Vaping – effectiveness of advertising restrictions and role of advertising and free distribution in uptake

Annex – Analysis of the existing evidence

Effectiveness of advertising restrictions

There is a lack of evidence on the effectiveness of advertising restrictions in reducing prevalence of use of vaping products, and the evidence that exists is mixed.

• A systematic review on the impacts of global approaches to regulating electronic nicotine products (ENPs) (2023) found few studies (N=7) have investigated the effectiveness of advertising restrictions. These either report no significant relationship between the implementation of the European Tobacco Products Directive ( which includes a ban on advertising and promotion among other measures) and use reduction; or simply assess the level of exposure to advertisements following a ban (rather than intention to use/uptake as a result of it). The authors concluded more research is needed.
• A cross-sectional study of the association between the implementation of bans on e-cigarette advertising and promotion recommended by the WHO, and current use of e-cigarette among youth (2024) identified that bans on the internet were associated with lower prevalence of use after controlling for individual-level factors and country income level.

Unintended consequences of advertising restrictions

A handful of primary studies suggest there could be unintended consequences of advertising restrictions such as increased exposure to adverts via unregulated channels.

• Three primary studies highlighted high or increased exposure to e-cigarette marketing for unrestricted channels (e.g. retail stores, posters/billboards, public transport and social media) following bans on traditional and other media (e.g. radio and TV)^[3].

Role of advertising in susceptibility/intention to try vaping

Three systematic reviews, an evidence review and a number of primary studies reviewed for this briefing found an association between exposure to advertising and susceptibility/intention to try vaping products.

• A systematic review and meta-analysis of e-cigarette and social media content and its influence on youth behaviours (2023) reports a significant association between exposure to e-cigarette content (both user- and advertiser-generated, including sponsored content posted by influencers) and increased e-cigarette susceptibility and use.
• A systematic review of socio-ecological factors influencing vaping prevalence among adolescents and young adults (2022) found that exposure to e-cigarette marketing was a risk factor for e-cigarette use.
• A systematic review on the social influence in the uptake and use of electronic cigarettes (2020) concluded that exposure to e-cigarette advertising (including when the advertisements were disseminated via social media) increased intention to use.
• An evidence review by NatCen on e-cigarette use and the impact of control measures (2020) concluded that it seems clear that policies to restrict or ban e-cigarette advertising are likely to minimise e-cigarette use. This conclusion was based on two studies specifically looking at the association between exposure to adverts and use of/intention to use e-cigarettes.
• Several recent primary studies not included in the systematic reviews above also confirmed the association between exposure to advertising and susceptibility of using vapes, especially when exposure occurred in retail settings, on social media and through billboards^[4].

Effects of advertising on youth’s perceptions

The sources reviewed for this briefing highlight how adolescents not only notice e-cigarette marketing more than adults, but their critical reasoning is not fully developed to protect them against the impact of advertising.

• A systematic review and meta-analysis on advertising (including of vaping products) and young people’s critical reasoning abilities (2022) concluded that: children can recognise that adverts intend to sell a product but not that these are intended to change their attitudes and behaviours; understanding is lower for digital formats (likely due to difficulties in distinguishing between entertainment and marketing content, and to greater personalisation and targeting of the adverts); advertising brings more positive attitudes towards brands and products regardless of age and level of understanding.
• A Cancer Research UK report (2021) presents data from the International Tobacco Control Policy Evaluation Project (ITC Projects) to show how young people noticed e-cigarette marketing more than adults across almost all channels, with a particular stark contrast observed for marketing on billboards (31.4% of young people vs 5.9% of adults noticing).

There is sufficient evidence to conclude that advertisement of vaping products contributes to a reduced perception of absolute and relative harm from vaping.

• A systematic review and meta-analysis of e-cigarette social media content and its influence on youth behaviours and attitudes (2023) concluded that there was a significant association between exposure to e-cigarette content and lower risk perceptions among never users.
• A meta-analysis on the effect of vape advertising campaigns on consumers-vaping tendency (2023) concluded that there was a reduced perception of risk when: the advertisement platform was social media (vs. traditional); the ads used picture-dominant (vs. text-dominant) cues; and the targeted audience was made up of teenagers (vs. adults) or non-smokers (vs. smokers).
• A meta-ethnography of young adults’ perceptions and experiences of e-cigarette use (2021) reported that young people found marketing claims that vaping is a safer alternative to smoking very persuasive.
• These findings are echoed by other primary studies reviewed for this briefing which linked advertising (including on social media) to a lower perception of risk and addictiveness^[5]. Of note, an experimental study and meta-analysis exploring the effects of e-cigarette adverts on children's perceptions of harms (2018) also found that exposure to e-cigarette marketing lowered perceived harm of occasional tobacco smoking.

A scoping review, a meta-ethnography and several primary studies concluded that advertisement of vaping products (especially through social media) increases appeal of products and willingness to try, in particular among young people.

• A scoping review on the commercial promotion of electronic cigarettes on social media and its influence on perceptions of vaping (2024) evidenced that electronic cigarette exposure on social networking sites is linked with positive attitudes towards vaping and vaping behaviours, especially among young people.
• A meta-ethnography of young adults’ perceptions and experiences of e-cigarette use (2021) reported that young people notice e-cigarette advertising due to the glamourisation of these products on social media and through celebrity endorsements, among other things.
• Several primary studies highlighted that the fashionable and technological features of vaping products, as marketed by vaping companies and influencers, and price promotions increased appeal and intention to try vaping^[6].

Role of free distribution/price promotion in subsequent use

There is only a small amount of evidence, based on primary studies, suggesting that coupons/price promotions and free distribution of vaping products may encourage those who never used them before to try them (including current smokers), current users to continue using them and ex-users to return to use them.

• Data from the ASH (England) SmokeFree GB Youth survey (2024) show that 2.9% of children aged 11-17 who have ever tried vaping said that their first vape was given to them by an e-cigarette company.
• Three primary studies analysing data from the US PATH Study found an association between receiving a free sample of a vaping product or a coupon/price promotion, and subsequent or increased use. One study on cumulative exposure to e-cigarette coupons and changes in e-cigarette use (2024) found that exposure to e-cigarette coupons was associated with greater odds of initiation (AOR=1.58, 95% CI=1.26–1.97), lower odds of cessation (AOR=0.78, 95% CI=0.67–0.91) and increased odds of return-to-use (AOR=1.39, 95% CI=1.14–1.69). A second study of the association between receiving e-cigarette price promotions and subsequent use among young adult, established, current cigarette smokers (2022) found that receiving e-cigarette price promotions was associated with subsequent use in general and use to help with quitting smoking at 1-year follow-up. A third study on the association between free tobacco product sample receipt and tobacco use (2020) found that a higher proportion of younger adults (aged 18-24) compared to older adults, and of youth aged 15-17 compared to youth aged 12-14 were offered free vaping products; and that receipt of a free vaping product was associated with ever, past 30-day and new product use.