Adapting the WHO MPOWER framework for E-cigarettes: Qualitative insights from South Korea

Electronic cigarettes introduce regulatory complexities that extend beyond the assumptions of traditional tobacco control. Existing global frameworks, including the WHO Framework Convention on Tobacco Control and its MPOWER policy package, were developed primarily in response to combustible tobacco and have not fully incorporated the challenges posed by e-cigarettes. We aimed to explore how e-cigarettes are experienced and regulated in South Korea, and to identify gaps within the MPOWER framework.

A qualitative case study design was employed, with data collected through six focus group discussions conducted in Seoul, in February 2025. Participants included 47 individuals (39 current tobacco or e-cigarette users and 8 non-users) recruited through purposive sampling. Data were analyzed through a two-stage approach combining inductive pattern identification with theory-driven pattern matching to MPOWER domains.

Three thematic regulatory gaps were identified: (1) ambiguity around synthetic nicotine, which falls outside conventional tobacco product definitions; (2) digital marketing practices that promote e-cigarettes through channels inadequately addressed by existing advertising regulations; and (3) hybrid and poly-use patterns that create behavioral dynamics insufficiently addressed by current cessation and monitoring policies. These gaps demonstrate that MPOWER's emphasis on tobacco does not fully address the regulatory and social realities of contemporary e-cigarette markets.

To address these gaps, we propose the E+MPOWER framework, which extends MPOWER to more explicitly incorporate e-cigarette regulation, strengthen oversight of digital marketing, and integrate cessation approaches responsive to dual-use patterns. Grounded in the Korean context, this framework offers a foundation for more adaptive and coherent e-cigarette control strategies.