; and the shaded boundaries show the highest and lowest state prevalence from among the 24 US states studied. Estimated prevalence at selected time points is presented in table 2 ; complete data are in online supplemental eTable 2 .

Time trends in state-specific cigarette smoking prevalence among 18–24 years, for the 24 most populous US states ranked by aggressiveness of tobacco control policies. Grey bands represent the minimum and maximum prevalence rate observed across the 24 most populous states. The dashed grey line is the US national cigarette smoking prevalence among 18–24 years. Source: TUS-CPS 1992/1993–2018/2019. Data are presented in online supplemental eTable 2 . TUS-CPS, Tobacco Use Supplement to the Current Population Survey.

Prevalence of 18–24 years cigarette smoking for 24 most populous US states grouped by state aggressiveness on tobacco control spending and cigarette price

In 1992/1993, US young adult smoking prevalence was 25.3% (95% CI 24.7% to 26.0%), and only California, New York and Maryland had a significantly lower prevalence ( online supplemental eTable 2 ). Between 2001/2002 and 2010/2011, young adult smoking declined significantly in six of the eight states in the highest price/expenditure tobacco control activity group and average prevalence in this group declined by 8.9 percentage points, from 23.0% (95% CI 21.6% to 24.5%) to 14.1% (95% CI 12.8% to 15.4%) ( table 2 ). In the middle price/expenditure group, only three states had significant declines (Colorado, Illinois and Wisconsin) and average prevalence for the middle group declined by 9.1 percentage points, from 26.8% (95% CI 25.1% to 28.5%) to 17.7% (95% CI 16.0% to 19.3%). Among the eight states in the lowest price/expenditure group, only two states (Virginia and Michigan) had significant declines in young adult smoking and the average prevalence for states in this group declined by 7.6 percentage points, from 26.2% (95% CI 24.3% to 28.1%) to 18.6% (95% CI 16.9% to 20.3%)

From 2010/2011 to 2018/2019, for the group of eight highest ranked states on price/expenditure activity, average young adult smoking prevalence declined by 7.6 percentage points, from 14.1% to 6.5% (95% CI 5.2% to 7.8%). The only state in this group without a significant decline was California, which was low on cigarette price and TC expenditure for the majority of this time. For the middle group, five of the eight states experienced significant young adult smoking declines; average prevalence in this group of states declined by 9.4 percentage points, from 17.7% to 8.3% (95% CI 6.6% to 9.9%). For the lowest group, six of the eight states had significant declines, with four having very large declines (Missouri 83%; Virginia 79%; Texas 75% and South Carolina 74%); average state young adult smoking prevalence for the group declined by 13 percentage points, from 18.6% to 5.6% (95% CI 4.5% to 6.8%).

Thus, while the highest price/expenditure groups experienced the largest decline in young adult smoking in the earlier time period (2001–2011), in the later period (2011–2019) this was reversed, and the lowest group had the largest decline. By the end of the study period, the prevalence of young adult smoking was similar for the highest (6.5%, 95% CI 5.2% to 7.8%) and lowest (5.6%, 95% CI 4.5% to 6.8%) price/expenditure groups of states. The 24-state mean prevalence was 6.7% (95% CI 5.9% to 7.6%) and there were seven states with a smoking prevalence more than 3 SDs above this mean (Ohio, Illinois, Indiana, Maryland, North Carolina Tennessee and Alabama); these came from each of the three tertiles.

Between 2000 and 2019, there was substantial heterogeneity across the 24 most populous US states in the level of both cigarette prices and expenditures on tobacco control programmes. However, all of these states experienced a major decline in young adult smoking prevalence over the period. In adjusted logistic regression models, after including the strong overall time effect and differing state-level intercepts, neither state-level price nor tobacco control expenditure was a significant predictor of young adult cigarette smoking. When we grouped the states into price/expenditure tobacco control activity tertiles, the highest activity tertile experienced the largest drop in young adult smoking prevalence between 2001/2002 and 2010/2011, confirming what has previously been reported. 34 However, from 2010/2011 to 2018/2019, the lowest activity group experienced the largest drop in young adult smoking, and, as a group, caught up to the low smoking prevalence of the highest price/expenditure group of states. There were seven states that lagged notably in their cigarette smoking decline compared with states in their tertile of price/expenditure rankings. Additional study is needed to identify influences that might be counteracting the strong national downward decline in cigarette smoking in this age group.

It has been proposed that the rise in e-cigarette vaping, 35 which was particularly marked in adolescents after 2017, 36 was a major driver of the decline in 18–24 years cigarette smoking between 2010 and 2020. However, in a recent paper, we provided evidence that the decline in young adult smoking was largely independent of the rise in e-cigarettes. 4 Importantly, most of the decline in young adult prevalence occurred prior to the surge in e-cigarette vaping, which occurred between 2014 and 2019. In only 4 of the 24 states was the rise in young adult e-cigarette vaping large enough to have replaced the observed decline in cigarette smoking. Across states, during this period, the correlation over time between vaping and smoking prevalence was a low 0.11. Thus, at best, e-cigarettes were a minor influence on the decline in smoking among US young adults.

In many of the logistic regression models of young adult smoking that we investigated the effect of tobacco control expenditure went in an unexpected direction, in which increased expenditure predicted increased probability of smoking. This indicates confounding of expenditure levels with other influences on young adult smoking prevalence, including cigarette price, other state-level influences and national time trends. There was also a striking level of change between 2010/2011 and 2018/2019 among the states in the lowest group as ranked on price/expenditure tobacco control activity. A likely explanation for this is the effectiveness of national campaigns that have targeted denormalisation of smoking among US youth, including the ‘Truth Initiative’, which conducted US-wide campaigns across the entire study period, 37–40 and the FDA’s Real Costs campaign, which started in 2014. 23 41 42 Other tobacco control initiatives with national scope include the successful ‘Tobacco 21’ advocacy campaign for federal legislation to raise the legal age for purchase of tobacco products to 21 years 43 ; the dissemination of smoke-free school campuses 44 and state enforcement of the MSA restrictions on national cigarette advertising aimed at youth. 45 There was also widespread dissemination of the harms of secondhand smoke and an accompanying voluntary introduction of smoke-free homes 46 during the study period, which can reduce young adult smoking prevalence. 47 Indeed, in 2018/2019, the proportion reporting a smoke-free home in Missouri (the state in our study with the lowest price/expenditure ranking) was the same as the US national average (78.6% vs 79.7%, data are not shown). This suggests that there may have been a major national trend away from the acceptability of smoking.

The lack of effect of state-level price in the final regression model may be because price changes were somewhat similar across states during the study period, leading to confounding of price with time. In addition, price changes were relatively modest: outside of periods associated with the implementation of the MSA (21) and the federal tax increase associated with the 2009 Tobacco Control Act (23), few states had price increases above 15% for the study period. This is far less than the yearly increases implemented in Australia that were associated with a prevalence decline. 48 It may suggest that higher prices may be needed to see significant changes in youth smoking rates.

Strengths and limitations

Strengths of the study include the use of large repeated cross-sectional surveys incorporating standard cigarette smoking questions to provide both state-specific and nationally representative prevalence estimates. Limitations include our use of cross-sectional rather than longitudinal data and that we did not include measures of the social acceptability of smoking among the study population. It is important to note that the inability of our analyses to quantify the effects of state-level prices and tobacco expenditure appears to be a limitation of these data, in the context of a national public health success in reducing youth cigarette smoking. We explicitly identified confounding of state expenditure levels with cigarette price, other state-level influences, and national time trends in these data; thus, our models are not evidence of lack of effect, but of the limitations of this approach. Our results suggest that the changing acceptability of cigarette smoking should be further explored as a possible explanation for the rapid decline in US youth smoking. Our results suggest that the changing acceptability of cigarette smoking should be further explored as a possible explanation for the rapid decline in US youth smoking.

Conclusions

The large decline in US 18–24 years cigarette smoking prevalence between 2001/2002 and 2018/2019 occurred broadly, across states with both relatively high and relatively low cigarette prices and tobacco control expenditures. This suggests a public health benefit from the national tobacco control programmes, helping drive down the social acceptability of cigarette smoking across all states and thus filling in gaps in state-level activity. Additional increases in cigarette price and tobacco control spending at the state level are needed to further drive down cigarette smoking among young adults. Additional research is needed to identify influences that are impeding this decline in several states, and whether the social acceptability of smoking is a key variable associated with the decrease in young adult smoking.

Ethics statements

Patient consent for publication.

Not applicable.

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X @MatthewDavStone

Contributors KM and JPP are responsible for the overall content and are the guarantors of the paper. JPP and KM conceptualised and designed the study, drafted the initial manuscript and reviewed and revised the manuscript. SM and JPP acquired funding for the study. ML and JC undertook the analyses for this study under the supervision of KM. MS, ML, ECL, SM, DS, YS and DRT had input into the study conceptualisation and critically reviewed the manuscript for important intellectual content. All authors approved the final manuscript as submitted and agreed to be accountable for all aspects of the work.

Funding This project was supported by the Tobacco-Related Disease Research Program (TRDRP) of the University of California, Office of the President (T31IR-1584 and T32IR-4988).

Disclaimer The funding body had no role in the development of this paper. The content is solely the responsibility of the authors and does not necessarily represent the official views of TRDRP.

Competing interests None declared

Provenance and peer review Not commissioned; externally peer reviewed.

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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Jennie smoking Vape 💨 in her vlog pic.twitter.com/yi3DH8DsQW — no na (@nona15648321) July 8, 2024

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National Center for Chronic Disease Prevention and Health Promotion (US) Office on Smoking and Health. E-Cigarette Use Among Youth and Young Adults: A Report of the Surgeon General [Internet]. Atlanta (GA): Centers for Disease Control and Prevention (US); 2016.

E-Cigarette Use Among Youth and Young Adults: A Report of the Surgeon General [Internet].

Chapter 1 introduction, conclusions, and historical background relative to e-cigarettes.

• 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 ).

Diversity of e-cigarette products. Source: Photo by Mandie Mills, CDC.

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 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
• 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.”
• 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.
• 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.
• 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.
• 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.
• 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.
• 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.
• Chapter Conclusions

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

• 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.”
• E-cigarettes represent an evolution in a long history of tobacco products in the United States, including conventional cigarettes.
• 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

• 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.
• 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).
• 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.
• 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.
• 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.
• 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.
• 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.
• 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

• Nicotine exposure during adolescence can cause addiction and can harm the developing adolescent brain.
• 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.
• 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.
• E-cigarette aerosol is not harmless “water vapor,” although it generally contains fewer toxicants than combustible tobacco products.
• 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

• 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.
• Prices of e-cigarette products are inversely related to sales volume: as prices have declined, sales have sharply increased.
• 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.
• 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

• The dynamic nature of the e-cigarette landscape calls for expansion and enhancement of tobacco-related 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.
• Strategic, comprehensive research is critical to identify and characterize the potential health risks from e-cigarette use, particularly among youth and young adults.
• The adoption of public health strategies that are precautionary to protect youth and young adults from adverse effects related to e-cigarettes is justified.
• 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.
• Health professionals represent an important channel for education about e-cigarettes, particularly for youth and young adults.
• 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 smoke-free 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.
• 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, 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 psycho-active 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 short-lived “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 yet been evaluated comprehensively enough (including for a sufficient time) to provide a scientific basis for concluding that they are associated with a reduced risk of dis ease compared to conventional tobacco use” ( Stratton et al. 2001 , p. 232). The committee added that “the major concern for public health is that tobacco users who might otherwise quit will use PREPs instead, or others may initiate smoking, feeling that PREPs are safe. That will lead to less harm reduction for a population (as well as less risk reduction for that individual) than would occur without the PREP , and possibly to an adverse effect on the population” ( Stratton et al. 2001 , p. 235). Subsequently, in 2006, Judge Kessler cited these findings in her decision which demanded the removal of light and low-tar labeling due to the misleading nature of these claims ( United States v. 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 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

Parts of an e-cigarette device. Source: Photo by Mandie Mills, CDC.

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.

Examples of e-liquid flavors. Source: Photo by Mandie Mills, CDC.

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 ).

E-liquids being poured into an e-cigarette device. Source: Photo by Mandie Mills, CDC.

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 ).

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 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 web-site users earning points for free or reduced-price products ( Richardson et al. 2015 ).

Multinational tobacco companies with e-cigarette brands.

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 ).

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.

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.

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.

• 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.
• 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

• 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;
• 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 ).

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.

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Cigarette cards catching on among kids in China, but the authorities want to snuff these out

Wednesday, 10 Jul 2024

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Kids are said to be drawn to these cards owing to their attractive designs and the sense of playing with something “forbidden”. - Photo: ST

BEIJING: Housewife Li Jiu would check her son’s belongings every other day to make sure that he was not playing with cigarette cards, which are made by cutting up old cigarette boxes and folding them into small rectangles.

She found a few of the cards neatly placed in her son’s mathematics textbook in June and confronted the Primary 5 boy about them.

“He said a classmate had given him those cards so that they could play games with them,” said Li, 37, who lives in northern Hebei province.

“I told him to return the cards to his friend, and to tell me if others offer these to him again.

“I’m afraid he might become addicted to playing with those cards, and become curious about smoking.”

The trend of children playing with yan ka, or cigarette cards, started in recent months but it is not clear how the trend started, Chinese media reported.

The young are said to be drawn to these cards because of their attractive designs and the sense of playing with something “forbidden”.

One game played using these cards involves each player placing a cigarette card on a flat surface.

Players take turns to try and flip the cards by slamming their hand on the surface.

If successful, they get to keep their opponents’ cards.

These cards have become so popular that the authorities are taking action for fear that they will expose children to tobacco brands and lead to more youngsters picking up the smoking habit.

On June 30, the semi-official Beijing Tobacco Control Association warned that cigarette cards are fast catching on among primary school pupils.

These are a form of “early exposure to tobacco trademarks that may lead to psychological suggestions to try out smoking”, it added.

It noted that cigarette cards contain information about tobacco, adding that children have been known to rummage through rubbish to look for discarded cigarette boxes.

During the past two weeks, local governments – from northern Shanxi to south-western Chongqing to eastern Shandong – have rolled out a slew of enforcement measures, including checks on stationery shops near schools and wholesale markets selling children’s items, to stamp out sales of the cards.

However, a Straits Times check on July 9 found that cigarette cards can be bought on e-commerce platform Taobao.

A box of 100 cigarette cards costs about 13 yuan (S$2.40), and e-commerce sellers market the cards as a way to get children to stop being addicted to mobile phones or rummaging through rubbish.

China, the world’s largest consumer of tobacco products with some 300 million users, has been on a years-long drive to lower its smoking rates, in a move to rein in ballooning healthcare costs.

It has banned smoking in most indoor public places and raised public awareness of its dangers.

A report by the National Health Commission and the Chinese Centre for Disease Control and Prevention showed that the smoking rate among middle-school students has fallen by 0.5 percentage point to 4.2 per cent from 2021 to 2023.

The report, released on May 31, World No Tobacco Day, surveyed more than 250,000 middle-school students aged between 13 and 18 across China between September 2023 and January 2024.

Developed cities such as Shanghai, Shenzhen and Beijing have also seen a decline in the number of adult smokers in recent years.

About one in five adults in Shanghai smoked in 2023, down from one in three in 2010.

In Beijing, the figure has fallen to 19.9 per cent in 2023, down from 23.4 per cent 10 years ago.

Still, parents told ST that they worry about cigarette cards, which they saw as a gateway to teenage smoking.

More should be done to curb teenage smoking, they said, including by having plain packaging for cigarettes, and banning vapes.

“What good can come out of playing with cigarette cards? I’m worried that my son will start smoking if he keeps coming into contact with the cards,” said Yu Binqi, 38, a restaurant manager in Beijing.

“All these discarded cigarette boxes smell of tobacco,” she added.

Purchasing manager Bo Lei, 40, in Beijing said he has been keeping a closer eye on his used cigarette packs after his 13-year-old son casually mentioned over dinner that his classmates had been playing with yan ka.

Bo said that he hoped his son does not pick up smoking as a result of exposure to cigarette cards.

“I constantly tell my son that it’s too late for me to try and quit because I’ve been smoking for at least the past 20 years, but there’s still hope for him,” he told ST.

Said Bo: “The clampdown will definitely help send the right signals that minors should be better protected from the dangers of smoking.” - The Straits Times/ANN

Tags / Keywords: China , Cigarette cards , kids , authorities , snuff out

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Blackpink’s Jennie’s ‘vaping incident’ under investigation in South Korea after petition

• Smoking cigarettes or vapes indoors is illegal in South Korea, and footage of the K-pop star smoking a vape triggered headlines and online outrage

A now-deleted video showing K-pop megastar Jennie of Blackpink smoking a vape indoors has sparked online outcry, after Seoul’s foreign ministry said on Tuesday it had received a formal complaint.

In the footage, uploaded as part of a live blog on YouTube for fans but subsequently removed even as copies of it spread across the internet, Jennie appears to exhale vape smoke while a bevy of hair and make-up artists work closely on her face.

Smoking cigarettes or vapes indoors is illegal in South Korea and the footage triggered headlines and online outrage, with “indoor smoking” and “Blackpink Jennie” becoming top trending topics on social media platform X in the South.

“Controversy over Jennie’s indoor smoking … exhaling smoke in the face of her staff,” was the headline of the Yonhap news agency’s report, typical of the widespread reporting in Korean-language media.

One internet user claimed the incident likely happened in Italy’s Capri, where Jennie had been filming, and said they had requested that the South Korean Embassy in Italy and the Ministry of Foreign Affairs probe the Blackpink star, the Korea Times reported.

The user urged Seoul to request “an investigation from the Italian authorities regarding Blackpink’s Jennie’s indoor smoking incident and take strict action,” the report said.

South Korea’s Ministry of Foreign Affairs said on Tuesday that they had received a petition related to the incident.

The star’s agency OA Entertainment acknowledged the vaping and apologised on her behalf, saying Jennie “deeply regrets her mistake”.

“We sincerely apologise to everyone who felt uncomfortable with Jennie’s actions,” the agency said in a statement on Tuesday.

“Jennie has personally apologised to all the staff on-site who may have been affected.”

Blackpink is one of South Korea’s most successful K-pop girl groups, with their songs topping charts locally and internationally.

Blackpink’s other achievements include being the first K-pop girl group to reach the top of the US Billboard 200 chart and the first Asian artists to headline prestigious music events such as Coachella.

“Posting such a video on her own SNS channel raises serious questions about her common sense … It is deeply disappointing,” said one commentator on South Korean portal Naver.

Smoking rates are relatively high in South Korea but, according to official data, only five per cent of South Korean women smoked as of 2022, compared with 30 per cent of men.

South Korean pop stars undergo rigorous training for years before their debut and are held to high behavioural standards, with smoking, dating and swearing largely forbidden, especially in the first years following their debut.

Jennie has previously confessed to struggling with these expectations.

“It’s really harsh,” Jennie, who debuted with Blackpink in 2016, said in a Netflix documentary.

“We were not allowed to drink, smoke or get a tattoo,” she recalled of her training period, adding that she had to endure “being told that I’m not good at stuff”.