Skip to main content An official website of the United States government Here's how you know Here's how you know Official websites use .gov A .gov website belongs to an official government organization in the United States. Secure .gov websites use HTTPS A lock ( Lock Locked padlock icon ) or https:// means you've safely connected to the .gov website. Share sensitive information only on official, secure websites. Search Log in Dashboard Publications Account settings Log out Search… Search NCBI Primary site navigation Search Logged in as: Dashboard Publications Account settings Log in Search PMC Full-Text Archive Search in PMC Journal List User Guide PERMALINK Copy As a library, NLM provides access to scientific literature. Inclusion in an NLM database does not imply endorsement of, or agreement with, the contents by NLM or the National Institutes of Health. Learn more: PMC Disclaimer | PMC Copyright Notice Front Public Health . 2026 Mar 27;14:1813366. doi: 10.3389/fpubh.2026.1813366 Search in PMC Search in PubMed View in NLM Catalog Add to search Governing E-cigarettes in China: regulatory challenges and strategies for adolescent protection in the post-flavor ban era Yu Yao Yu Yao 1 School of Law, China Jiliang University, Hangzhou, China Conceptualization, Funding acquisition, Project administration, Supervision, Validation, Writing – original draft, Writing – review & editing Find articles by Yu Yao 1 , Luyang Yao Luyang Yao 1 School of Law, China Jiliang University, Hangzhou, China Writing – original draft Find articles by Luyang Yao 1 , Fei Yang Fei Yang 1 School of Law, China Jiliang University, Hangzhou, China Conceptualization, Supervision, Writing – review & editing Find articles by Fei Yang 1, * Author information Article notes Copyright and License information 1 School of Law, China Jiliang University, Hangzhou, China * Correspondence: Fei Yang, [email protected] Roles Yu Yao : Conceptualization, Funding acquisition, Project administration, Supervision, Validation, Writing – original draft, Writing – review & editing Luyang Yao : Writing – original draft Fei Yang : Conceptualization, Supervision, Writing – review & editing Received 2026 Feb 18; Revised 2026 Mar 15; Accepted 2026 Mar 16; Collection date 2026. Copyright © 2026 Yao, Yao and Yang. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms. PMC Copyright notice PMCID: PMC13066186 PMID: 41971277 Abstract China’s e-cigarette governance has entered a complex post-flavor ban era under the “1 + 2 + N” regulatory framework. While this system integrates centralized transaction platforms and mandatory safety standards, critical vulnerabilities remain. Current regulatory asymmetry, characterized by strict e-cigarette flavor prohibitions alongside lenient policies for flavored combustible tobacco, may inadvertently redirect consumption toward traditional smoking products. Meanwhile, the expansion of covert online marketing and illicit social media networks continues to facilitate adolescent access, weakening enforcement effectiveness. Addressing these challenges requires a coordinated policy response. This article proposes extending flavor restrictions to combustible cigarettes to enhance regulatory consistency and raising the legal purchase age with reference to international “Tobacco 21” experience. It further highlights the need to strengthen algorithmic governance to curb hidden digital promotion and to apply nudge-based interventions, such as neutral packaging and graphic warnings, to reduce product appeal. Integrating these supply- and demand-side measures is essential to limit youth initiation, contain illicit market growth, and reinforce long-term public health protection. Keywords: electronic cigarettes, flavor ban, public health, regulatory frameworks, tobacco product 1. Introduction In recent years, e-cigarettes have gained global popularity, largely based on claims of harm reduction ( 1 , 2 ) and smoking cessation ( 3 ). However, growing evidence increasingly challenges these assertions. Emerging evidence has suggested that e-cigarette use is associated with adverse oral ( 4 , 5 ), cardiovascular, and respiratory outcomes ( 6 ), as well as heightened viral susceptibility ( 7 ). Critically, the extent to which e-cigarettes affect health outcomes varies considerably across product types and use contexts. Key technical and behavioral determinants, such as dual and polytobacco use, device heterogeneity, variations in e-liquid composition, and user behavior ( 8 ), differ substantially across product classes and flavor categories. Harm-reduction potential is therefore inherently product-specific and may be functionally undermined in devices or usage patterns that exceed critical risk thresholds. Moreover, unlike established nicotine replacement therapies, e-cigarettes have not been endorsed by the World Health Organization (WHO) as effective cessation tools due to insufficient high-quality clinical evidence ( 9 ). Conversely, some studies have reported associations between e-cigarette use and the subsequent initiation of combustible tobacco use. A systematic review and meta-analysis of prospective studies found that e-cigarette users are more likely to subsequently initiate cigarette smoking compared to non-users ( 10 ), though the magnitude of this association varies substantially across studies and the possibility of residual confounding remains debated. While a “gateway effect” has been proposed as one explanation for these associations, it is not the only plausible framework. The common liability framework suggests that shared predispositions, including genetic factors, behavioral disinhibition, and sensitivity to reward, underlie the propensity to use multiple substances, rather than one product causally driving progression to another ( 11 ). The diversion hypothesis, by contrast, posits that e-cigarettes may prevent some adolescents from initiating conventional cigarette smoking by satisfying a pre-existing propensity for nicotine use in those who would otherwise have turned to combustible tobacco ( 12 ). Regardless of initiation sequence, dual use of e-cigarettes and combustible tobacco represents a distinct pattern of concern in its own right. Evidence suggests that individuals who consume both products experience a higher risk of developing chronic obstructive pulmonary disease than exclusive users ( 13 ). According to recent global estimates, approximately 14.7 million adolescents aged 13–15 currently use e-cigarettes, with youth prevalence rates averaging nine times those of adults ( 14 ). In addition, exposure to secondhand and thirdhand nicotine aerosol poses long-term developmental risks to pregnant women and children ( 15 ), raising ongoing public health concerns. Given China’s large population and its central role in global e-cigarette manufacturing, the potential public health implications of e-cigarette use warrant close regulatory attention. In response to these concerns, China has implemented a series of regulatory reforms aimed at strengthening oversight of e-cigarette production, distribution, and marketing. A cornerstone of these reforms is the Administrative Measures for Electronic Cigarettes (hereinafter referred to as the E-Cigarettes Measures ) ( 16 ), effective May 1, 2022, which explicitly prohibits the sale of non-tobacco flavored products and open-system devices. Furthermore, these measures prioritize youth protection by banning sales to minors and prohibiting all online sales and advertising. Available evidence indicates that these interventions have produced an initial regulatory effect among adolescents. In 2022, adolescents accounted for approximately 30% of China’s e-cigarette users, and the ever-use rate among middle school students reached 16.1% in 2021. One year after the implementation of the E-Cigarettes Measures, this figure declined to 13.5% in 2023 ( 17 ). Consistently, the current e-cigarette use rate among this demographic fell to 2.4% in 2023, representing a decrease of 1.2 percentage points compared to 2021 ( 18 ). Despite these gains, the post-flavor ban landscape presents new regulatory challenges. A persistent gap remains between regulatory intent and market practice, reflected in the proliferation of illegal products, the circumvention of flavor restrictions, and the shift of sales toward decentralized, privately mediated social media channels ( 19 ). Although e-cigarette advertising is formally prohibited, covert promotional activities continue to proliferate online, relying on subtle and adaptive digital strategies to evade detection. Meanwhile, existing regulatory measures inadequately address the risk of substitution from e-cigarettes to combustible tobacco. Against this backdrop, this paper examines the practical dilemmas of e-cigarette governance in China’s post-flavor ban era and proposes targeted regulatory strategies aimed at strengthening youth protection. 2. China’s e-cigarette regulatory system 2.1. The “1 + 2 + N” regulatory framework China’s e-cigarette regulatory system can be summarized as the “1 + 2 + N” model, which is structured as follows: The “1” refers to the 2021 revised Regulations for the Implementation of the Tobacco Monopoly Law of the People’s Republic of China ( 20 ). This primary administrative regulation mandates that e-cigarettes and other next-generation tobacco products be regulated by reference to the relevant provisions governing traditional cigarettes. The “2” comprises the E-Cigarettes Measures and the Mandatory National Standards for E-Cigarettes (GB 41700-2022) (hereinafter referred to as the E-Cigarettes Standards ) ( 21 ). The E-Cigarettes Measures stipulate the requirements for the production, sale, and import–export of e-cigarettes. Meanwhile, the E-Cigarettes Standards provides unified specifications for materials, technical requirements, and other safety parameters of e-cigarette products. The “N” refers to a multitude of legally binding regulatory documents that facilitate operational oversight. These include specific protocols for product identification and testing, technical reviews, quality supervision, traceability, packaging and labeling, logistics, and the industry credit system. Together, these elements constitute a hierarchical and multi-dimensional framework for the specific implementation of e-cigarette regulation in China. 2.2. Key regulatory instruments The E-Cigarettes Standards define e-cigarettes as electronic delivery systems used to generate aerosols for human inhalation, while the E-Cigarettes Measures further categorize these products into cartridges, smoking sets, and integrated products sold as a combination of both. Independent of nicotine content or combustion, this definition extends regulatory oversight to individual product components. This inclusive approach grants the framework significant flexibility to address diverse e-cigarette forms. Consequently, the following instruments ensure compliance across production, distribution, and advertising ( Table 1 ). Table 1. Primary regulatory instruments for e-cigarettes in China. Regulatory instrument Key descriptions Legal sources Traceability & trading platform All e-cigarette transactions must be conducted exclusively through the “Unified National E-cigarette Transaction Management Platform,” prohibiting sales via any other information networks. Additionally, products must display standardized QR codes on all packaging to enable mandatory traceability across production and wholesale stages. Articles 19 and 23 of the E-Cigarettes Measures; Article 5 of the Detailed Rules for the Implementation of E-cigarette Product Packaging ( 50 ) Flavor bans Prohibits all characteristic flavors except tobacco. Ingredients must strictly adhere to a “positive list” of 101 permitted additives. Article 26 of the E-Cigarettes Measures; Section 4.1.3.1 of the E-Cigarettes Standards Sales age limit Strict prohibition on sales to individuals under age 18. Article 22 of the E-Cigarettes Measures Advertising restrictions Bans tobacco advertisements in mass media, public spaces, and transport. All tobacco advertising targeting minors is prohibited. Article 22 of the Advertising Law of the People’s Republic of China ( 51 ) Packaging and health warnings The color contrast between background and warning text must satisfy ∆ E ab ≥40. Packaging must feature health warnings of the mandated size and is prohibited from using misleading language or flavor descriptors appealing to minors. Articles 3 and 9 of the Regulations on E-cigarette Warning Labels ( 52 ); Article 22 of the E-cigarette Measures Consumption tax A tax rate of 36% is applied at the production and import stages, while a rate of 11% is applied at the wholesale stage. Announcement on the Collection of Consumption Tax on E-cigarettes ( 53 ) Open in a new tab 3. Regulatory challenges in e-cigarette governance 3.1. Unintended consequences of the flavor ban China’s flavor ban currently faces risks arising from regulatory asymmetry. While e-cigarette flavors are strictly prohibited, comparable restrictions do not apply to higher-risk flavored combustibles like capsule cigarettes. Without a clear justification, this disparity may undermine the perceived legitimacy of the flavor ban and inadvertently redirect consumer demand toward the combustible tobacco market. Empirical research on American youth suggests that following the introduction of flavor restrictions, 12.5% of exclusive e-cigarette users increased combustible tobacco use, 7.8% switched to it entirely; and 38.6% of dual users increased cigarette consumption ( 22 ), confirming the existence of a substitution effect. Although longitudinal tracking data in China remain limited, a qualitative analysis of mainstream news reports before and after the implementation of the flavor ban indicates that fewer than 30% of surveyed e-cigarette users accepted the national standard tobacco flavor. Common responses included hoarding flavored products, seeking flavored items through informal or illegal channels, or returning to traditional cigarettes ( 23 ), reflecting a substitution pattern similar to that observed in other jurisdictions. This risk is amplified by the expansion of flavored combustible cigarettes in China. Between 2010 and 2020, the annual growth rate of capsule cigarettes in China reached 73.6% ( 24 ), underscoring the role of flavor as a central market strategy for the tobacco industry. Under such asymmetrical regulation, the e-cigarette flavor ban may displace demand into combustible markets or unregulated channels, thereby generating new public health risks and increasing regulatory enforcement costs. 3.2. Expansion of hidden online communication and trading networks The gap between strict flavor prohibitions and persistent consumer demand has diverted substantial volumes of e-cigarette transactions into illegal markets ( 25 ). Although China has established a centralized monopoly trading platform to supervise lawful distribution, this mechanism is ineffective against unlicensed e-cigarettes that fall outside regulatory oversight at the production stage. Consequently, distribution monitoring remains structurally limited. A survey of Shenzhen middle school students found that since the implementation of the Administrative Measures, 85.71% of respondents reported no added difficulty in obtaining e-cigarettes ( 26 ). In practice, online vendors frequently evade keyword controls by avoiding terms such as “e-cigarette,” instead using suggestive brand names, generic descriptors like “atomizer,” or misleading images. This digital evasion is reinforced by a strategic migration from physical storefronts to private online domains. Field investigations in Shanghai and Chengdu revealed that 26% of physical stores provided QR codes redirecting consumers to private WeChat accounts to complete transactions ( 27 ). Concurrently, the modality of promotion on mainstream social media has evolved. On platforms such as Weibo and Xiaohongshu, e-cigarette promotion often appears as “hidden advertising” embedded in lifestyle content, blurring the line between personal expression and commercial marketing. Comment sections have likewise become high-risk spaces for illicit promotion, with some accounts using embedded links or mini-programs as concealed gateways to sales pages ( 28 , 29 ). A U.S. longitudinal cohort study further demonstrates the behavioral risks of online promotion. Among adolescents with no prior e-cigarette use at baseline, 9.6% initiated use by follow-up. Baseline exposure to e-cigarette advertising on Facebook was associated with higher odds of subsequent use (OR = 2.20, 95% CI 1.37–3.52), even after controlling for demographics and baseline smoking ( 30 ). Because such transactions often bypass age-verification mechanisms, adolescents can more easily obtain illegal products with unknown ingredients ( 23 ), exacerbating risks to public health and market order. 4. Discussion Before elaborating on specific regulatory recommendations, it is worth noting that the measures discussed in this paper are grounded in China’s specific legal, institutional, and cultural context and may not be directly transferable to other jurisdictions. Different governance systems operate under distinct constitutional arrangements, administrative capacities, and public health priorities, meaning that comparable measures may require alternative legislative pathways or voluntary industry frameworks elsewhere. Cultural dimensions further shape the feasibility and reception of regulatory instruments, as norms surrounding individual autonomy, community responsibility, and digital engagement vary considerably across societies, and interventions calibrated for one context may prove misaligned in another. Even within China, the expansion of these stringent measures faces domestic impediments. Informal social commerce networks have proved remarkably agile in evading platform-level controls, enforcement capacity varies considerably across localities, and entrenched industry interests continue to complicate regulatory implementation. These considerations do not diminish the public health imperative to regulate e-cigarettes, but they do underscore the need for contextually sensitive policy design. The recommendations herein should therefore be understood as proposals developed within China’s regulatory environment, with the recognition that adaptation would be necessary for application in other settings. 4.1. Bridging the regulatory gap: expanding flavor bans and raising the age limits At the legislative level, China should address regulatory asymmetry in flavor restrictions between e-cigarettes and combustible cigarettes. Existing evidence indicates that banning flavors only in e-cigarettes may induce some users to substitute with combustible cigarettes ( 31 ). By contrast, comprehensive flavor bans covering both e-cigarettes and combustible cigarettes produce the largest increase in complete tobacco cessation, although they may be accompanied by a limited rebound in combustible cigarette use ( 32 ). As of 2024, over 50 jurisdictions worldwide have prohibited or are considering prohibitions on all or partially flavored tobacco products ( 33 ). Under the precautionary principle, China should extend the current e-cigarette flavor ban to combustible cigarettes. Given that immediate, comprehensive restrictions on prevalent flavored products may encounter both industrial resistance and deep-seated consumption patterns, a phased reduction in production quotas offers a pragmatic transitional path. However, acknowledging that this phased implementation leaves a temporary window of availability, China should concurrently raise the minimum purchase age for all tobacco products. This measure acts as an immediate defensive strategy to mitigate early exposure and addiction risks among adolescents and young adults while the comprehensive flavor ban is progressively enforced. This approach is supported by behavioral evidence. A cross-sectional analysis of Wave 1 data from the Population Assessment of Tobacco and Health (PATH) Study in the United States shows that 81.0% of youth aged 12–17 and 86% of young adults aged 18–24 who had ever used tobacco reported flavored products as their first tobacco experience ( 34 ). Raising the minimum sales age for all tobacco products to 21 has been associated with declines in both cigarette and e-cigarette use among adolescents ( 35 , 36 ). A Japanese study further found that individuals who initiate smoking before age 20 exhibit significantly lower cessation success rates than those who begin at age 20 or older ( 37 ), indicating that delayed initiation improves long-term cessation outcomes. Consistent with this evidence, the United States raised the federal tobacco purchase age to 21 in 2019 under the “Tobacco 21” policy, after which smoking prevalence dropped by an estimated 12% and related mortality by 10% ( 38 ). Although these effects were primarily observed for combustible cigarettes, the policy also targets adolescent e-cigarette use and has been widely adopted by U.S. states following the surge in youth vaping in 2018. Given the comparable addiction risks of e-cigarettes and combustible cigarettes ( 39 ), age-based restrictions should apply equally to both product categories. Accordingly, this paper recommends that China uniformly raise the legal purchase age for all tobacco products from 18 to 21, thereby reducing tobacco exposure at its point of entry. Neuroscientific research indicates that the prefrontal cortex, which governs executive function and impulse control, does not fully mature until approximately age 25 ( 40 ), suggesting that individuals aged 21–25 remain in a sensitive developmental period. Raising the sale age limit, as a paternalistic intervention, must adhere to the principle of proportionality. Setting the threshold at 21 targets the highest-risk group while maintaining a reasonable balance between public health protection and individual autonomy, reflecting a soft-paternalistic approach. Within this framework, flavor bans complement age restrictions by offering additional protection to young adults aged 21–25, together forming a layered prevention strategy. However, a 2023 U.S. survey on awareness of the Tobacco 21 policy found that over one-third of respondents were unaware of the increased purchasing age ( 41 ). Accordingly, if similar measures are adopted in China, regulatory reforms should be accompanied by enhanced public education and compliance outreach to ensure effective implementation. 4.2. Strengthening platform responsibility and algorithmic governance Third-party e-commerce platforms should shift from passive content blocking to proactive transaction prevention in regulating e-cigarette sales. Platforms need to continuously upgrade multimodal intelligent recognition technologies to detect and block variant keywords (especially brand names), train domain-specific semantic models to capture obscure expressions, and apply computer vision for image-text matching to intercept e-cigarette-shaped images and suggestive descriptions. Controls on external links should also be strengthened to prevent redirection to private messaging apps for illicit deals. In parallel, platforms should improve complaint and reporting mechanisms, broaden social supervision channels, and improve response speed and accuracy. Governance of e-cigarette information on social media platforms is more complex and requires precise targeting of implicit marketing while preserving user experience. For minors, strict age-verification mechanisms comparable to anti-addiction systems in video games should be adopted, including restricting keyword searches on minor accounts, algorithmically prioritizing health education content, and blocking posts describing e-cigarette use experiences. For adult users, regulation should focus on distinguishing commercial promotion from personal expression. Algorithms should be developed to automatically identify features such as high-frequency brand names and marketing terminology and to limit traffic to suspected promotional content, accompanied by robust appeal and correction mechanisms. For ambiguous content, mandatory warning labels such as “Smoking is harmful to health” should be applied. At the technical level, platforms can strengthen governance by targeting recurring marketing themes, especially conceptual flavors conveyed through indirect descriptors, such as terms implying fruit or dessert tastes (e.g., “Tropical” implying pineapple). This approach requires the establishment and dynamic updating of e-cigarette concept databases, together with more refined marketing content detection techniques ( 42 ). Existing research provides a methodological basis by organizing e-liquids into major categories such as tobacco and fruit and further dividing them into around 90 subcategories, such as berries and citrus, within a flavor wheel ( 43 ). This hierarchical framework offers a standardized vocabulary for classifying marketing descriptions. Building on it, automated image recognition, data extraction, and large language models can be applied to map marketing descriptors onto the flavor wheel and construct a semantic database of e-cigarette descriptions. In light of cultural differences in flavor expression, Chinese platforms should further identify localized descriptive terms and develop corresponding semantic mappings to enhance regulatory precision. Government authorities should incentivize platforms to internalize compliance and governance costs, rather than rely solely on administrative orders or subsidies. This can be achieved by clarifying statutory responsibilities, strengthening enforcement and penalties, providing technical guidance and shared resources, and offering incentives such as preferential compliance ratings, thereby supporting sustainable public health goals. 4.3. Refining packaging design: a nudge-based approach Compared with strict regulation, tobacco packaging design functions as a milder complementary instrument that can guide consumers away from e-cigarette use through nudge theory. Nudge theory seeks to correct irrational behavior through subtle, non-coercive interventions while preserving individual choice, thereby facilitating behavior change ( 44 ). Tobacco packaging primarily consists of background, warning labels (text and images), and implicit thematic marketing. Current Chinese regulations mainly address text–background contrast, warning label size and color, and language restrictions. Some studies propose positive nudges through differentiated packaging to direct consumers toward “lower-harm” products, such as using color intensity to signal nicotine levels or emotive icons to indicate harm ( 45 ). However, such approaches often complicate choice architecture, increasing information load and decision failure. Moreover, vivid background colors are closely associated with thematic marketing, for example orange evoking fruit flavors ( 42 ), which may circumvent language restrictions by conveying sensory cues that enhance product appeal and mislead consumers. Accordingly, packaging nudges should shift toward direct negative interventions. This includes adopting uniform neutral background colors, such as black or white, to sever visual links to marketing themes, and using high-visibility colors like yellow or orange for warning text ( 46 , 47 ) to generate strong contrast and draw attention. Evidence further indicates that text-only warnings currently used in China have limited deterrent effects, whereas combined graphic warnings depicting internal pathology or affected individuals are more effective than single-modality warnings ( 48 , 49 ). In summary, future tobacco packaging regulation in China should adopt an integrated design combining neutral backgrounds, high-contrast warning text, and graphic warning labels explicitly depicting tobacco-related diseases. Such a model delivers stronger negative nudges and enhances public risk awareness in coordination with other regulatory measures. 5. Conclusion Aligning flavor restrictions with increased age limits, supported by strengthened platform governance and evidence-based packaging design, is essential to reduce youth vaping initiation and contain illicit market expansion. Although the absence of long-term domestic longitudinal data remains a key limitation, these measures establish a necessary foundation for public health protection. Future regulatory adjustments should remain evidence-based, with particular emphasis on sustained research into behavioral changes among Chinese adolescents to ensure the long-term effectiveness of tobacco control policies. Funding Statement The author(s) declared that financial support was received for this work and/or its publication. This work was supported by the Fundamental Research Funds for the Provincial Universities of Zhejiang (2025YW72). Footnotes Edited by: Jennifer Marie Murray , Queen’s University Belfast, United Kingdom Reviewed by: Sabeeh Baig , National Institutes of Health (NIH), United States Data availability statement The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author. Author contributions YY: Conceptualization, Funding acquisition, Project administration, Supervision, Validation, Writing – original draft, Writing – review & editing. LY: Writing – original draft. FY: Conceptualization, Supervision, Writing – review & editing. Conflict of interest The author(s) declared that this work was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Generative AI statement The author(s) declared that Generative AI was not used in the creation of this manuscript. Any alternative text (alt text) provided alongside figures in this article has been generated by Frontiers with the support of artificial intelligence and reasonable efforts have been made to ensure accuracy, including review by the authors wherever possible. If you identify any issues, please contact us. Publisher’s note All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher. References 1. Hajek P, Phillips-Waller A, Przulj D, Pesola F, Myers Smith K, Bisal N, et al. A randomized trial of e-cigarettes versus nicotine-replacement therapy. N Engl J Med. (2019) 380:629–37. doi: 10.1056/NEJMoa1808779, [ DOI ] [ PubMed ] [ Google Scholar ] 2. George J, Hussain M, Vadiveloo T, Ireland S, Hopkinson P, Struthers AD, et al. Cardiovascular effects of switching from tobacco cigarettes to electronic cigarettes. J Am Coll Cardiol. (2019) 74:3112–20. doi: 10.1016/j.jacc.2019.09.067, [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 3. Lindson N, Livingstone-Banks J, Butler AR, McRobbie H, Bullen CR, Hajek P, et al. Electronic cigarettes for smoking cessation. Cochrane Database Syst Rev. (2025) 2025:CD010216. doi: 10.1002/14651858.CD010216.pub10, [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 4. Szumilas P, Wilk A, Szumilas K, Karakiewicz B. The effects of e-cigarette aerosol on oral cavity cells and tissues: a narrative review. Toxics. (2022) 10:74. doi: 10.3390/toxics10020074, [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 5. Zhang Q, Wen C. The risk profile of electronic nicotine delivery systems, compared to traditional cigarettes, on oral disease: a review. Front Public Health. (2023) 11:1146949. doi: 10.3389/fpubh.2023.1146949, [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 6. Wang JB, Olgin JE, Nah G, Vittinghoff E, Cataldo JK, Pletcher MJ, et al. Cigarette and e-cigarette dual use and risk of cardiopulmonary symptoms in the health eHeart study. PLoS One. (2018) 13:e0198681. doi: 10.1371/journal.pone.0198681, [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 7. Gaiha SM, Cheng J, Halpern-Felsher B. Association between youth smoking, electronic cigarette use, and COVID-19. J Adolesc Health. (2020) 67:519–23. doi: 10.1016/j.jadohealth.2020.07.002, [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 8. Gordon T, Karey E, Rebuli ME, Escobar YH, Jaspers I, Chen LC. E-cigarette toxicology. Annu Rev Pharmacol Toxicol. (2022) 62:301–22. doi: 10.1146/annurev-pharmtox-042921-084202, [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 9. Wallace AM, Foronjy RE. Electronic cigarettes: not evidence-based cessation. Transl Lung Cancer Res. (2019) 8:7–10. doi: 10.21037/tlcr.2019.03.08, [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 10. Baenziger ON, Ford L, Yazidjoglou A, Joshy G, Banks E. E-cigarette use and combustible tobacco cigarette smoking uptake among non-smokers, including relapse in former smokers: umbrella review, systematic review and meta-analysis. BMJ Open. (2021) 11:e045603. doi: 10.1136/bmjopen-2020-045603, [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 11. Vanyukov MM, Tarter RE, Kirillova GP, Kirisci L, Reynolds MD, Kreek MJ, et al. Common liability to addiction and “gateway hypothesis”: theoretical, empirical and evolutionary perspective. Drug Alcohol Depend. (2012) 123:S3–S17. doi: 10.1016/j.drugalcdep.2011.12.018, [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 12. Selya AS, Foxon F. Trends in electronic cigarette use and conventional smoking: quantifying a possible “diversion” effect among US adolescents. Addiction. (2021) 116:1848–58. doi: 10.1111/add.15385, [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 13. Kim T, Kang J. Association between dual use of e-cigarette and cigarette and chronic obstructive pulmonary disease: an analysis of a nationwide representative sample from 2013 to 2018. BMC Pulm Med. (2021) 21:231. doi: 10.1186/s12890-021-01590-8, [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 14. World Health Organization . WHO global report on trends in prevalence of tobacco use 2000–2024 and projections 2025–2030 (2025), Available online at: https://www.nmpa.gov.cn/yaopin/ypggtg/ypqtgg/20200107151901190.htm (Accessed February 16, 2026). 15. McGrath-Morrow SA, Gorzkowski J, Groner JA, Rule AM, Wilson K, Tanski SE, et al. The effects of nicotine on development. Pediatrics. (2020) 145:e20191346. doi: 10.1542/peds.2019-1346, [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 16. State Tobacco Monopoly Administration . Administrative measures for electronic cigarettes. (2022). Available online at: https://www.gov.cn/gongbao/content/2022/content_5697988.htm (Accessed February 16, 2026). 17. Wang J, Xia W. Urgent need for new regulations to stop e-cigarettes from encouraging smoking among Chinese youth. J Smok Cessat. (2025) 20:e006. doi: 10.48130/jsc-0025-0007 [ DOI ] [ Google Scholar ] 18. CCTV News . 2023 China youth tobacco survey results released: e-cigarette use rate among middle school students declines significantly. (2024). Available online at: https://xinwen.bjd.com.cn/content/s6659989fe4b0115c9f8557d7.html (Accessed February 16, 2026). 19. Legal Daily . E-cigarettes sold extensively online disguised as “atomizers”. (2024). Available online at: http://epaper.legaldaily.com.cn/fzrb/content/20240924/Articel04002GN.htm (Accessed February 16, 2026). 20. State Council of the People’s Republic of China . Regulations for the implementation of the tobacco monopoly law of the people’s republic of China (2021). Available online at: https://xzfg.moj.gov.cn/front/law/detail?LawID=1679 (Accessed February 16, 2026). 21. State Administration for Market Regulation & Standardization Administration of the People’s Republic of China . Mandatory national standards for electronic cigarettes (GB 41700-2022). (2022). Available online at: https://openstd.samr.gov.cn/bzgk/std/newGbInfo?hcno=ABB028BCBF0391D0039E80FDAB8D3AF7 (Accessed February 16, 2026). 22. Tam J, Jimenez-Mendoza E, Buckell J, Sindelar J, Meza R. Responses to real-world and hypothetical e-cigarette flavor bans among US young adults who use flavored e-cigarettes. Nicotine Tob Res. (2024) 26:1113–7. doi: 10.1093/ntr/ntad258, [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 23. Wang Z, Xu X, Laestadius L, Wang Y. Understanding stakeholder responses to the electronic cigarette flavor ban in China: a news media analysis. Public Health. (2024) 238:303–9. doi: 10.1016/j.puhe.2024.12.003, [ DOI ] [ PubMed ] [ Google Scholar ] 24. Kyriakos CN, Qi D, Chang K, Laverty AA, Filippidis FT. Global market trends of flavor capsule cigarettes and menthol (non-capsule) cigarettes: an ecological analysis using commercial data across 78 countries, 2010-2020. Tob Induc Dis. (2022) 20:85. doi: 10.18332/tid/153974, [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 25. Aagesen K, Moretti A, Demant J. Social media nicotine markets: criminogenic affordances and market displacements. Int J Drug Policy. (2025) 145:104943. doi: 10.1016/j.drugpo.2025.104943, [ DOI ] [ PubMed ] [ Google Scholar ] 26. Lyu M, Lu W, Zou L, Xiong J, Yang J. The impact of new regulations on prevention and control of e-cigarettes on adolescents in middle schools - a city in China, 2022-2023. China CDC Weekly. (2024) 6:289–93. doi: 10.46234/ccdcw2024.056, [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 27. Deng H, Fang L, Zhang L, Wen S, Zhang S, Wang F, et al. An observational study of the marketing practice of e-cigarette specialty stores in two large cities in China: is there potential to normalize the use of e-cigarettes? Tob Induc Dis. (2024) 22:1–12. doi: 10.18332/tid/191840, [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 28. Zhou X, Hao X, Chen Y, Deng H, Fang L, Zhang L, et al. Social media marketing strategies for electronic cigarettes: content analysis of chinese weibo accounts. J Med Internet Res. (2024) 26:e51594. doi: 10.2196/51594, [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 29. Ji T, Liu Z, Su Z, Xia X, Liu Y, Xie Y, et al. E-cigarette narratives of user-generated posts on xiaohongshu in China: content analysis. J Med Internet Res. (2025) 27:e71173. doi: 10.2196/71173 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 30. Camenga D, Gutierrez KM, Kong G, Cavallo D, Simon P, Krishnan-Sarin S. E-cigarette advertising exposure in e-cigarette naïve adolescents and subsequent e-cigarette use: a longitudinal cohort study. Addict Behav. (2018) 81:78–83. doi: 10.1016/j.addbeh.2018.02.008, [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 31. Buckell J, Marti J, Sindelar JL. Should flavours be banned in cigarettes and e-cigarettes? Evidence on adult smokers and recent quitters from a discrete choice experiment. Tob Control. (2019) 28:168–175. doi: 10.1136/tobaccocontrol-2017-054165, [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 32. Bold KW, Kong G, O’Malley SS. The scientific basis for the regulation of flavors in tobacco products. Annu Rev Clin Psychol. (2024) 20:381–406. doi: 10.1146/annurev-clinpsy-080921-075624, [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 33. Oliveira da Silva AL, Bialous S. Global landscape of nicotine and tobacco products additives policies. Tob Control. (2024) 14:1–6. doi: 10.1136/tc-2024-058622 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 34. Villanti AC, Johnson AL, Ambrose BK, Cummings KM, Stanton CA, Rose SW, et al. Flavored tobacco product use in youth and adults: findings from the first wave of the PATH study (2013-2014). Am J Prev Med. (2017) 53:139–51. doi: 10.1016/j.amepre.2017.01.026, [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 35. Friedman AS, Pesko MF. Tobacco 21 laws and youth tobacco use: the role of policy attributes. Am J Public Health. (2024) 114:90–7. doi: 10.2105/AJPH.2023.307447, [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 36. Abouk R, De PK, Pesko MF. Estimating the effects of tobacco-21 on youth tobacco use and sales. J Health Econ. (2024) 94:102860. doi: 10.1016/j.jhealeco.2024.102860, [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 37. Mittal S, Komiyama M, Ozaki Y, Yamakage H, Satoh-Asahara N, Wada H, et al. Impact of smoking initiation age on nicotine dependency and cardiovascular risk factors: a retrospective cohort study in Japan. Eur Heart J Open. (2023) 4:oead135. doi: 10.1093/ehjopen/oead135, [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 38. Hudson SV, Kurti M, Howard J, Sanabria B, Schroth KRJ, Hrywna M, et al. Adoption of tobacco 21: a cross-case analysis of ten US states. Int J Environ Res Public Health. (2021) 18:6096. doi: 10.3390/ijerph18116096, [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 39. Glantz S, Jeffers A, Winickoff JP. Nicotine addiction and intensity of e-cigarette use by adolescents in the US, 2014 to 2021. JAMA Netw Open. (2022) 5:e2240671. doi: 10.1001/jamanetworkopen.2022.40671, [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 40. Arain M, Haque M, Johal L, Mathur P, Nel W, Rais A, et al. Maturation of the adolescent brain. Neuropsychiatr Dis Treat. (2013) 9:449–61. doi: 10.2147/NDT.S39776 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 41. McCauley DM, Halpern-Felsher B. Gaps in awareness of the United States minimum legal age of e-cigarette and cigarette sales: implications for public health messaging. J Adolesc Health. (2025) 76:154–7. doi: 10.1016/j.jadohealth.2024.08.017, [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 42. Ma S, Qiu Z, Hernandez G, Zhang S, Thai V, Chaudhry E, et al. E-cigarette concept flavors in the United States: an analysis of product packages from online stores. Prev Med Rep. (2025):103361. doi: 10.1016/j.pmedr.2025.103361 [ DOI ] [ Google Scholar ] 43. Krüsemann EJZ, Boesveldt S, de Graaf K, Talhout R. An e-liquid flavor wheel: a shared vocabulary based on systematically reviewing e-liquid flavor classifications in literature. Nicotine Tob Res. (2019) 21:1310–9. doi: 10.1093/ntr/nty101, [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 44. Thaler RH, Sunstein CR. Nudge: Improving Decisions about Health, Wealth, and Happiness. New Haven, CT: Yale University Press; (2008). [ Google Scholar ] 45. Liu L. Reasonable exploration of regulation of flavored electronic cigarettes. Law science. (2022) 12:65–77. [ Google Scholar ] 46. King JL, Simper C, Razzouk J, Merten JW. The impact of varying warning color on e-cigarette advertisements: results from an online experiment among young adults. Nicotine Tob Res. (2021) 23:1536–41. doi: 10.1093/ntr/ntab043, [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 47. Lempert LK, Glantz SA. Implications of tobacco industry research on packaging colors for designing health warning labels. Nicotine Tob Res. (2016) 18:1910–4. doi: 10.1093/ntr/ntw127, [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 48. Brewer NT, Jeong M, Hall MG, Baig SA, Mendel JR, Lazard AJ, et al. Impact of e-cigarette health warnings on motivation to vape and smoke. Tob Control. (2019) 28:e64–70. doi: 10.1136/tobaccocontrol-2018-054878 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 49. Lazard AJ, Ebrahimi Kalan M, Nicolla S, Hall MG, Ribisl KM, Sheldon JM, et al. Optimising messages and images for e-cigarette warnings. Tob Control. (2025) 34:6–13. doi: 10.1136/tc-2022-057859, [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 50. State Tobacco Monopoly Administration . Detailed rules for the implementation of e-cigarette product packaging. (2022). Available online at: http://www.tobacco.gov.cn/gjyc/tzgg/202204/610ef372b09042ae9760d1287b665f80.shtml (Accessed February 16, 2026). 51. Standing Committee of the National People’s Congress of the People’s Republic of China . Advertising law of the people’s republic of China. (2021). Available online at: http://www.npc.gov.cn/npc/c2/c12435/201905/t20190521_276667.html (Accessed February 16, 2026). 52. State Tobacco Monopoly Administration . Regulations on e-cigarette warning labels. (2022). Available online at: http://www.tobacco.gov.cn/gjyc/tzgg/202205/13c3fb81aba04a6f875a27a09e5dca22.shtml (Accessed February 16, 2026). 53. Ministry of Finance, General Administration of Customs, & State Taxation Administration . Announcement on the collection of consumption tax on e-cigarettes. (2022). Available online at: https://fgk.chinatax.gov.cn/zcfgk/c102416/c5201994/content.html (Accessed February 16, 2026). Associated Data This section collects any data citations, data availability statements, or supplementary materials included in this article. Data Availability Statement The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author. Articles from Frontiers in Public Health are provided here courtesy of Frontiers Media SA ACTIONS View on publisher site PDF (216.4 KB) Cite Collections Permalink PERMALINK Copy RESOURCES Similar articles Cited by other articles Links to NCBI Databases Cite Copy Download .nbib .nbib Format: AMA APA MLA NLM Add to Collections Create a new collection Add to an existing collection Name your collection * Choose a collection Unable to load your collection due to an error Please try again Add Cancel Follow NCBI NCBI on X (formerly known as Twitter) NCBI on Facebook NCBI on LinkedIn NCBI on GitHub NCBI RSS feed Connect with NLM NLM on X (formerly known as Twitter) NLM on Facebook NLM on YouTube National Library of Medicine 8600 Rockville Pike Bethesda, MD 20894 Web Policies FOIA HHS Vulnerability Disclosure Help Accessibility Careers NLM NIH HHS USA.gov Back to Top