There has been a sharp rise in the presence of electronic cigarettes (“e-cigarettes”) since its introduction in the mid-2000s. Similarly, there has been a considerable increase in e-cigarette research. Many studies have focused on the pharmacokinetics, specifically how nicotine is transferred from device to user.¹ Studies have also considered whether or not e-cigarettes are more or less harmful than traditional cigarettes, which still remains without a satisfactory determination.² Research has contemplated policy implications of e-cigarettes, including how to properly classify, regulate, and limit access to the products, and has brought attention to e-cigarette use and demographics, specifically for consumer impressions and youth use.^3–14

Recent estimates show the highest prevalence of e-cigarette use among individuals ages 18–24 and 25–44 (21.6% and 16.6%, respectively), and surveys suggest that consumers perceive e-cigarettes to be a healthier alternative to traditional tobacco products and even a viable method for cessation of traditional, combustible tobacco products.^15–16 Along with understanding e-cigarettes’ mechanics, potential for harm or smoking cessation, and appeal to particular racial/ethnic and age groups, it is important to identify where e-cigarettes are physically available for purchase and consumption. Research shows that traditional tobacco products are more likely to be available and marketed in non-White and low-income neighborhoods, and significant health disparities exist among tobacco users.^17–20 For example, populations with a history of disadvantage in the United States – specifically Blacks and low-income people – experience adverse health outcomes due to cigarette smoking and tobacco use at disproportionately higher rates. The Centers for Disease Control and Prevention (CDC), the U.S. Department of Health and Human Services (HHS), and organizations such as the American Lung Association continue to report racial and socioeconomic disparities in tobacco-related health outcomes. While Blacks tend to initiate tobacco use later in life and smoke fewer cigarettes than Whites, Blacks are more likely to die from smoking-related diseases than Whites.²¹ Similarly, people with a lower income are more likely to suffer from smoking-related diseases than people with a higher income.²¹ Additionally, people with a lower income smoke more heavily than people with a higher income.²¹ While lower-income people and Blacks are as likely and more likely, respectively, to attempt quitting smoking than their socioeconomic and racial counterparts, both groups are less likely to succeed in quitting. Taxation of products, policies banning public use, stringent monitoring of youth access, and awareness/counter-advertising initiatives are major mechanisms that are used to reduce smoking and tobacco use. HHS currently has a national media campaign, “Tips from Former Smokers,” that highlights various people who deal with, have dealt with, or have died due to complications related to their tobacco use or exposure to tobacco use. Another HHS campaign, “The Real Cost,” focuses on health consequences associated with tobacco use by youth.²² The “truth” campaign, a nationwide anti-tobacco campaign funded and produced by the American Legacy Foundation, has recently aired commercials highlighting the disproportionate number of tobacco advertisements found in low-income, predominantly Black neighborhoods.²³ Additionally, many local and state municipalities have banned tobacco use in indoor and outdoor public areas and establishments such as restaurants, bars, and government buildings. Disparate health outcomes associated with tobacco use persist among Black and lower-income populations despite targeted anti-tobacco use campaigns, policies that have restricted tobacco use, and financial deterrents from tobacco use such as taxes.^24–25 Therefore an important line of inquiry to consider is the availability and access to tobacco products. Ashe and colleagues argued that the threshold needed to convince lawmakers to reduce availability and access to tobacco via “police power” is lower than that of alcohol.²⁶ However, many local and state municipalities are slow to utilize their full legislative ability to reduce tobacco outlet density despite evidence that constitutional challenges would not be a major issue, and despite evidence that shows reduction in tobacco outlet density does lead to reductions in smoking.^27–31 Given this research, and while studies have investigated e-cigarette availability via the Internet, there are few published studies that have focused on physical e-cigarette availability and marketing.^32–36

Alcohol outlets are a prevalent and salient retail space for the purchase and consumption of not only alcohol products, but also processed foods, lottery tickets, and tobacco products such as cigarettes and cigarillos in Baltimore, Maryland.^37–38 The abundance of alcohol outlets in Baltimore and the consequential widespread availability of alcohol and other products provides a practical analog for the availability of e-cigarettes in the city.^39–40 Therefore, this study investigates the presence of e-cigarettes within licensed alcohol outlets in Baltimore. Additionally, we explore the sociodemographics – specifically, median household income and race/ethnicity profiles – of neighborhoods where alcohol outlets are located and examine the relationship between e-cigarette availability and the selling of other products within outlets. Influenced by the findings of previous research on relationships between sociodemographics and the availability of tobacco products, the hypothesis was that the availability of e-cigarettes within alcohol outlets would be greater in areas of Baltimore with a higher-than-average non-White population and a lower-than-average median household income.^19–20

This exploratory study investigated the availability of e-cigarettes within alcohol outlets in Baltimore and demonstrated that overall availability was relatively sparse in comparison to the availability of cigarettes and other combustible tobacco products in the same retailers. Specifically, e-cigarettes were primarily found within off-premise outlets where patrons purchase alcoholic beverages and cannot consume them on the property. Among alcohol outlets with e-cigarette availability, nearly all were visible only at a height physically accessible to adults, while very few had e-cigarettes available at heights physically accessible and visible for youth only or physically accessible and visible for both adults and youth.

Low income and urban non-White neighborhoods often have higher rates of tobacco and alcohol availability.^{19–20;50–51} Consistent with those previous studies, a similar pattern of e-cigarette availability within alcohol outlets was found. This is contrary to Rose et al., who found that e-cigarettes were more likely to be found in higher income and lower percent non-White neighborhoods; however, they evaluated a much greater availability than just liquor stores (gas stations, convenience marts, etc.).²² It is possible those results may reflect a greater availability of services such as supermarkets and pharmacies in higher income areas that also happen to sell e-cigarettes. Our findings suggest that within alcohol outlets, which are already found in higher concentrations within non-White and low-income neighborhoods, e-cigarettes are being sold as a complement, rather than a replacement, to existing tobacco and drug products.

There were limitations to this study. Notably, the decision was made to focus on basic descriptives via spatial mapping as opposed to spatial analyses due to the exploratory nature of the study. It is acknowledged that the hypothesis was due to the researchers’ understanding of Baltimore’s sociodemographic dynamics and that statistical methodology such as spatial regression does allow researchers to parse through multifaceted relationships such as the contextual interaction of race and socioeconomic status. However, it was determined that examining such an inherently complex relationship would be better suited for subsequent research influenced by the findings of this study. Additionally, it was also determined that this study would also focus on the relationship between established drug products and paraphernalia, including traditional tobacco products, and the availability of e-cigarettes within salient retail spaces, in this case alcohol outlets.

This study contributes to a limited literature on physical e-cigarette availability and illustrates the relationships with sociodemographics and availability of drug/tobacco products in a major urban U.S. city. In Baltimore, alcohol outlets are a primary location for many residents – including youth and those in lower-income neighborhoods – to purchase goods, alcohol or otherwise. As a result, they are establishments in which many residents are introduced to new products such as e-cigarettes, which due to acclimation could lead to curiosity and ultimately use of the product. With the growing but still limited knowledge of how e-cigarettes may affect health, there could be a potential hazard if availability grows within Baltimore alcohol outlets and exposure increases for populations who are potentially most disadvantaged by its consumption. In May 2016, the U.S. Food and Drug Administration (FDA) announced efforts to regulate e-cigarettes and other tobacco products in the same manner as traditional cigarettes and smokeless tobacco, including the restriction of purchase to individuals aged 18 years and older.⁵² This is an important step in limiting access to e-cigarettes at the point of purchase, particularly for minors, but additional policy may be needed to address product availability. Currently within the Maryland Business Regulation, Title 16 (Cigarettes) and Title 16.5 (Other Tobacco Products Licenses), there exists no language that provides a framework or restrictions on retailer locations as a condition for issuance of a cigarette or other tobacco product (OTP) license. Additionally, per the Baltimore City charter and zoning codes, there is no language that provides guidelines for the physical location of businesses and retailers that sell cigarettes and OTP such as e-cigarettes.^53–54

In addition to the access to e-cigarettes through alcohol outlets, future studies should determine the extent of e-cigarette availability in other venues throughout Baltimore, including in convenience stores, shopping center kiosks, and “vape” shops, which have seen a sharp increase in popularity along with e-cigarettes.⁵⁵ Additionally, an investigation of e-cigarette sales among alcohol outlets and other establishments should be conducted to elucidate whether or not current e-cigarette availability is supported by consumer demand. Finally, research is inconsistent as to racial differences in e-cigarette use despite advertising that appears tailored towards younger White individuals.¹⁴ Giovenco and colleagues’ recent study provides evidence that e-cigarettes are not targeted at non-White consumers in regards to availability, showing that New Jersey census tracts with a higher proportion of non-Hispanic black residents had significantly lower odds of having a vape shop.⁵⁶ Therefore, further study is warranted to examine for potential racial differences in e-cigarette advertising influence.

This study successfully mapped the presence of e-cigarettes within Baltimore alcohol outlets and provides insight into substances and products that relate to its availability. Additionally, this study provides key findings for the genesis of future research of e-cigarettes’ impact on various sociodemographic populations, especially as more evidence is presented to elucidate our understanding of the pharmacokinetic effects of e-cigarette consumption on the human body.