EC Pulmonology and Respiratory Medicine

Research Article Volume 15 Issue 8 - 2026

Tobacco, Vaping, and E-Cigarette Regulation in the United States: A Pulmonary-Policy Literature Review

Ved Kartik1 and Alok S Shah2*

1Flintridge Preparatory School - La Canada Flintridge, California, USA
2Pulmonary Department, University of Chicago, USA

*Corresponding Author: Alok S Shah, Pulmonary Department, University of Chicago, USA.
Received: July 14, 2026; Published: July 28, 2026



Combustible tobacco remains the leading cause of preventable death in the United States, killing approximately 480,000 Americans annually. The emergence of electronic nicotine delivery systems (ENDS) introduced two concurrent public health challenges: potential harm reduction for adult smokers on one hand, and a youth nicotine-initiation crisis on the other. The 2019 EVALI outbreak (2,807 hospitalizations, 68 deaths by February 2020 [60]) forced both dimensions into acute regulatory focus. This narrative literature review traces the science-to-policy pipeline connecting pulmonary evidence on tobacco and vaping products to federal and state regulatory action in the United States, drawing on peer-reviewed research, CDC surveillance data, FDA regulatory documents, and case law from 2009 through 2026. Three specific evidence-to-policy fractures emerge. First, EVALI was caused by vitamin E acetate in illicit THC products, yet the regulatory response primarily targeted legal nicotine ENDS, a jurisdictional mismatch that remains unresolved. Second, the evidence that non-tobacco flavors drive youth e-cigarette initiation is strong, yet enforcement against the unauthorized disposable products that dominate the youth market has been weak. Third, the FDA’s population-level regulatory standard requires a single authorization decision per product for a problem that involves two distinct populations (adults who benefit from switching and youth who are harmed by initiating), producing structural policy paralysis. U.S. tobacco and vaping regulation is scientifically defensible in principle but administratively overwhelmed in practice.

Keywords: E-Cigarette; Vaping; EVALI; Tobacco Regulation; FDA; PMTA; Flavor Ban; Pulmonary Health

  1. S. Department of Health and Human Services, The Health Consequences of Smoking - 50 Years of Progress: A Report of the Surgeon General. Atlanta, GA: U.S. DHHS, CDC (2014).
  2. JL Barrington-Trimis and AM Leventhal. “Adolescents' use of 'pod mod' e-cigarettes - urgent concerns”. New England Journal of Medicine 12 (2018): 1099-1102.
  3. A Jamal., et al. “Tobacco product use among middle and high school students - NYTS, United States, 2024”. Morbidity and Mortality Weekly Report41 (2024): 917-924.
  4. JE Layden., et al. “Pulmonary illness related to e-cigarette use in Illinois and Wisconsin - final report”. New England Journal of Medicine 10 (2020): 903-916.
  5. VP Krishnasamy., et al. “Update: characteristics of a nationwide outbreak of EVALI - United States, August 2019-January 2020”. Morbidity and Mortality Weekly Report3 (2020): 90-94.
  6. BC Blount., et al. “Vitamin E acetate in bronchoalveolar-lavage fluid associated with EVALI”. New England Journal of Medicine 8 (2020): 697-705.
  7. TA Bhat., et al. “An animal model of inhaled vitamin E acetate and EVALI-like lung injury”. New England Journal of Medicine 12 (2020): 1175-1177.
  8. AK Werner., et al. “Hospitalizations and deaths associated with EVALI”. New England Journal of Medicine 17 (2020): 1589-1598.
  9. J Taylor., et al. “Characteristics of e-cigarette products used by patients with associated lung injury and products seized by law enforcement - Minnesota, 2018 and 2019”. Morbidity and Mortality Weekly Report47 (2019): 1096-1100.
  10. I Ghinai., et al. “E-cigarette product use among persons with associated lung injury - Illinois and Wisconsin, April-September 2019”. Morbidity and Mortality Weekly Report39 (2019): 865-869.
  11. BA King., et al. “The EVALI and youth vaping epidemics - implications for public health”. New England Journal of Medicine 8 (2020): 689-691.
  12. R McConnell., et al. “Electronic cigarette use and respiratory symptoms in adolescents”. American Journal of Respiratory and Critical Care Medicine 8 (2017): 1043-1049.
  13. BW Chaffee., et al. “E-cigarette use and adverse respiratory symptoms among adolescents and young adults in the United States”. Preventive Medicine 153 (2021): 106766.
  14. W Xie., et al. “Association of electronic cigarette use with respiratory symptom development among U.S. young adults”. American Journal of Respiratory and Critical Care Medicine 11 (2022): 1320-1329.
  15. D Owusu., et al. “ENDS, cigarettes, and respiratory illness: longitudinal associations among U.S. youth”. American Journal of Preventive Medicine 4 (2024): 636-645.
  16. E Bircan., et al. “Electronic cigarette use and its association with asthma, COPD and asthma-COPD overlap syndrome among never cigarette smokers”. Tobacco Induced Diseases 19 (2021): 23.
  17. HC Erythropel., et al. “Formation of flavorant-propylene glycol adducts with novel toxicological properties in chemically unstable e-cigarette liquids”. Nicotine and Tobacco Research 9 (2019): 1248-1258.
  18. TA Wills., et al. “E-cigarette use and respiratory disorders: an integrative review of converging evidence”. European Respiratory Journal 1 (2021): 1901815.
  19. P Hajek., et al. “A randomized trial of e-cigarettes versus nicotine-replacement therapy”. New England Journal of Medicine 7 (2019): 629-637.
  20. R Auer., et al. “Electronic nicotine-delivery systems for smoking cessation”. New England Journal of Medicine 7 (2024): 601-610.
  21. N Lindson., et al. “Electronic cigarettes for smoking cessation”. Cochrane Database of Systematic Reviews 1 (2025): CD010216.
  22. NA Rigotti. “Electronic cigarettes for smoking cessation - have we reached a tipping point?”. New England Journal of Medicine 7 (2024): 664-665.
  23. E Banks., et al. “Electronic cigarettes and health outcomes: epidemiological and public health challenges”. International Journal of Epidemiology 4 (2023): 984-992.
  24. ON Baenziger., et al. “E-cigarette use and combustible tobacco cigarette smoking uptake among non-smokers: umbrella review, systematic review and meta-analysis”. BMJ Open3 (2021): e045603.
  25. National Academies of Sciences, Engineering, and Medicine, Public Health Consequences of E-Cigarettes. Washington, DC: The National Academies Press (2018).
  26. S. Congress, Family Smoking Prevention and Tobacco Control Act, Pub. L. No. 111-31, 123 Stat. 1776 (2009).
  27. SA Glantz and DW Bareham. “Compromise or capitulation? US FDA jurisdiction over tobacco products”. PLOS Medicine 7 (2009): e1000118.
  28. DG Aaron. “The FDA as gatekeeper and the menthol exemption”. American Journal of Public Health 6 (2020): 775-776.
  29. S. FDA. “Deeming tobacco products to be subject to the FD&C Act; final rule”. Federal Register 81.90 (2016): 28973-29106.
  30. S. HHS, Office of Inspector General. “FDA has improved its premarket review of new tobacco products, but more could be done to address application backlog”. OIG Report OEI-01-20-00240 (2023).
  31. S. FDA. “Premarket tobacco product marketing granted orders”. FDA Center for Tobacco Products (2026).
  32. S. FDA. “Enforcement priorities for ENDS and other deemed products on the market without premarket authorization” (2020).
  33. MC Diaz., et al. “Menthol e-cigarette sales rise following 2020 FDA guidance”. Tobacco Control 6 (2021): 700-703.
  34. G Kong., et al. “E-cigarette devices, brands, and flavors attract youth: informing FDA's policies”. Addictive Behaviors 119 (2021): 106935.
  35. FRM Ali., et al. “E-cigarette unit sales by product and flavor type, United States, 2020-2022”. Morbidity and Mortality Weekly Report25 (2023): 672-677.
  36. FDA v. Wages and White Lion Investments, 604 U.S. 542 (2025).
  37. M Kingsley., et al. “Impact of Massachusetts' statewide sales restriction on flavored and menthol tobacco products”. American Journal of Public Health 8 (2022): 1147-1150.
  38. S Asare., et al. “Spatial analysis of changes in cigarette sales following the Massachusetts menthol flavor ban”. JAMA Network Open9 (2022): e2232103.
  39. AC Liber., et al. “Early evidence of flavored tobacco product restrictions in Massachusetts and New York State”. Tobacco Induced Diseases 21 (2023): 140.
  40. MF Pesko., et al. “The impact of two state-level approaches to restricting flavored tobacco products”. BMC Public Health1 (2022): 1786.
  41. Public Health Law Center. “State e-cigarette registry bills and what to make of them”. Mitchell Hamline School of Law (2024).
  42. VP Krishnasamy., et al. “EVALI: looking back, moving forward”. Public Health Reports 1 (2021): 3-6.
  43. JK Pepper., et al. “Adolescents' interest in trying flavoured e-cigarettes”. Tobacco Control 2 (2016): ii62-ii66.
  44. C Meernik., et al. “Impact of non-menthol flavours in e-cigarettes on perceptions and use: an updated systematic review”. BMJ Open10 (2019): e031598.
  45. A McNeill., et al. “Nicotine vaping in England: an evidence update including health risks and perceptions, 2022”. OHID, UK (2022).
  46. Australian Government. “Therapeutic Goods (Standard for Vaping Goods) (TGO 110) Order 2021”. TGA (2021).
  47. KL Marynak., et al. “Nicotine pouch unit sales in the US, 2016-2020”. The Journal of the American Medical Association 6 (2021): 566-568.
  48. E Park-Lee., et al. “E-cigarette and nicotine pouch use among middle and high school students - United States, 2024”. Morbidity and Mortality Weekly Report35 (2024): 774-778.
  49. MO Robichaud., et al. “Tobacco companies introduce 'tobacco-free' nicotine pouches”. Tobacco Control e1 (2020): e145-e146.
  50. SV Jabba., et al. “Chemical adducts of reactive flavor aldehydes formed in e-cigarette liquids are cytotoxic and inhibit mitochondrial function in respiratory epithelial cells”. Nicotine and Tobacco Research 1 (2020): S25-S34.
  51. D Hammond and JL Reid. “Trends in vaping and nicotine product use among youth in Canada, England and the USA, 2017-2022”. Tobacco Control 1 (2025): 115-118.
  52. E Karey., et al. “Longitudinal association between e-cigarette use and respiratory symptoms among US adults: findings from the PATH Study Waves 4-5”. PLOS ONE2 (2024): e0299834.
  53. Z Boas., et al. “Activation of inflammation in healthy young adult smokers and e-cigarette users”. JAMA Cardiology3 (2017): 278-284.
  54. Y Wang., et al. “Impact of electronic cigarette usage on the onset of respiratory symptoms and COPD among Chinese adults”. Scientific Reports 14 (2024): 5598.
  55. L Deyton., et al. “Tobacco product regulation - a public health approach”. New England Journal of Medicine 19 (2010): 1753-1756.
  56. LT Olson., et al. “Youth tobacco use before and after local sales restrictions on flavored and menthol tobacco products in Minnesota”. Journal of Adolescent Health 6 (2022): 978-984.
  57. Loper Bright Enterprises v. Raimondo, 603 U.S. ___ (2024).
  58. Ohio H.B. 33, 135th Assemb., Reg. Sess. (Ohio 2023) (tobacco flavor preemption provisions, effective 2024).
  59. Consolidated Appropriations Act, 2022, Pub. L. No. 117-103, §111, 136 Stat. 49.
  60. “Outbreak of lung injury associated with the use of e-cigarette, or vaping, products”. CDC.gov.Online. (Final case count: 2,807 hospitalizations, 68 deaths as of Feb. 18, 2020).
  61. City of Columbus et al. v. State of Ohio, Franklin County Common Pleas (2024); affirmed, Ohio 10th Ct. App. (2025). (Holding Ohio H.B. 33 tobacco preemption provisions unconstitutional; appeal to Ohio Supreme Court pending).

Ved Kartik and Alok S Shah. “Tobacco, Vaping, and E-Cigarette Regulation in the United States: A Pulmonary-Policy Literature Review”. EC Pulmonology and Respiratory Medicine 15.8 (2026): 01-12.

ECronicon Journal

Our Services

Quick Links

Information

Creative Commons LicenseOpen Access by ECronicon is licensed under a Creative Commons Attribution 4.0 International License
Based on a work at www.ecronicon.net