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PurposeThis study analyses the Food and Drug Administration (FDA) warning letters sent to e-cigarette companies from 1 January 2020 to 9 September 2021. Study results can inform regulation of e-cigarettes.MethodologyWarning letters retrieved from FDA’s website were coded for company type (retailer, manufacturer or distributor), location (domestic or international), infractions listed (PMTA (premarket tobacco product application), selling to minors, advertising to youth or packaging violation/mislabelling), product type (e-liquid, device or both), flavour (fruit, candy, tobacco, menthol/mint, concept flavour) and consequence (civil money penalties, product seizure and injunction, product detention and refusal of entry to the USA, no-tobacco-sales order, criminal prosecution).ResultsOf 303 coded letters (126 from 2020 and 177 from 2021), 97.4% were sent to small online retailers. Overall, 94.1% of the companies cited were located within the USA, 75.2% of the infractions were identified by reviewing a company’s website and 70.5% were PMTA violations. In 2020, 55.6% of infractions were PMTA violations; in 2021, nearly all infractions were PMTA violations. The letters cited 880 products; 92.2% of which were e-liquid products, with 32.4% fruit and 31.1% concept flavours.DiscussionWarning letters targeted small online retailers rather than large e-cigarette brands or products most used by youth: pod mods and disposables. The focus of these enforcement actions comprises a small share of the market and the impact on use was likely minimal. With PMTA decisions pending for the largest brands of e-cigarettes, the FDA should use its enforcement powers to target manufacturers, distributors and sellers of the tobacco products that have the greatest impact on youth and products that provide no public health benefit.

Highlights • Over half of young current e-cigarette users intend to quit, 15% in next 30 days. • One-third of young current e-cigarette users made a quit attempt in the past year. • Harm perceptions dependence and use frequency were associated with outcomes. • There is a critical need for programs and policies to facilitate and support e-cigarette cessation., While youth and young adult e-cigarette use has risen in the U.S., few studies have explored e-cigarette cessation behavior. This study estimates quit attempts and intentions among young people (aged 15–36) since the rise of high-nicotine products, and examines factors associated with e-cigarette quit attempts and intentions. Current e-cigarette users (past 30-day use, not already quit) were drawn from a national probability-based cohort sample. Data were collected from September to December 2019 (n = 1158). Weighted proportions of past-year quit attempts, intentions to quit in next 30 days, and general intentions to quit (at some point) were calculated. Models estimated cessation outcomes with respect to harm perceptions, friend use, dependence, use frequency, combustible use and demographic factors. Among current e-cigarette users, 54.2% reported general intentions to quit, 15.3% reported intention to quit within 30 days, and 33.3% reported a past-year quit attempt. Past-year quit attempts were associated with higher levels of harm perceptions (adjusted odds ratio (aOR) = 2.08, 95% confidence interval (CI): 1.49–2.92), dependence (aOR = 1.92, 95% CI: 1.44–2.56) and daily use (28 + days) compared to infrequent use (1–5 days) (aOR = 0.23, 95% CI: 0.12–0.43). General intentions to quit were positively associated with harm perceptions (aOR = 1.77, 95% CI: 1.23–2.56) and dependence (aOR = 1.89, 95% CI: 1.41–2.52), and negatively associated with daily use compared to infrequent use (aOR = 0.35, 95% CI: 0.19–0.65). Findings indicate that over half of young e-cigarette users want to quit, highlighting a critical need for policies and resources to promote and sustain e-cigarette cessation among young people.

BackgroundLittle is known regarding how oral nicotine products (eg, nicotine pouches, lozenges) are marketed to consumers, including whether potential implicit reduced harm claims are used. In the current study, we explored the marketing claims present in a sample of direct-mail oral nicotine advertisements sent to US consumers (March 2018–August 2020).MethodsDirect-mail ads (n=50) were acquired from Mintel and dual-coded for the following claims: alternative to other tobacco products, ability to use anywhere, spit-free, smoke-free and product does not contain tobacco leaf. We merged the coded data with Mintel’s volume estimate (number of mail pieces sent to consumers) and calculated the proportion of oral nicotine advertisements containing claims by category.ResultsOf the 38 million pieces of oral nicotine direct-mail sent to US consumers, most featured claims that the product could be used anywhere (84%, 31.8 million pieces); was an alternative to other tobacco products (69%, 26.1 million pieces); and did not contain tobacco leaf (eg, ‘tobacco leaf-free’, ‘simple’ approach of extracting nicotine from tobacco; 55%, 20.7 million pieces). A slightly smaller proportion contained claims that oral nicotine was ‘spit-free’ (52%, 19.8 million pieces) or ‘smoke-free’ (31%, 11.7 million pieces).ConclusionOur results provide an early indication of marketing claims used to promote oral nicotine. The strategies documented, particularly the use of language to highlight oral nicotine is tobacco-free, may covey these products as lower-risk to consumers despite the lack of evidence or proper federal authorisation that oral nicotine products are a modified-risk tobacco product. Future research is needed to examine consumer perceptions of such claims.