Impact of e-cigarette advertising, promotion, and sponsorship on cognition and behavior: a systematic review of public responses

BACKGROUND: Exposure to advertising, promotion, and sponsorship (APS) for e-cigarettes has expanded rapidly across retail, online, and social media platforms. Concerns remain that APS may shape harm perceptions, increase susceptibility, and encourage initiation and sustained use, particularly among youth and young adults. Yet evidence remains fragmented across regulatory contexts and outcomes, with limited synthesis of cognitive and behavioural effects. This study systematically reviews associations between APS exposure and e-cigarette-related cognition and behaviour. METHODS: Electronic databases, including PubMed, Medline, Embase, PsycINFO, and Web of Science, were searched (last accessed May 14, 2025) using a comprehensive strategy that combined e-cigarette and APS-related terms. Eligible studies empirically assessed APS exposure and reported at least one relevant outcome. Screening and data extraction were conducted independently by two reviewers. Risk of bias assessments were performed using different Joanna Briggs Institute (JBI) critical appraisal tools. Results were synthesized narratively. RESULTS: A total of 79 studies were included, comprising cross-sectional surveys (n = 39), longitudinal studies (n = 24), randomized controlled trials (RCTs) (n = 10), and quasi-experimental studies (n = 6). Most were from high-income countries. Across settings and populations, APS exposure was commonly associated with increased susceptibility and intention to use, and e-cigarette use, particularly among youth and young adults exposed through social media and retail environments. Evidence for the association between APS exposure and ever and current use was generally positive but varied by channel, with traditional media (TV, print, radio) showing weaker or nonsignificant effects. Longitudinal studies supported temporal associations between APS exposure and initiation, while experimental studies demonstrated that ad framing (e.g., social themes, promotions) can directly influence perceptions and openness to use. CONCLUSIONS: Exposure to e-cigarette APS, most notably across digital, social media, and retail environments, was consistently associated with heightened susceptibility, stronger intentions to use, and increased uptake, with these patterns becoming more pronounced in recent years. While much of the existing evidence is cross-sectional and therefore cannot establish causal pathways, the overall body of findings underscores the importance of reinforcing regulatory attention and ongoing monitoring of marketing activities in digital and retail spaces, particularly to safeguard youth and other vulnerable groups.