User:QuackGuru/Sand 25

First diagram: Regulated US Food and Drug Administration products such as nicotine inhalers may be safer than e-cigarettes, but e-cigarettes are generally seen as safer than combustible tobacco products. Second diagram: The short-term health effects of e-cigarettes can be severe, and the short-term harms of e-cigarettes is greater than tobacco products. Third diagram: E-cigarettes are often perceived as a less harmful alternative to conventional cigarettes; however, evidence to substantiate this assumption has not materialized. Although vaping shares certain toxic characteristics with tobacco, it also introduces distinct exposures and physiological effects not observed in tobacco use. Therefore, the belief that vaping is merely a safer or diluted form of smoking lacks scientific credibility.

Regulated US Food and Drug Administration products such as nicotine inhalers may be safer than e-cigarettes,^[4] but e-cigarettes are generally seen as safer than combustible tobacco products.^[5] The short-term health effects of e-cigarettes can be severe,^[6] and the short-term harms of e-cigarettes is greater than tobacco products.^[7] E-cigarettes are often perceived as a less harmful harmful alternative to conventional cigarettes; however, evidence to substantiate this assumption has not materialized.^[8] Although vaping shares certain toxic characteristics with tobacco, it also introduces distinct exposures and physiological effects not observed in tobacco use.^[7] Therefore, the belief that vaping is merely a safer or diluted form of smoking lacks scientific credibility.^[7]

The benefits and the health effects of electronic cigarettes are uncertain.^[9] There is a wide diversity in the types of e-cigarettes and e-liquids available, which cause differences in the aerosols delivered to users.^[10] Regulated US Food and Drug Administration products such as nicotine inhalers may be safer than e-cigarettes,^[4] but e-cigarettes are generally seen as safer than combustible tobacco products^{[note 1]}^[5]^[2] such as cigarettes and cigars.^[14] Since vapor does not contain tobacco and does not involve combustion, users may avoid several harmful constituents usually found in tobacco smoke,^[15] such as ash, tar, and carbon monoxide.^[16] However, vaping is more dangerous in the short-term than smoking.^[7]^[17] Because of the risk of nicotine exposure to the fetus and adolescent causing long-term effects to the growing brain, the World Health Organization does not recommend it for children, adolescents, pregnant women, and women of childbearing age.^[18] Vaping itself has no proven benefits^[7] and with or without nicotine it cannot be considered harmless.^[19] Their indiscriminate use is a threat to public health.^[20]

The long-term effects of e-cigarette use are unclear.^[21]^[22]^[23] Although uncommon,^[24] short-term use may lead to death.^[7] Less serious adverse effects include abdominal pain, headache, blurry vision,^[25] throat and mouth irritation, vomiting, nausea, and coughing.^[10] They may produce similar adverse effects compared to tobacco use.^[26] E-cigarettes reduce lung function, reduce cardiac muscle function, and increase inflammation.^[27] In 2019 and 2020, there was an outbreak of severe lung illness linked to vaping in the US^[28] and Canada,^[29] with 68 confirmed deaths in the US,^{[note 2]}^[28] and one confirmed death in Europe.^[34] There are also risks from misuse or accidents^[15] such as nicotine poisoning (especially among small children^[35]),^[36] contact with liquid containing nicotine,^[37] fires caused by device malfunction,^[10] and explosions resulting from extended charging, unsuitable chargers, design flaws,^[15] or user modifications.^[38] Battery explosions are caused by an increase in internal battery temperature and some have resulted in severe skin burns.^[39] There is a small risk of a battery explosion in devices modified to increase battery power.^[40]

The cytotoxicity of e-liquids varies,^[41] and contamination with various chemicals have been detected in the liquid.^[42] Metal parts of e-cigarettes in contact with the e-liquid can contaminate it with metal particles.^[15] Many chemicals including carbonyl compounds such as formaldehyde can inadvertently be produced when the nichrome wire (heating element) that touches the e-liquid is heated and chemically reacted with the liquid.^[43] The later-generation and "tank-style" e-cigarettes with a higher voltage (5.0 V^[41]) may generate equal or higher levels of formaldehyde compared to smoking.^[44] Using nicotine can result in cardiovascular disease, increased serum cholesterol levels, cancer, and possibly birth defects.^[45] Children, youth,^[6] and young adults are especially sensitive to the effects of nicotine.^[46] Several studies demonstrate nicotine is carcinogenic.^[47] There are no recognized benefits of vaping for youth.^[48] Propylene glycol, glycerin, volatile organic compounds, and free radicals can impair lung health.^[49] Many flavors are irritants^[50] and certain flavoring agents can induce respiratory toxicity.^[51]

E-cigarettes create vapor that consists of fine and ultrafine particles of particulate matter, with the majority of particles in the ultrafine range.^[10] The vapor contains propylene glycol, glycerin, nicotine, flavors, small amounts of toxicants,^[10] carcinogens,^{[note 3]}^[52] and heavy metals, as well as metal nanoparticles, and other substances.^[10] Exactly what the vapor consists of varies significantly in composition and concentration across and within brands, and depends on the e-liquid contents, the device design, and user behavior, among other factors.^{[note 4]}^[53] E-cigarette vapor potentially contains harmful chemicals not found in tobacco smoke^[54] such as propylene glycol.^[55] E-cigarette vapor contains fewer toxic chemicals,^[10] and lower concentrations of potentially toxic chemicals than in cigarette smoke.^[56] Concern exists that the exhaled e-cigarette vapor may be inhaled by bystanders, particularly indoors.^[57] There is limited information available on the environmental issues around production, use, and disposal of e-cigarettes that use cartridges.^[58] E-cigarettes that are not reusable may contribute to the problem of electronic waste.^[59]

Health effects

Overview of benefits and effects

A 2015 Centers for Disease Control and Prevention video on e-cigarettes.^[61]

Reviews on the safety of electronic cigarettes, evaluating roughly the same studies, have reached significantly different conclusions.^[64] Broad-ranging statements regarding their safety cannot be reached because of the vast differences of devices and e-liquids available.^[65] A consensus has not been established for the benefits as well as the effects related to their use.^[51] A substantial amount of research has been conducted in the past decade prior to 2020 to examine the health effects of e-cigarette use, often providing conflicting evidence and claims.^[9] What will cause the most or least undesirable effects of various blends of solvents, flavoring, and nicotine in e-liquids is unknown.^[46]

The types of devices being offered vary considerably, as do the chemical compositions of their liquid solutions, which include varying nicotine strengths, different carrier solvents such as propylene glycol, either alone or combined with glycerin, and a broad selection of additives and flavors.^[10] Consequently, the contents of the aerosol inhaled and exhaled by users also vary.^[10] Due to the large variation in the quantities of each constituent across products and an ever-evolving product marketplace, it is challenging to fully understand the clinical relevance of e-cigarette use on the individual's health.^[1] Although there is inconsistencies among the methodologies used (detection method, liquid or aerosol, animal models, conditions), the data generated by these investigations remains informative.^[66] Moreover, due to various methodological issues, severe conflicts of interest, and inconsistent research, no firm views can be made regarding their effects.^[67] However, e-cigarette use with or without nicotine cannot be considered harmless.^[19] Nicotine-free e-cigarette aerosol contains chemicals that cause cancer as well as chemicals associated with severe lung damage.^[22]

The levels of carcinogens found in e-cigarettes and nicotine replacement products are comparable, and the lack of a defined threshold for carcinogenesis means that e-cigarettes cannot be regarded as entirely safe.^[68] An uncountable amount of studies aimed at evaluating e-cigarette potential consequences on human health and the most updated panorama of scientific literature provides increasing evidence of vaping harmfulness.^[69] Among e-cigarettes adverse health effects, respiratory impact is by far the most extensively studied.^[69] Nicotine is the most studied biologically active chemical present in e-cigarettes, and several of the cardiovascular effects of e-cigarettes have been attributed to this alkaloid from the tobacco plant.^[70] Nicotine has well-established effects on the metabolism and cardiovascular system.^[70] In the same way as conventional cigarettes smokers, vapers' pulmonary epithelium is typically damaged and bronchial mucosa chronically inflamed.^[69]

Vaping has been promoted as being safer than cigarette smoking; however, users may inhale toxicants like diacetyl and carcinogens like formaldehyde,^[71] as well as contaminants such as traces of arsenic and other heavy metals.^[26] Because of the belief that e-cigarettes are less dangerous than traditional cigarettes, users may use them more frequently than traditional cigarettes, and as a consequence, could produce higher levels of second-hand contaminants.^[72] Vaping itself has no proven benefits,^[7] and it is a deliberate exposure in contrast to numerous other toxicological exposures.^[73] The potential benefits of nicotine vaping are vastly outweighed by its harmful effects, which include the threat of addiction, cancer, heart disease, hypertension, respiratory infections, and gastrointestinal discomfort.^[74]

E-cigarettes were initially positioned as a "healthy alternative", though they may produce similar adverse effects compared to tobacco use.^[26] There is emerging evidence demonstrating adverse effects attributable to e-cigarette use on every single human organ system.^[75] Whether e-cigarettes are helping smokers or creating a new source of addiction is extensively being debated.^[76] The overall public health effect related to their use is actively debated.^[77] Available evidence on the benefits and risks of e-cigarette use are mixed and interpreted differently.^[78] Some believe that e-cigarettes have the potential to reduce the burden of disease in smokers, while others worry about their impact on public health and either do not recommend them or even advocate banning their use.^[78]

Alternative to smoking

Tobacco companies have deliberately promoted the use of alternatives to traditional cigarettes with supposedly safer tobacco products, such as e-cigarettes, in an effort to reduce the harm caused by tobacco consumption.^{[note 5]}^[82] There is a lack of evidence in favor of using e-cigarettes as a safe option to classical cigarettes and as a substitute to public health approaches that aim at curtailing tobacco use.^[83]

A 2019 editorial in The Lancet stated that there is no solid proof showing that e-cigarettes is safer than cigarettes, but this conclusion was met with criticism by Professor JN Newton, Director of Health Improvement at Public Health England (PHE), who insisted that there is a worldwide consensus that their use is probably significantly less dangerous than smoking.^[84] Clinical trials and other studies have demonstrated that e-cigarettes are not a safer option.^[85] Since e-liquids and vaping aerosols contain nicotine and many of the same toxic chemicals and carcinogens as classical cigarettes do, it may be assumed, especially when taking into account the growing evidence of toxic tobacco inhalation that has been observed in the users of these devices, that there is the possibility that vaping may result in similar unwanted effects.^[86]

Vaping long-term is anticipated to raise the risk of developing some of the diseases linked to smoking.^[50] Since vapor does not contain tobacco and does not involve combustion, users may avoid several harmful constituents usually found in tobacco smoke,^[15] such as ash, tar, and carbon monoxide.^{[note 6]}^[16] The public health community is divided, even polarized, over how the use of these devices will impact the tobacco epidemic.^[88] Some tobacco control advocates predict that e-cigarettes will increase rates of cigarette uptake, especially among youth.^[88] Others envision that these devices have potential for aiding cessation efforts, or reducing harm among people who continue to smoke.^[88] Scientific studies advocate caution before designating e-cigarettes as beneficial but vapers continue to believe they are beneficial.^[89]

E-cigarette vapor contains higher levels of carcinogens and toxicants than in an US Food and Drug Administration (FDA) regulated nicotine inhaler, which suggests that regulated US FDA devices may deliver nicotine more safely.^[4] E-cigarettes are generally seen as safer than combustible tobacco products^[14]^[90]^[5]^[2] such as cigarettes and cigars.^[14] Due to the lack of long-term toxicological and safety studies on humans, stating with certainty that e-cigarettes are less hamaul than traditional cigarettes is "impossible".^[11]

Early research seemed to indicate that vaping might be safer than traditional cigarettes and provide a different method to give up smoking, though mounting evidence does not substantiate this.^[12] Evidence has not been presented to demonstrate that e-cigarettes are less dangerous than tobacco.^[13] The short-term health effects of e-cigarettes can be severe,^[6] and the short-term harms of e-cigarettes is greater than tobacco products.^[7] E-cigarettes are frequently viewed as a safer alternative to conventional cigarettes; however, evidence to support this perspective has not materialized.^[8] This appears to be due to the presence of toxicants in e-liquid composition, their adverse effects in animal models, association with acute lung injury and cardiovascular disease, and ability to modulate different cell populations in the lung and blood towards pro-inflammatory phenotypes.^[8] Although uncommon,^[24] short-term use may lead to death.^[7]

The surge in vaping among youth and the vaping-induced lung illness epidemic has increased the controversy surrounding vaping and casts doubt about their feasibility for public health gains as an alternative to traditional cigarettes.^[84] E-cigarette vapor potentially contains harmful substances not found in tobacco smoke^[54] such as propylene glycol and/or glycerin and various flavoring agents along with other unknown chemicals.^[55]

Opinions that e-cigarettes are a safe substitute to traditional cigarettes may compromise tobacco control efforts.^[91] While quitting smoking may be firmly recommended for smokers who have asthma, it is not clear whether replacing e-cigarettes for cigarettes is a universally safer alternative.^[92]

Studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive.^[93] There is a lack of evidence that they are safe during repeated inhalation in long-term use.^[93] Long-term data showing that vaping is a "healthier alternative" than cigarette smoking does not exist.^[4]

Effects on increased availability of vaping products

A serious concern regarding e-cigarettes is that they could entice children to initiate smoking, either by subjecting them to nicotine that leads to smoking or by making smoking appear more acceptable again.^[94] Concerns surrounding adolescent e-cigarette use stem from research indicating that nicotine use could potentially result in detrimental effects to the brain.^[95]

The medical community is concerned that increased availability of e-cigarettes could increase worldwide nicotine dependence, especially among the young as they are enticed by the various flavor options e-cigarettes have to offer.^[96] Since vaping does not produce smoke from burning tobacco, the opponents of e-cigarettes fear that traditional smokers will substitute vaping for smoking in settings where smoking is not permitted without any real intention of quitting traditional cigarettes.^[96] Furthermore, vaping in public places, coupled with e-cigarette commercials on national television, could possibly undermine or weaken current anti-smoking regulations.^[96] Fear exists that wide-scale promotion and use of e-cigarettes, fueled by an increase in advertising of these products, may carry substantial public health risks.^[97] Public health professionals have voiced concerns regarding vaping while using other tobacco products - particularly combustible products.^[98]

The increased dominance of the vaping market by global tobacco giants has raised concerns within the public health sector, due to the industry's well-documented history of deceiving the public with dubious claims, including that low-tar and "light" cigarettes would decrease the health risks linked to smoking.^[98] While tobacco companies now tout their interest in these products as a move toward harm reduction, numerous observers suspect that their real motivation is financial gain.^[98] E-cigarettes are expanding the tobacco epidemic by attracting lower-risk youth into the market, many of whom then transition to smoking cigarettes.^[99] A 2016 review recommended the precautionary principle to be used for e-cigarettes because of the long history of the tobacco crisis, in order to assess their benefits and long-term effects and to avoid another nicotine crisis.^[100]

Effects on dual use of vaping and smoking

Overview

The entrance of large US tobacco manufacturers, such as Altria Group, Reynolds American, and Lorillard, into the e-cigarette sector raises many potential public health issues.^[103] Instead of pushing for quitting smoking, the tobacco industry may promote e-cigarettes as a way to get around clean indoor air laws, which promotes dual use and the increased sale of traditional cigarettes.^[103] A 2015 review recommended the precautionary principle to be used because dual use could end up being an additional risk.^[64] The industry could also lead vapers to tobacco products, which would increase instead of decrease overall addiction.^[103] Concerns exist that the emergence of e-cigarettes may benefit Big Tobacco to sustain an industry for tobacco.^[104]

Evidence on the effects of dual e-cigarette and traditional cigarette use compared to using one product alone is limited.^[9] The long-term research on the effects of dual use of tobacco smoking and vaping are not available.^[105] Many continue to use both, exposing themselves to the harms of tobacco smoking and e-cigarette use.^[106] A 2018 study found that both e-cigarette and cigarette users had similar levels of metals toluene, benzene, and carbon disulfide, while dual users had the greatest amount of exposure to nicotine, tobacco biomarkers, metals toluene, benzene, and carbon disulfide.^[86]

Dual use offers no significant advantages.^[98] Vaping can hinder smokers from trying to quit, resulting in increased tobacco use and associated health problems.^[107] Compared to just smoking, dual use of smoking and vaping may increase the chance of developing heart disease, lung disease, and cancer.^[108] Quitting smoking entirely would probably have much greater beneficial effects to overall health than vaping to decrease the number of cigarettes smoked.^[10]

Metabolic effects

Ten large, good-quality surveys, including between 3,400 and almost 450,00 persons from the general population, investigated the cardiovascular and metabolic health effects of dual use.^[78] The best available of these studies had adjusted for tobacco consumption and found higher HbA1c levels in dual users than in exclusive smoking of conventional cigarettes, but significance levels were not tested.^[78]

Four of the good-quality surveys investigated cardiovascular risk factors and found that dual users had a significantly higher unadjusted and adjusted odds ratios of cardiovascular disease, significantly higher prevalence unadjusted and adjusted odds ratios of cardiovascular risk factors and diagnosis of metabolic syndrome, significantly higher unadjusted and adjusted odds ratios of elevated human c-reactive protein, significantly higher risk of stroke, significantly higher prevalence of arrythmia, significantly higher unadjusted and adjusted odds ratios of elevated c-reactive protein, and significantly higher unadjusted and adjusted odds ratios of abdominal obesity than exclusive smoking of conventional cigarettes.^[78]

The two remaining surveys found higher unadjusted and adjusted odds ratios of myocardial infarction and stroke, but significance level was not tested, and higher but not significant unadjusted and adjusted odds ratios of hypertension in dual users than in exclusive smoking of conventional cigarettes.^[78] Furthermore, one survey found that dual users had similar fasting glucose as exclusive smoking of conventional cigarettes, and another study found the same levels of insulin resistance.^[78]

Asthma

In a large survey, homeless persons with dual use reported significantly higher rates of asthma and cancer compared to exclusive smoking of conventional cigarettes.^[78] A positive association between dual use and the prevalence of asthma was reported in one systematic review in 2021, while a 2021 meta-analysis found that the association with asthma prevalence was even stronger for dual use than for traditional cigarette use alone.^[9] Temporality and a dose–response relationship were not determined due to the cross-sectional nature of the associations and lack of information on the intensity and duration of use.^[9]

Breathing and heart effects

E-cigarette use, as compared to traditional cigarette use, contributes independently to respiratory risk.^[9] Dual users reported a lower general health score, and more difficulty in breathing in the past month, compared to cigarette-only users.^[109] Additionally, a significant difference was observed in the history of arrhythmia between cigarette-only users (14.2%) and dual users (17.8%).^[109] More respiratory symptoms were found in dual smokers than in smokers who did not use e-cigarettes, and the possibility of reversible cerebral vasoconstriction syndrome was more likely to be observed in dual users.^[109]

There is a greater risk for a heart attack with the use of both e-cigarettes and traditional cigarettes.^[110] Using e-cigarettes daily doubles the risk of heart attack according to research performed by the Center for Tobacco Control Research and Education at the University of California, San Francisco in 2018.^[111] This study provided the first evidence of a substantial human health impact of electronic nicotine devices.^[111] This new study with nearly 70,000 people found that the heightened risk of heart attack for e-cigarette users is similar to one of the main effects of c-cigarettes.^[111] Together, in those who use both c- and e-cigarettes daily, the odds increase five times.^[111]

Other effects

A 2020 clinical study performed vascular function testing in almost 500 young persons and reported that dual users had similar arterial stiffness as exclusive smoking of conventional cigarettes.^[78] Large good-quality surveys (only one did not weight data) including adults found that dual users had significantly worse fitness and significantly higher levels of uric acid and prevalence of hyperuricemia compared with exclusive smoking of conventional cigarettes.^[78] Large surveys including adolescent dual users reported insufficient sleep significantly more often than exclusive smoking of conventional cigarettes, and higher odds of dental problems.^[78] Finally, in a small human clinical study in 2020, dual users had higher levels of most biomarkers of systemic inflammation than exclusive smoking of conventional cigarettes, but the difference was not significant.^[78]

Effects on smoking cessation

Overview

The safety of e-cigarette consumption and its potential as a smoking cessation method remain controversial due to limited evidence.^[79] Moreover, it has been reported that the heating process itself can lead to the formation of new decomposition compounds of questionable toxicity.^[79] There is concern that e-cigarettes may result in many smokers rejecting historically effective smoking quitting smoking methods.^[112]

Concern exists that the majority of smokers attempting to quit with the help of vaping may stop smoking but will keep on using nicotine, because their long-term effects are not clear.^[113] Many individuals use e-cigarettes as a way to quit smoking, but there is not clear evidence that e-cigarettes help people quit smoking entirely.^[106] E-cigarettes may help smokers reduce the number of cigarettes they smoke, though decreasing daily cigarette use is still not safe.^[106]

Effects

Since e-cigarettes are intended to be used repeatedly, they can conveniently be used for an extended period of time, which may contribute to increased adverse effects.^[114] The most frequently reported less harmful effects of vaping compared to smoking were reduced shortness of breath, reduced cough, reduced spitting, and reduced sore throat.^[89] More serious adverse effects frequently related with smoking cessation including depression, insomnia, and anxiety are uncommon with e-cigarette use.^[25] Many health benefits are associated with switching from tobacco products to e-cigarettes including decreased weight gain after smoking cessation and improved exercise tolerance.^[115] Quitting smoking with the use of a vape alleviated chronic idiopathic neutrophilia in a smoker.^[116] Vaping can be harmful by hindering efforts to quit smoking, serving as an entry point to tobacco use for non-smokers, or causing a relapse in those who have previously quit smoking.^[117]

Toxicity

They are similar in toxicity to other nicotine replacement products,^[118] but e-cigarettes manufacturing standards are variable, and many as a result are probably more toxic than nicotine replacement products.^[119] E-cigarettes produce more toxicants than other forms of nicotine replacement products and are likely to be more harmful.^[120]

Effects on vaping cessation

The short-term effects of vaping causing greater airway resistance and inflammation may not be permanent following quitting vaping.^[121] A 2022 review states that a better choice for quitting smoking or quitting nicotine might be to immediately stop using e-cigarettes and smoking combustible cigarettes, which might be a better way to reduce organ injuries.^[122] Cardiotoxicity can be irreversible, when necrosis or apoptosis of the myocardial cells occurs, or reversible, as in the case of short-term nicotine product consumption.^[123]

Primary-care interventions

Research indicates that screening patients for e-cigarette usage in primary practice is not frequently undertaken by medical practitioners.^[124] A 2015 study found a low prevalence of screening for e-cigarettes in primary-care practice relative to smoking screening (14% versus 86%) in a sample of 776 practitioners across the US.^[124] This low uptake is concerning, given the serious health risks of e-cigarettes.^[124] A 2016 qualitative study in the US further confirmed that there is insufficient knowledge of e-cigarettes among physicians, including both the potential benefits and health risks.^[124] A 2017 study in US college students found that most students did not receive any form of counseling about risks from medical practitioners, including dental hygienists.^[124] Studies have also shown that there is a need for stronger education on e-cigarettes in medical curricula, which will allow physicians to begin addressing e-cigarette use in teenagers.^[124]

As of 2022, there is little information on primary-care interventions for e-cigarette use in teenagers and young adults.^[124] A 2020 case study of a 23-year-old e-cigarette user shows promising results for tapering e-cigarette use with the assistance of a pharmacist, which suggests that different healthcare practitioners may play a role helping patients with gradually tapering off e-cigarettes.^[124] A 2021 randomized controlled trial of asthmatic teenagers who attended one of four clinics found that physicians discussed smoking during 38.2% of thee visits, but vaping was never brought up as a topic.^[124] According to a 2022 review, this emphasizes that physicians should discuss both smoking and vaping during appointments, in particular in youth presenting with asthma.^[124]

Overall risk relative to smoking

Vaping is estimated to be 95% less harmful than smoking claims

A 2015 Public Health England report claimed that "e-cigarettes were 95% safer than cigarettes, and it was widely cited, as a definitive scientific consensus, despite its tobacco and e-cigarette funding source and lack of any specific empirical evidence supporting the estimate of relative safety."^[82] Moreover, "The tobacco industry's history of funding scientific research to undermine the evidence of harms from tobacco is well documented."^[82]

—Yogi H Hendlin and colleagues, American Journal of Public Health^[82]

A 2018 PHE report stated, "The previous estimate that, based on current knowledge, vaping is at least 95% less harmful than smoking remains a good way to communicate the large difference in relative risk unambiguously so that more smokers are encouraged to make the switch from smoking to vaping," but noted that this in no way means that vaping is safe.^[125] They also noted it is associated with some risks as well as uncertainties.^[7] A 2015 PHE report stated that e-cigarettes are estimated to be 95% less harmful than smoking,^[126] but the studies used to support this estimate were viewed as having a weak methodology.^[127] The estimate has been extensively disputed in published journals.^[128] Many vigorously criticized the validity of the estimate that vaping is 95% less harmful than smoking.^[98] The PHE's encouragement of using vaping products has been characterized as "a reckless and irresponsible decision".^[7] The authors of the 2015 PHE report stated that their objective was to educate the public about the differences in relative risk.^[129]

Influential health organizations in England, including PHE, the Royal College of Physicians, the Royal Society for Public Health, and the National Health Service, have unequivocally stated that e-cigarettes are 95% safer than traditional cigarettes.^[99] This claim originated from a single consensus meeting of 12 people convened by D.J. Nutt in 2014.^[99] They reached this conclusion without citing any speciﬁc evidence.^[99] The Nutt et al. paper did include this caveat: "A limitation of this study is the lack of hard evidence for the harms of most products on most of the criteria", which has generally been ignored by those quoting this report.^[99]

Funding for researchers and groups that are supportive of promoting tobacco use

The Nutt et al. meeting was funded by Euroswiss Health and Lega Italiana Anti Fumo.^[99] EuroSwiss Health is one of several companies registered at the same address in a village outside Geneva with the same chief executive, who was reported to have received funding from British American Tobacco for writing a book on nicotine as a means of harm reduction and who also endorsed British American Tobacco's public health credentials.^[99] Another of Nutt's co-authors, Riccardo Polosa, was Chief Scientiﬁc Advisor to Lega Italiana Anti Fumo, received funding from Lega Italiana Anti Fumo, and reported serving as a consultant to Arbi Group Srl, an e-cigarette distributor.^[99] He also received funding from Philip Morris International.^[99]

Polosa, founder of the Center of Excellence for the Acceleration of Harm Reduction, has repeatedly and variously neglected to declare the money he was given for research came from Philip Morris International, his advisory costs from British American Tobacco, the Center of Excellence for the Acceleration of Harm Reduction's ties to the Foundation for a Smoke-Free World, and the Foundation for a Smoke-Free World's ties to Philip Morris International.^[131] In regard to the Foundation for a Smoke-Free World, John Britton stated that this organization is the newest in a series of third-party entities established by the tobacco industry to further its agenda.^[132] It serves as a financial conduit for researchers and groups that are supportive of tobacco use, thereby enhancing their careers or advancing pro-tobacco initiatives.^[132]

Peter Hajek, a contributing author of the 2015 PHE report, has worked as a consultant for, and obtained research funding from, companies specializing in smoking-cessation products, including Pfizer, GSK, and Johnson & Johnson.^[133] Hayden McRobbie, a co-author of the same report, participated in educational sessions funded by Pfizer and Johnson & Johnson, and also received research funding from Pfizer for investigator-led studies.^[133]

Conflicts of interests and flawed and flimsy evidence

In 2015, The BMJ published an investigative report that raised broader issues surrounding potential conflicts of interest between individuals involved in the Nutt et al. paper.^[99] The BMJ provided an infographic illuminating undisclosed connections between key people involved in the paper and the tobacco and e-cigarette industries as well as links between the paper and Public Health England via one of the coauthors.^[99] Even so, as of June 2017, the "95% safer" ﬁgure remains widely quoted, despite the fact that evidence of the dangers of e-cigarette use has rapidly accumulated since 2014.^[99] As of 2018, the evidence indicates that the risk of e-cigarette use is substantially higher than the "95% safer" figure would indicate.^[99]

Several of the authors who came up with the "95% safer" assertion have ties to the tobacco industry.^[127] A 2015 editorial in The Lancet identiﬁed ﬁnancial conflicts of interest associated with Nutt et al., noting that "there was no formal criterion for the recruitment of the experts."^[99] It was also criticized by the journal The Lancet for constructing its conclusions on "flimsy" evidence, which included citing literature with apparent conflicts of interest.^[134] Some researchers consider that the 95% figure is flawed and confusing, by making opinions at odds with existing knowledge.^[135] Despite this, most other health organizations have been more cautious in their public statements on the safety of e-cigarettes.^[136]

Harm reduction

The term harm reduction implies any reduction in relative harm from a prior level, even a small reduction such as reducing smoking by one or two cigarettes per day.^[138] Harm minimization strives to reduce harms to zero (i.e., ideally to no use and thus no harmful exposure).^[138] When a consumer does not want to stop all nicotine use, then harm minimization implies striving for the complete elimination of smoked tobacco exposure by substituting it with the use of less harmful noncombusted forms of nicotine instead of smoking.^[138] Tobacco harm reduction may serve as a substitute for traditional cigarettes with lower risk products to reduce tobacco-related death and disease.^[139]

Tobacco harm reduction has been a controversial area of tobacco control.^[68] Health advocates have been slow to support a harm reduction method out of concern that tobacco companies cannot be trusted to sell products that will lower the risks associated with tobacco use.^[68] E-cigarettes can reduce smokers' exposure to carcinogens and other toxic chemicals found in tobacco.^[38] A large number of smokers want to reduce harm from smoking by using e-cigarettes.^[140] The argument for harm reduction does not take into account the adverse effects of nicotine.^[141] The European Respiratory Society has stated that "The tobacco harm reduction strategy is based on well-meaning but incorrect or undocumented claims or assumptions,"^[142] while Ghazi Zaatari, the chair of the World Health Organization study group on tobacco product regulation, has indicated that "The notion of harm reduction is a trap by the tobacco industry trying to perpetuate nicotine addiction."^[143] There cannot be a defensible reason for harm reduction in children who are nicotine vaping.^[144] Quitting smoking is the most effective strategy to tobacco harm reduction.^[145]

First diagram: Short-term e-cigarette use is more dangerous than tobacco smoking. Second diagram: Short-term e-cigarette use may lead to death. Third diagram: Short-term e-cigarette use increases the risk of lung injury.

Short-term e-cigarette use is more dangerous than tobacco smoking.^[7] Short-term e-cigarette use may lead to death.^[7] Short-term e-cigarette use increases the risk of lung injury.^[7]

Tobacco smoke contains 100 known carcinogens, and 900 potentially cancer causing chemicals, but e-cigarette vapor contains less of the potential carcinogens than found in tobacco smoke.^[112] A study in 2015 using a third-generation device found levels of formaldehyde were greater than with cigarette smoke when adjusted to a maximum power setting.^[146] Due to their similarity to traditional cigarettes, e-cigarettes could play a valuable role in tobacco harm reduction.^[147] However, the public health community remains divided concerning the appropriateness of endorsing a device whose safety and efficacy for smoking cessation remain unclear.^[147] Overall, the available evidence supports the cautionary implementation of harm reduction interventions aimed at promoting e-cigarettes as attractive and competitive alternatives to cigarette smoking, while taking measures to protect vulnerable groups and individuals.^[147]

The core concern is that smokers who could have quit entirely will develop an alternative nicotine addiction.^[68] Dual use may be an increased risk to a smoker who continues to use even a minimal amount of traditional cigarettes, rather than quitting.^[10] Whether they ought to be recommended as a tobacco harm reduction aid is unclear because the longer term health consequences of inhaling e-cigarette-exclusive chemicals is not fully known.^[148] Evidence to substantiate the potential of vaping to lower tobacco-related death and disease is unknown.^[149] The health benefits of reducing cigarette use while vaping is unclear.^[150] E-cigarettes could have an influential role in tobacco harm reduction.^[147] Without clear evidence of a role in the reduction of tobacco dependence, e-cigarettes risk renormalizing and re-glamorizing smoking.^[151] This is of paramount concern, potentially undoing years of effort by the public health and medical communities.^[151]

A 2014 review recommended that regulations for e-cigarettes could be similar to those for dietary supplements or cosmetic products to not limit their potential for harm reduction.^[139] A 2012 review found e-cigarettes could considerably reduce traditional cigarettes use and they likely could be used as a lower risk replacement for traditional cigarettes, but there is not enough data on their safety and efficacy to draw definite conclusions.^[152] There is no research available on vaping for reducing harm in high-risk groups such as people with mental disorders.^[59]

A 2014 PHE report concluded that hazards associated with products currently on the market are probably low, and apparently much lower than smoking.^[140] However, harms could be reduced further through reasonable product standards.^[140] The British Medical Association encourages health professionals to recommend conventional nicotine replacement therapies, but for patients unwilling to use or continue using such methods, health professionals may present e-cigarettes as a lower-risk option than tobacco smoking.^[153] The American Association of Public Health Physicians suggests those who are unwilling to quit tobacco smoking or unable to quit with medical advice and pharmaceutical methods should consider other nicotine containing products such as nicotine replacement products, e-cigarettes, or smokeless tobacco instead of smoking.^[154] A 2014 World Health Organization report concluded that some smokers will switch completely to e-cigarettes from traditional tobacco but a "sizeable" number will use both.^[155] This report found that such "dual use" of e-cigarettes and tobacco "will have much smaller beneficial effects on overall survival compared with quitting smoking completely."^[155] While e-cigarettes may contribute to reducing harm for traditional smokers, a 2025 review advises exercising caution with their use, especially for individuals diagnosed with or at heightened risk for heart failure.^[156]

Regulation

Guidelines for the design, manufacture, and assessment of the safety of e-cigarette devices has not been established.^[157] Following years of regulatory discussions, suggested policies and directives, e-cigarettes mainly targeting the youth continue to be underregulated, as of 2020.^[158] A 2020 meta-analysis states that e-cigarettes should not be available as consumer products, though they may be considered for sale as a prescription drug.^[108] A 2015 review suggested that e-cigarettes could be regulated in a similar way as inhalation therapeutic medicine, meaning, they would be regulated based on toxicology and safety clinical trials.^[40] A 2014 review recommended that e-cigarettes could be adequately regulated for consumer safety with existing regulations on the design of electronic products.^[139] A 2015 review recommended that regulations provide detailed quality standards for products, policies to not allow chemicals of justifiable concern, and allocate testing for plausible contaminants.^[64]

According to a 2020 review, regulation is needed to inform e-cigarette users of possible metal/metalloid exposure through vaping as well as to prevent metal/metalloid exposure during e-cigarette use.^[159] A 2024 review showed that increasing taxation, banning flavors, sale licenses, and label warnings on e-cigarettes have decreased the incidences of youth vaping in affluent countries.^[160] Although no single regulation has been found to be the most effective, having multiple regulations does make an impact in decreasing vaping among the youth in affluent countries.^[160]

Regulation of the production and promotion of e-cigarettes may help lower some of the adverse effects associated with tobacco use.^[161] Scientists are doing research to obtain more data regarding e-cigarettes and their usage.^[162] This knowledge could result in additional regulations in the US.^[162] E-cigarettes are permitted for sales in the US, though some organizations in the US have recommended they be completed banned.^[76] The American Heart Association had urged a total ban on e-cigarette sales, stating that there is sufficient evidence linking e-cigarettes with adolescent's addiction to nicotine and with lure of never-smokers to smoking.^[76]

In order to protect the public from both second-hand smoke and second-hand e-cigarette aerosol, the Surgeon General of the United States emphasized that smoke-free policies should be modernized to incorporate e-cigarettes, an approach that "will maintain current standards for clean indoor air, reduce the potential for renormalization of tobacco product use, and prevent involuntary exposure to nicotine and other aerosolized emissions from e-cigarettes."^[163] A 2019 review states, it is imperative to establish regulations for e-cigarette construction, e-liquid and aerosol composition, health warnings, marketing, promotion, sales, taxation, and exposure to second-hand aerosol, with standards that are at least on par with those for traditional tobacco products.^[164]

Public health consequences

The public health consequence of vaping is actively being debated.^[165] Under certain conditions, nicotine-containing e-cigarettes may reduce rates of combustible tobacco smoking; however, their overall impact on public health remains a subject of significant controversy.^[166] The health community, pharmaceutical industry, and other groups have raised concerns about the emerging phenomenon of e-cigarettes, including the unknown health risks from their long-term use.^[139] The rise in e-cigarette use among the general population raises concern.^[106] E-cigarettes pose potential risks to the population as a whole.^[167] Concerns have been raised that higher rates of never smokers initiating e-cigarettes would result in net public health harms via increased nicotine addiction.^[147]

One of the serious concerns in public health is the increase in trying an e-cigarette among people who have not smoked, particularly children and adolescents, which can result in nicotine addiction and possible progression to smoking.^[164] The prevalence of newer types of e-cigarettes, including Juul, with greater levels of nicotine is a public health catastrophe.^[86] In December 2018, the US Surgeon General said vaping among youth is an epidemic.^[86] Misinformation may downplay the risks of vape use and may be in part responsible for the recent youth vaping epidemic.^[168] The rise in the rate of vaping among youth in Australia and New Zealand are a major public health concern.^[22] The direct health risks, the association of e‐cigarette use with taking up tobacco smoking, and the uncertainty about their effects on major health outcomes mean that e‐cigarette use by non‐smokers, especially children and adolescents, is an important public health problem.^[102] Their indiscriminate use is a threat to public health.^[20]

E-cigarettes could cause public health harm if they: increase the number of youth and young adults who are exposed to nicotine, or lead non-smokers to start smoking conventional cigarettes and other burned tobacco products such as cigars and hookah, or sustain nicotine addiction so smokers continue using the most dangerous tobacco products – those that are burned – as well as e-cigarettes, instead of quitting completely, or increase the likelihood that former smokers will again become addicted to nicotine by using e-cigarettes, and will start using burned tobacco products again.^[167] Many questions remain unanswered regarding their overall effect on public health.^[10]

The range of e-liquid flavors available to consumers is extensive and is used to attract both current smokers and new e-cigarette users, which is a growing public health concern.^[79] The widespread availability and popularity of flavored e-cigarettes is a key concern regarding the potential public health implications of the products.^[169] A critical public health concern is the increased use among pregnant women.^[170] E-cigarettes are not safe for youth, young adults, pregnant women, or adults who do not currently use tobacco products.^[171] Because of the risk of nicotine exposure to the fetus and adolescent causing long-term effects to the growing brain, the World Health Organization does not recommend it for children, adolescents, pregnant women, and women of childbearing age.^[18] E-cigarettes are an increasing public health concern due to the rapid rise among adolescents and the uncertainty of potential health consequences.^[172]

Another area of concern is the public health consequences of second-hand e-cigarette vapor on bystanders.^[173] Second-hand e-cigarette vapor is a significant public health issue because of the tremendous growth in the number of e-cigarette users.^[57] The use of e-cigarettes in public areas poses a serious health risk considering the various toxic constituents that have been shown to affect both the primary user and bystanders of passive vaping.^[173] It is pertinent to note that smoke-free laws in the US were passed before e-cigarettes entered the market and do not specifically mention the prohibition of e-cigarette vaping in many places.^[173] As such, this non-clarity may lead to non-compliance or exploitation of smoke-free rules.^[173] Greater e-cigarette vapor exposure to bystanders may undermine public policies to restrict second-hand smoke and may renormalize smoking habits.^[174]

Adverse effects

The short-term and long-term effects from e-cigarette use remain unclear.^[22] The long-term health consequences from vaping is probably somewhat greater than nicotine replacement products.^[176] They may cause long-term and short-term adverse effects, including airway resistance, irritation of the airways, eyes redness, and dry throat.^[177] Serious adverse events related to e-cigarettes were hypotension, seizure, chest pain, rapid heartbeat, disorientation, and congestive heart failure but it was unclear the degree to which they were the result of e-cigarettes.^[25] Less serious adverse effects include abdominal pain, dizziness, headache, blurry vision,^[25] throat and mouth irritation, vomiting, nausea, and coughing.^[10] There are no recognized benefits of vaping for youth.^[48]

Nicotine poisoning associated with e-cigarettes may arise from inhalation, absorption, or ingestion via the skin or eyes.^[36] Accidental poisoning can result from using undiluted concentrated nicotine when mistakenly used as prepared e-liquids.^[178] There is a possibility that inhalation, ingestion, or skin contact can expose people to high levels of nicotine.^[161] Concerns with exposure to the e-liquids include leaks or spills and contact with contaminants in the e-liquid.^[179] E-liquid presents a poisoning risk, particularly for small children, who may see the colorful bottles as toys or candy.^[163] The e-liquid can be toxic if swallowed, especially among small children.^[35]

The possibility of injury caused by e-cigarette explosions is a concern for adults and children.^[37] The exact causes of such incidents are not yet clear.^[180] Some batteries are not well designed, are made with poor quality components, or have defects.^[39] Major injuries have occurred from battery explosions and fires.^[10] Direct harms from an e-cigarette blast include hand harms, face harms, waist/groin harms, and inhalation harms.^[181] Indirect harms happened when the vaporing device set on fire another object and resulted in a house fire, followed by harm from fire burns or inhalation.^[181] Several people have died as a result of e-cigarette blasts with parts of the device hitting the head and neck area.^[6]

Toxicology

The chemicals and toxicants used in e-cigarettes have not been completely disclosed and their safety is not guaranteed.^[161] While there is variability in the ingredients and concentrations of ingredients in e-cigarette liquids, tobacco smoke contains thousands of chemicals, most of which are not understood and many of which are known to be harmful.^[139] The long-term health impacts of the main chemicals nicotine and propylene glycol in the e-cigarette aerosol are not fully understood.^[182] Because there are numerous variations of vaping devices, diverseness in e‑liquids, and differences in usage behaviors, the potential toxicity of the inhaled emissions to the user is hard to quantify.^[183] Many variables affect the levels of toxicants in the e-cigarette aerosol, including the design, the type of liquid, and user behavior.^[116]

Research indicates that while research on the cancer risks of vaping remains limited, there is considerable evidence linking e-cigarette exposure to biomarkers correlated with cancer risk.^[184] The International Agency for Research on Cancer does not consider nicotine to be a carcinogen, though several studies demonstrate it is carcinogenic.^[47] Because it can form nitrosamine compounds (particularly N-Nitrosonornicotine (NNN) and nicotine-derived nitrosamine ketone (NNK)) through a conversion process, nicotine itself exhibits a strong potential for causing cancer.^[185] Although nicotine in the form of nicotine replacement products is less of a cancer risk than with smoking,^[186] there is evidence that nicotine may cause oral, esophageal, or pancreatic cancers.^[187] Nicotine has a strong tumor-inducing effect on several kinds of cancers.^[5] This is because nicotinic receptors are present on the surfaces of both tumor and immune cells, allowing nicotine to exert direct influence on the tumor microenvironment.^[5]

Nicotine can enhance cancer cell survival via attaching to nicotinic receptors.^[5] It may also diminish cancer cell death resulting from chemotherapy, radiotherapy, or tyrosine kinase inhibitors.^[5] Nicotine promotes metastasis by causing cell cycle progression, epithelial-to-mesenchymal transition, migration, invasion, angiogenesis, and avoidance of apoptosis in a number of systems.^[188] Low concentrations of nicotine stimulate cell proliferation, while high concentrations are cytotoxic.^[189] Nicotine has been shown to induce chromosomal aberration, chromatid exchange, single-strand DNA strand breaks, and micronuclei in vitro.^[189] The majority of e-cigarettes evaluated included carcinogenic tobacco-specific nitrosamines; heavy metals such as cadmium, nickel, and lead; and the carcinogen toluene.^[161] NNN and NNK are classified by International Agency for Research on Cancer as human carcinogens.^[189] There is growing concern that vaping may increase the likelihood of developing lung cancer.^[185]

When propylene glycol is heated and aerosolized, it could turn into propylene oxide, which the International Agency for Research on Cancer states is possibly carcinogenic to humans.^[10]^[190] There is very limited toxicological data on inhaling flavoring additives.^[92] Some flavors are regarded as toxic and a number of them resemble known carcinogens.^[42] Cinnamaldehyde has been described as a highly cytotoxic material in vitro in cinnamon-flavored refill liquids.^[39] The International Agency for Research on Cancer has categorized formaldehyde as a human carcinogen, and acetaldehyde is categorized as a possible carcinogen to humans.^[43] The health effects of long-term nicotine use is unknown.^[147] Nicotine affects practically every cell in the body.^[191] The complex effects of nicotine are not entirely understood.^[45] The toxicity of nanoparticles is unknown.^[150] Metals including nickel, cadmium, lead, and silicate can be found in the e-cigarette aerosols, and are thought to be carcinogenic, nephrotoxic, neurotoxic, and hemotoxic.^[177]

Long-term health effects

The impact of traditional cigarettes on human health has been well-defined in both animal and human studies.^[192] In contrast, little is known about the adverse effects of e-cigarette exposure on human health.^[192] There is a lack of many long-term studies that can identify future health risks associated with e-cigarette use.^[111] There is no sufficient evidence on their long-term organ effects.^[192] Their long-term exposure health effects remain largely unknown.^[192] Data on the prolonged use of e-cigarettes use among people with pre-existing chronic diseases are missing.^[192] Long-term exposure to e-cigarettes may cause adverse effects on various organ systems.^[192]

The long-term effects on lung function is unknown.^[4] There is concern that e-cigarette use could result in respiratory diseases among youth.^[193] Repeated exposure to acrolein, which is produced by heating the propylene glycol and glycerin in e-liquids, causes chronic pulmonary inflammation, reduction of host defense, neutrophil inflammation, mucus hypersecretion, and protease-mediated lung tissue damage, which are linked to the development of chronic obstructive pulmonary disease.^[99] Vaping cannabinoid plants may lead to lung injury similar to that of smoking tobacco.^[194] Vaping poses unique risks, as contaminants and additives to the vape medium may cause significant lung damage apart from cannabinoids.^[194]

There is limited available evidence on their long-term cardiovascular effects.^[195] Their cardiovascular effects in individuals who do not have cardiovascular disease is uncertain.^[196] E-cigarettes may lead to adverse effects on the cardiovascular system through various mechanisms, such as oxidative stress, inflammation, endothelial dysfunction, atherosclerosis, hemodynamic effects, and platelet activity.^[197] Research on the consequences of vaping on blood pressure is limited.^[198] Compared to non-users, e-cigarette use increases the chance of experiencing a heart attack by 33%.^[199] The evidence suggests that vaping has the ability to induce tachycardia-induced cardiomyopathy.^[200]

The long-term effects of e-cigarette use on the brain is unknown.^[1] Vaping may increase the risk of suicidal thoughts and suicide.^[201] A 2021 observational study found an association between e-cigarette use and stroke.^[202] The risk of early death is anticipated to be similar to that of smokeless tobacco.^[203] There is a significant risk of long-lasting lung injury from vaping that may contribute to or lead to death, in old people.^[204] Nicotine exposure leads to epigenetic changes that affect lung function in future generations.^[205] Vaping or the use of any nicotine-based product during pregnancy, or both during pregnancy and the breastfeeding postpartum period, causes the "concurrent exposure of three generations to nicotine."^[206]

2019–2020 vaping lung illness outbreak

Some of the vaping products that contained exceedingly high amounts of vitamin E acetate, including Dank Vapes, pictured here.

Some of the vaping products analyzed by the Wadsworth Center contained exceedingly high amounts of vitamin E acetate, including Dank Vapes, pictured here.^[207]

In 2019 and 2020, an outbreak of severe vaping-induced lung illness (called e-cigarette, or vaping, product use-associated lung injury^[211]) had affected certain users of vaping products in the US^[28] and Canada.^[29] The first cases, which involved a cluster of lung illnesses, were first identified in Illinois and Wisconsin in April 2019.^[212] Published case reports of vaping-related lung illnesses can be traced back to 2012.^[213] Similar cases of vaping-induced lung injuries were reported in the UK and Japan before the outbreak occurred.^[11]^[214] The prevalence of vaping-induced lung injuries ocurring worldwide remains unclear.^[11] As of February 18, 2020, a total of 2,807 hospitalized cases have been reported to the Centers for Disease Control and Prevention (CDC) from all 50 US states, the District of Columbia, and two US territories (Puerto Rico and US Virgin Islands).^[28] 68 deaths in the US have been confirmed in 29 states and the District of Columbia, as of February 18, 2020.^[28] Cases peaked in September 2019, and a slow decline followed.^{[note 7]}^[28] Chief Public Health Officer of Canada announced on October 11, 2019 that they are aware of the initial cases of vaping-induced lung injury.^[215] As of August 14, 2020, 20 cases of lung injuries have been reported to the Public Health Agency of Canada.^[29] The majority of cases in Canada involving lung injuries do not seem to have been connected with the use of THC-infused products.^[29]

Of the 2,807 reported cases, 2,022 hospitalized persons had data on substance use, as of January 14, 2020.^[28] 82% reported THC use, 33% reported exclusive THC use, 57% reported using nicotine-containing products, and 14% reported exclusive use of nicotine-containing products.^[28] Many of the samples tested by the states or by the US FDA as part of the 2019 investigation have been identified as vaping products containing tetrahydrocannabinol (THC, a psychoactive component of the cannabis plant).^[216] Most of those samples with THC tested also contained significant amounts of vitamin E acetate.^[216] The CDC reported that their findings suggest vaping products containing THC are linked to most of the cases and play a major role in the outbreak.^[28] The CDC stated that the chemical vitamin E acetate is a very strong culprit of concern in the lung illnesses related to THC-based vaping products, but did not rule out other chemicals as possible causes.^{[note 8]}^[217] The majority of those affected were young adults aged 18 to 34, which is the group with the greatest prevalence of cannabis use in the US.^[30] Nicotine e-cigarette use has been linked to the vaping-induced lung injury cases in a small subset of users.^[32]

Thickening agents were used to dilute vape oils.^[218] There has been an increase in attention to companies that sell diluent products that are made with vitamin E acetate.^[218] Previously, vitamin E acetate was used in low concentrations, or lower than 20% of the formula in vape cartridges.^[218] As a result of a limited availability of cannabis in California as well as high demand, illicit sellers had used about 50% or higher of diluent thickeners in their formulas to bulk up tiny potency vape cartridges.^[218] In September 2019, New York Governor Andrew Cuomo instructed the state health department to issue subpoenas against three sellers of thickening agents used in illicit vaping products.^[219] The use of vitamin E acetate in vaping products is not banned in the US,^[201] though Colorado,^[220] Ohio,^[220] and Washington have banned it in vaping products,^[221] and Oregon has banned it in cannabis vaping products.^[222] Health Canada does not permit vitamin E acetate in cannabis vaping products in Canada.^[223] On November 18, 2022, six people involved in an elaborate criminal THC vape cartridge ring were convicted, and each one received fines or probation.^[224] Jacob and Tyler Huffhines, and their mom Courtney, were convicted of criminal charges related to THC vape cartridges without receiving a prison sentence.^[225] Wesley Webb, Hannah Curt, and Daniel Graumenz, were all fined.^[224] Both Jordan Lynam and Tarail King were anticipated to be sentenced in November 2022.^[226]

The e-cigarette industry is placing the blame on illicit vaping liquids for the lung injuries.^[227] Juul Labs stated that some news agencies report that several cases of lung illness are associated with vaping THC, found in cannabis, "a Schedule 1, controlled substance that we do not sell."^[228] The CDC and US FDA recommend that people not use THC-containing e-cigarette, or vaping, products, particularly from informal sources like friends, family, or in-person or online dealers, as of February 18, 2020.^[28] The US FDA considers it prudent to avoid inhaling vitamin E acetate.^[216] On September 6, 2019, the US FDA stated that because consumers cannot be sure whether any THC vaping products may contain vitamin E acetate, consumers are urged to avoid buying vaping products on the street, and to refrain from using THC oil or modifying/adding any substances to products purchased in stores.^[216] The Public Health Agency of Canada recommends for adults and parents or guardians who are smoking or vaping to contact a health care provider for guidance on ways to stop.^[29] The vaping-induced lung injuries has led to concern around the world.^[229] In 2020, the first uptick in vaping-induced lung injury cases had occurred in Utah since the decline of 2019.^[33]

Pathogens

Microbial toxins

The existing research pertaining to the microbiomes of e-liquids and cartridges are sparse.^[230] A 2019 study found popular US vape liquids were contaminated with B-D-glucan and endotoxin.^[231] Asthma and hypersensitivity pneumonitis are connected with these two microbial toxins.^[231] B-D-glucans and endotoxin may induce respiratory discomfort, but studies have not been conducted on the long-term effects at the levels detected in vape liquids.^[71]

Virulence

E-cigarette exposure can enhance the virulence of certain pathogens.^[232] This strengthens their potential to stay alive in the host.^[232] Differing bacterial strains became more destructive in a larval infection model after exposure to e-cigarette vapor.^[232] Methicillin-resistant Staphylococcus aureus colonized in e-cigarette vapor extract were more damaging in mice, and had an increased ability to create biofilms, permeate and occupy within epithelial cells, and withstand the antimicrobial LL-37.^[232]

E-cigarette vapor rapidly augment biofilm formation on the polystyrene surface by various Gram-positive and Gram-negative pathogens in a dose- and bacterial-strain-dependent manner.^[233] Reactive oxygen species and nicotine are the main chemical drivers of e-cigarette vapor-dependent biofilm augmentation.^[233] Exposure to e-cigarette vapor induces adherence of Staphylococcus aureus and Porphyromonas gingivalis to host cells and proteins while the adherence of Streptococcus pneumoniae or Pseudomonas aeruginosa is unaffected by e-cigarette vapor exposure.^[233]

The bioactive chemicals in e-cigarette vapor may affect pathogenic bacteria in the nasopharyngeal microflora, which may have implications on the pathophysiology of respiratory infections in e-cigarette users.^[233] Research shows that the e-cigarette vapor-mediated alterations in bacterial virulence were dependent on the length of exposure and the strain of pathogen under examination and that reactive oxygen species and nicotine were the primary chemical drivers of e-cigarette vapor-mediated alterations in the pathogen virulence.^[233] Exposure to e-cigarette vapor induces pleiotropic changes affecting the physiology of the host and the pathogens known to asymptomatically colonize the respiratory tract and the mouth.^[233]

E-cigarette aerosol

Composition

The chemical composition of the electronic cigarette aerosol varies significantly across and within brands.^{[note 9]}^[53] Limited data exists regarding their chemistry.^[53] The aerosol of e-cigarettes is generated when the e-liquid comes in contact with a coil heated to a temperature of roughly 100–250 °C (212–482 °F) within a chamber, which is thought to cause pyrolysis of the e-liquid and could also lead to decomposition of other liquid ingredients.^{[note 10]}^[40] The aerosol (mist^[42]) produced by an e-cigarette is commonly but inaccurately called vapor.^{[note 11]}^[53] The e‑cigarette aerosol is absorbed through the lungs, and at this point it rapidly travels through the heart and subsequently delivers nicotine to the brain within a matter of a few seconds.^[75] Nicotine in the brain of e-cigarette users is typically between 0.05 and 0.5 μM.^[234] The use of an e-cigarette simulates the action of smoking,^[39] but without tobacco combustion.^[152] The e-cigarette aerosol somewhat resembles cigarette smoke.^[235] E-cigarettes do not produce aerosol between puffs.^[236] Both smoke and carbon monoxide are not generated,^[164] although insignificant quantities of incomplete combustion products are produced.^[237]

The e-cigarette aerosol usually contains propylene glycol, glycerin, nicotine, flavors, aroma transporters, and other substances.^{[note 12]}^[35] The levels of nicotine, tobacco-specific nitrosamines, aldehydes, metals, volatile organic compounds, flavors, and tobacco alkaloids in e-cigarette aerosols vary greatly.^[53] The yield of chemicals found in the e-cigarette aerosol varies depending on, several factors, including the e-liquid contents, puffing rate, and the battery voltage.^{[note 13]}^[190] About 250 chemicals have been found in e-cigarette vapors.^[240] There is emerging evidence indicating that over a thousand chemicals can be present in the e-liquid and aerosol.^[241] There is also a variety of unknown chemicals in the e-cigarette aerosol.^[55]

Metal parts of e-cigarettes in contact with the e-liquid can contaminate it with metal particles.^[15] Heavy metals and metal nanoparticles have been found in tiny amounts in the e-cigarette aerosol.^{[note 14]}^[15] Once aerosolized, the ingredients in the e-liquid go through chemical reactions that form new compounds not previously found in the liquid.^[41] Many chemicals including carbonyl compounds such as formaldehyde can inadvertently be produced when the nichrome wire (heating element) that touches the e-liquid is heated and chemically reacted with the liquid.^[43] Propylene glycol-containing liquids produced the most amounts of carbonyls in e-cigarette vapors.^[43] In 2015, e-cigarettes companies attempted to reduce the formation of formaldehyde and metal substances of the e-cigarette vapor by producing an e-liquid in which propylene glycol is replaced by glycerin.^[243]

Propylene glycol and glycerin are oxidized to create aldehydes that are also found in cigarette smoke when e-liquids are heated and aerosolized at a voltage higher than 3 V.^[53] Depending on the heating temperature, the carcinogens in the e-cigarette aerosol may surpass the levels of cigarette smoke.^[41] Reduced voltage e-cigarettes generate very low levels of formaldehyde.^[43] Initial studies reported that formaldehyde was formed during the vaping process under high heat conditions.^[11] Although some of the more recent e-cigarette devices limit temperature in an attempt to minimize this, multiple reports have documented the formation of acetaldehyde, acrolein, diacetyl, and formaldehyde under a wide range of conditions.^[11] As e-cigarette engineering evolves, the later-generation and "hotter" devices could expose users to greater amounts of carcinogens.^[44]

Second-hand exposure

Since e-cigarettes have not been in widespread use for a significant amount of time, the long-term biological effects are currently unknown.^[10] The short-term health effects from the second-hand vapor is also not known.^[56] There is limited information available regarding the health effects of second-hand vapor on children.^[245] The long-term effects of second-hand vapor exposure on children are unknown.^[245]

E-cigarettes are marketed as "free of primary and second-hand smoke risk" due to no carbon monoxide or tar is expected to be generated during use.^[246] However, there is a concern for the health impact of nicotine and other ingredients.^[246] The available evidence demonstrates that the e-cigarette vapor emitted from e-cigarettes is not just "harmless water vapor" as is repeatedly stated in the advertising of e-cigarettes, and they can cause indoor air pollution.^[10]

Some non-users have reported adverse effects from the second-hand vapor.^[116] Studies have provided evidence about the health risks of e-cigarette passive exposure, which are, in some respects, comparable to those associated with passive tobacco exposure.^[247] Exhaled vapor consists of nicotine and some other particles, primarily consisting of propylene glycol, glycerin, flavors, and aroma transporters.^[35] Bystanders are exposed to these particles from exhaled e-cigarette vapor.^[10] The exhaled vapor may involuntarily expose bystanders to toxicants that are in the range as some cigarettes.^[18] This is due to the fact that some vaping devices generate toxicants in the range as some cigarettes do.^[18] Second-hand e-cigarette aerosol may be dangerous to children.^[248]

There are benefits to banning vaping indoors in public and working areas, since there is a potential harm of renormalizing tobacco use in smoke-free areas, in addition to, vaping may result in spread of nicotine and other chemicals indoors.^[249] Concerns exist that the increased rates of e-cigarette users who have never smoked could cause harms to public health from the increased nicotine addiction.^[147] Vaping in areas where smoking is banned indoors could be a move in the wrong direction for public health when considering air quality in addition to being unfavorable for an individual who may have quit nicotine use if they did not vape.^[250]

Third-hand exposure

Third-hand exposure happens when nicotine and other substances from exhaled e-cigarette aerosol settle on surfaces, which then exposes people by way of touching, ingesting, or inhaling.^[36] Non-users, especially vulnerable populations such as children, the elderly, and pregnant women, face potential danger from third-hand exposure to e-cigarettes.^[251]

There is concern about the health impacts of pediatric exposure to third-hand e-cigarette vapor.^[37] E-cigarette use by a parent might lead to inadvertent health risks to offspring.^[252] E-cigarettes pose many safety concerns to children.^[252] For example, indoor surfaces can accumulate nicotine where e-cigarettes were used, which may be inhaled by children, particularly youngsters, long after they were used.^[252]

Chemicals present in third-hand emissions include nicotine and semi-volatile organic compounds, which can react with oxidizing chemicals in the environment to form secondary carcinogenic pollutants such as nitrosamines.^[253] Additionally, nicotine vaping aerosols can adsorb to clothing, furniture, and other surfaces and persist within indoor environments.^[253] Third-hand vaping exposures are pervasive, and studies have shown nicotine residues several days after vaping had ended.^[253] The level of exposure from third-hand vaping is likely highly variable and may be dependent on the surface, as well as on the nicotine vaping devices' format and e-liquid formulation.^[253]

Initial data suggests that nicotine from e-cigarettes may stick to surfaces and would be hard to remove.^[36] The extent of third-hand contamination indoors from e-cigarettes in real-world settings has not been established but would be of particular concern for children living in homes of e-cigarette users, as they spend more time indoors, are in proximity to and engage in greater activity in areas where dust collects and may be resuspended (e.g., carpets on the floor), and insert nonfood items in their mouths more frequently.^[169]

Effects on pregnancy and infants

No evidence has shown that e-cigarettes are safe for pregnant women to use, and no amount of nicotine is safe for pregnant women.^[255] The potential health effects of using e-cigarettes during pregnancy remain largely uncertain.^[256] E-cigarette use during pregnancy can be harmful to the fetus.^[257] Many ingredients used in e-liquids have not been studied for their safety during pregnancy.^[255]

Nicotine exposure during pregnancy is extremely harmful to the fetus.^[258] Nicotine is also a health danger for pregnant people.^[259] Prenatal nicotine exposure is associated with adverse effects on the growing fetus, including effects to normal growth of the endocrine, reproductive, respiratory, cardiovascular, and neurologic systems.^[255] Nicotine has been found in breast milk.^[260] Nicotine-free e-cigarette aerosols may cause harm to the fetus.^[247] Cannabis use during pregnancy can be harmful to the baby's health.^[261]

The belief that e-cigarettes are safer than traditional cigarettes could increase their use in pregnant women.^[39] Concerns exist regarding pregnant women exposure to e-cigarette vapor through direct use or via exhaled vapor.^[10] According to a 2017 review, the evidence that nicotine harms infant development justifies the need for public health initiatives to shield pregnant women from being exposed to nicotine.^[262] Cannabis use during pregnancy is a serious public health problem.^[263]

Environmental impact

There are a range of consequences for the environment surrounding the use of e-cigarettes, such as air quality effects, energy and materials used, issues related to environmentally responsible disposal, and land-use decisions.^[264]

There is limited information available on any environmental issues connected to the production, usage, and disposal of e-cigarette models that use cartridges.^[58] Studies directly describing environmental exposure to chemicals from e-cigarette waste on minorities and low-income populations are limited.^[265] As of 2014^[update], no formal studies have been done to evaluate the environmental effects of making or disposing of any part of e-cigarettes including the batteries or nicotine production.^[58] As of 2014^[update], it is uncertain if the nicotine in e-liquid is United States Pharmacopeia-grade nicotine, a tobacco extract, or synthetic nicotine when questioning the environmental impact of how it is made.^[58] It is not clear which manufacturing methods are used to make the nicotine used in e-cigarettes.^[58] The emissions from making nicotine could be considerable from manufacturing if not appropriately controlled.^[58] Some e-cigarette brands that use cartridges state their products are 'eco-friendly' or 'green', despite the absence of any supporting studies.^[58] Some writers contend that such marketing may raise sales and increase e-cigarette interest, particularly among minors.^[58]

E-cigarettes that are thrown away that end up in landfills is a rising public health concern.^[16] A July 2018–April 2019 garbology study found e-cigarette products composed 19% of the waste from all traditional and electronic tobacco and cannabis products collected at 12 public high schools in the San Francisco Bay Area.^[266] It is unclear how many traditional cigarettes are comparable to using one e-cigarette that uses a cartridge for the average user.^[58] Information is limited on energy and materials used for production of e-cigarettes versus traditional cigarettes, for comparable use.^[58] E-cigarettes can be made manually put together in small factories, or they can be made in automated lines on a much bigger scale.^[58] Larger plants will produce greater emissions to the surrounding environment, and thus will have a greater environmental impact.^[58] Tobacco factories create toxic nicotine waste from the manufacturing of tobacco products.^[267] While cigarettes still comprise almost 90% of all tobacco sales globally as of 2020 (except for South Asia), other tobacco products, especially e-cigarettes, also weigh heavily on the environment.^[268] The rise of e-cigarettes in industrialized countries is changing the composition of the environmental harms of tobacco.^[268] Because these products are composed of low-value but sophisticated electronics, the environmental costs from manufacturing e-cigarettes may be substantially more severe than cigarettes per unit.^[268] The tobacco industry is aware of the new scope of environmental harms e-cigarettes pose.^[268]

Although some brands have begun recycling services for their e-cigarette cartridges and batteries, the prevalence of recycling is unknown, as is the prevalence of information provided by manufacturers on how to recycle disposable parts.^[58] E-cigarettes that are not reusable may contribute to the problem of electronic waste.^[59] When non-reusable e-cigarettes are discarded, heavy metals may be leached into the environment.^[190] E-cigarettes batteries contaminate the land and water and may release lead into the environment.^[16] E-liquids that are not entirely used up could contain nicotine and heavy metals.^[16] This is another risk for the environment.^[16] Littered or improperly discarded e-cigarettes can leach heavy metals, battery acids, and organic chemicals, potentially affecting humans and other organisms.^[265] Small components (e.g., pods, cartridges) may be eaten by birds and other animals.^[265] Since the majority of e-cigarettes are reusable they are possibly more environmentally friendly than using single-use devices.^[269] Compared to traditional cigarettes, e-cigarettes do not create litter in the form of discarded cigarette butts.^[269] Tobacco cigarette waste can be seen on city sidewalks and public beaches.^[270] Traditional cigarettes tend to end up in the ocean where they cause pollution.^[269]

According to the US FDA, e-cigarettes, including rechargeable batteries and the cartridges and bottles that contain e-liquids (liquid nicotine mixtures), can pose a threat to the environment if they are not disposed of properly.^[271] E-cigarette and e-liquid waste should not be thrown in the regular trash or flushed down a sink.^[271] Instead, these items should be taken safely to a hazardous waste facility, the US FDA states.^[271] Improper disposal of e-cigarettes and e-liquid products can hurt the environment.^[271] If thrown in the trash or flushed into the sewer system, the nicotine solution in an e-liquid product can seep into the ground or water and become a danger for wildlife and humans.^[271]

As e-cigarette batteries degrade, the compounds in them can also seep into nearby water.^[271] Additionally, lithium ion batteries have been linked to explosions in recycling trucks when batteries are not properly disposed of.^[271] As sales of e-cigarettes have increased significantly in the past few years leading up to 2020, institutions face a burden to dispose of e-cigarette waste in a way that protects the environment.^[271] Schools face challenges with waste littered by students on school property.^[271] According to the Minnesota Pollution Control Agency, products that contain nicotine including e-liquids and e-cigarettes, pose a threat to the environment if they are not discarded of properly.^[272]

History of e-cigarette research and vaping industry strategies

For over 50 years, there has been a compelling assemblance of irrefutable evidence demonstrating that smoking cigarettes leads to disease in nearly every human organ.^[164] At least as early as the 1950s the tobacco industry has intentionally mislead the public regarding the health risks of smoking.^[273] Big Tobacco has partnered with firms, including the Electronic Cigarette Association, Consumer Advocates for Smoke-Free Alternatives Association, and Vapers International, Inc., that were set up to promote the use of e-cigarettes.^[4] These factions, coupled with other vested interested parties, have had taken steps to stall or abolish legislation targeted at curbing the sales and the use of e-cigarettes.^[4]

Previous studies have identified several strategies used in tobacco and e-cigarette advertising that are particularly appealing to young individuals.^[274] These include marketing flavors, especially fruity ones, offering price reductions and discounts, displaying product design, promoting harm reduction claims like e-cigarettes being less harmful than traditional cigarettes, incorporating activities and environments, highlighting sports events or bars, and utilizing emotional appeals and humor.^[274]

While cigarettes have been the leading source of tobacco consumption, a diverse range and usage of more recently created products had been accelerating by 2021.^[275] These newly created tobacco, nicotine, and other aerosolized products were perpetually being introduced into the marketplace and were vigorously being pushed both in affluent countries where cigarette consumption is descending and where people are able to pay for the latest products, in addition to less affluent countries, thus sidestepping laws prohibiting tobacco advertising or the importation of nicotine vaping devices.^[275]

Their short as well as their long-term consequences, including their potential carcinogenicity, are actively being scientifically investigated.^[276] Biased research paid for by the tobacco industry continues to be rampant in the e-cigarette topic area, as of 2019.^[277] The tobacco companies have had an impact on research-based conclusions by providing funding for scientists.^[278] The extent to which research related to e-cigarettes has ties to businesses and other special interests in this industry, is an area of concern.^[279]

Summary of ethical concerns

**Ethical considerations surrounding the availability and use of e-cigarettes**^[147]
Ethical considerations^[147]	Supporting arguments^[147]	Opposing arguments^[147]
Tobacco harm reduction^[147]
Potential for smoking cessation^[147]	E-cigarettes may be as effective as the nicotine patch.^[147]	Inconclusive evidence of efficacy for smoking cessation.^[147]
Potential for smoking reduction^[147]	Demonstrated in multiple studies.^[147]	Unlikely that cigarette reduction results in significant health benefits.^[147]
Product safety^[147]
Potential for long-term adverse effects^[147]	Unknown impact of long-term propylene glycol inhalation.^[147]	There were no publicized serious adverse events in 2016.^[147]
	Propylene glycol inhalation causes short-term respiratory irritation.^[147]
Autonomy to use a product of unknown risk^[147]	Ethical imperative given informed consent.^[147]	Public health concerns trump individual rights.^[147]
Use among non-smokers^[147]
Potential to lead to nicotine addiction^[147]	Perceived harmlessness may lead never smokers to initiate e-cigarettes.^[147]	No evidence for increased nicotine addiction to cause net public health harms.^[147]
Potential gateway effect^[147]	Nicotine acts as a priming agent for the brain.^[147]	Unclear implications for transitioning to tobacco cigarettes.^[147]
Use among youth^[147]
Potential to lead to nicotine addiction^[147]	Minors require protection.^[147]	No evidence of increased nicotine addiction causing net public health harms.^[147]
	E-liquid flavorings are attractive to youth.^[147]
Potential gateway effect^[147]	Nicotine is a priming agent for the brain.^[147]	Unclear implications for transitioning to tobacco cigarettes.^[147]
Nicotine poisoning among children^[147]	Increased calls to poison control centers.^[147]	None.^[147]
	E-liquid flavors are appealing to youth.^[147]
Use in public places^[147]
Potential for passive vaping^[147]	Stem cell cytotoxicity.^[147]	Limited evidence that passive vaping poses significant health concerns.^[147]
	Aerosolized nicotine emissions.^[147]
Renormalized smoking culture^[147]
Potential to subvert decades of anti-smoking efforts^[147]	Increased acceptability of smoke-like vapor and smoking behavior.^[147]	No evidence that e-cigarettes would be conflated with tobacco cigarettes.^[147]
Market ownership^[147]
Unethical collaboration with the tobacco industry^[147]	Public health endorsement of e-cigarettes increases tobacco company market share.^[147]	Possible necessity to collaborate with the tobacco industry to achieve public health gains.^[147]

Public perception

Overview

Marketing and advertisement play a significant role in the public's perception of e-cigarettes.^[147] E-cigarettes have been promoted as replacements for traditional tobacco products.^[280] This has led to the creation of a misleading sense of safety among those who use them.^[280] Concerns have arisen regarding the pro-vaping messages dominating social media, raising ethical questions about the industry's impact on public perception and behavior.^[281] E-cigarette advertisements with warnings could strengthen e-cigarette harm perceptions, and lower the likelihood of buying e-cigarettes.^[282]

The public generally thinks that vaping is correlated with few health risks.^[174] Some tobacco users think vaping is safer than tobacco or other smoking cessation aids.^[283] It is generally considered by users that e-cigarettes are safer than tobacco.^[141] Emerging research indicates that vaping is not as safe as previously thought.^[284] Many users think that e-cigarettes are healthier than traditional cigarettes for personal use or for other people.^[285]

Perceived health risks

Studies have found that perceptions play a significant role in predicting e-cigarette use among young people.^[286] Many youths believe vaping is a safe substitute to traditional cigarettes.^[287] Youth exposed to mostly negative e-cigarette news were significantly more likely to increase their beliefs about e-cigarette harms compared with exposure to only positive news headlines.^[286] The evidence suggests that the parental perception of a child's health risks connected to e-cigarette exposure during both prenatal and post-natal life is low.^[247]

Belief in the risk information about nicotine vaping products from public health organizations was linked to a decreased likelihood of both using these products and viewing them as less hazardous.^[288] On the other hand, individuals who had confidence in information from nicotine vaping products companies tended to consider these products less hazardous than traditional cigarettes.^[288]

Adolescents may find e-cigarettes initially more enticing than traditional cigarettes due to perceived health risks, unique product traits (like taste, price, and discreetness), and the increased acceptance they receive from peers and others.^[289] Youths who have lower harm perceptions may be particularly susceptible to e-cigarette and polytobacco use, conversely those who perceive e-cigarettes as more harmful would be less likely to use them.^[290] Usually, only a small proportion of users are concerned about the potential adverse health effects or toxicity of e-cigarettes.^[285] Research indicates that an individual's perception of a substance's potential harms and benefits and their behavior of use is influenced by the availability of information discussing the health effects of that substance.^[291] A significant number of teenagers do not realize what substances they are inhaling when they vape.^[292]

Perceived misconceptions regarding safety

There is a public misconception that vaping is safer than cigarette smoking.^[293] The rise in e-cigarette usage may be due in part to the mistaken belief that they are a safer option compared to regular cigarettes.^[294] Individuals who opt for non-cigarette tobacco products seem to not understand the full extent of the health risks involved.^[295] Beliefs on vaping may be surpassing our scientific knowledge of these products.^[296] Proponents of vaping have stated that nicotine is 'as safe as caffeine'.^[297] E-cigarettes are believed to be considerably safer compared to smoking, while nicotine is thought to be relatively benign, except for its addiction potential.^[298] Consequently, it is believed that using them indoors or near babies does not involve any risk.^[298]

The vaping community’s apparent disregard for the potential negative impacts of e-cigarettes seems to have tarnished their reputation among many public health officials.^[299] Persisting on this trajectory may foster the perception that they are indifferent to public health, they care more about selling their burgeoning businesses to the highest bidder from the tobacco industry, and will resist any sensible regulations on their products—thus mirroring the notorious tactics used by tobacco companies.^[299] Initially, it was claimed that e-cigarettes were completely harmless.^[251] However, they are generally viewed as 'reduced harm' alternatives to traditional cigarettes.^[251] This latter viewpoint remains contentious and lacks definitive evidence, particularly given the significant differences among e-cigarette products.^[251] In underdeveloped countries, false beliefs about their safety are widespread.^[300]

Perceived health risks in various countries

A 2014 worldwide survey found that 88% of respondents stated that vaping were less harmful than cigarette smoke and 11% believed that vaping were absolutely harmless.^[301] A 2013 four-country survey found higher than 75% of current and former smokers think e-cigarettes are safer than traditional cigarettes.^[39]

Among high income countries, compiled data from the International Tobacco Control Policy Evaluation Project found that the percentage of respondents of adult smokers believing e-cigarette use is just as risky or riskier to health than cigarettes were: Republic of Korea in 2016 was 66%, the US in 2016 was 37%, Netherlands in 2015 was 32%, Canada in 2016 was 30%, the UK in 2016 was 24%, Australia in 2016 was 22%, Uruguay in 2014 was 19%, and among low income countries, Malaysia in 2013 was 70%, Zambia in 2014 was 57%, Thailand in 2012 was 54%, Mexico from 2014 to 2015 was 38%, Bangladesh from 2014 to 2015 was 37%, Brazil from 2012 to 2013 was 22%, and China from 2013 to 2015 was 15%.^[302]

Among middle income countries, compiled data from the International Tobacco Control Policy Evaluation Project found that the percentage of respondents of adult smokers believing e-cigarette use is just as risky or riskier to health than cigarettes were: Malaysia in 2013 was 70%, Zambia in 2014 was 57%, Thailand in 2012 was 54%, Mexico between 2014 to 2015 was 38%, Bangladesh between 2014 to 2015 was 37%, Brazil between 2012 to 2013 was 22%, and China between 2013 to 2015 was 15%.^[302]

According to data from an International Tobacco Control Policy Evaluation survey, countries with more relaxed policies on the use and marketing of nicotine vaping products, such as the UK, have higher levels of awareness and usage.^[288] Additionally, the perception that nicotine vaping products are less dangerous than traditional cigarettes is significantly greater in the UK compared to Australia, which is indicative of the UK's more lenient regulatory stance.^[288]

Perceived health risks in adolescence in various countries

A 2015 study showed that 60% of all adolescence stated vaping were safe or a minor health risk and that 53.4% considered vaping safer than cigarette smoking.^[95] In terms of harm perception, a 2016 study found that flavored e-cigarette use reduced the prevalence of perception of the dangers of tobacco use among youth.^[303] Another 2016 study found more nuanced results, demonstrating that tobacco flavor increased harm perception while fruit and sweet flavors decreased harm perception among UK adolescents.^[303]

A 2016 survey of people 14 years of age and up in Germany reported that 20.7% of participants consider e-cigarettes to be not as harmful as cigarettes, 46.3% just as harmful, and 16.1% thought they were more harmful, and 17.0% gave no answer.^[304] Many adolescent asthmatics have a favorable view of vaping.^[92]

Perceived health risks regarding pregnant women

Based on literature from January 2006 to October 2016, a 2017 review found, that examined the perceptions regarding vaping during pregnancy, that the majority of respondents perceived vaping can carry health risks to mother and child, but also thought they may be less harmful than traditional cigarettes.^[305] A nation-wide US survey among adults found 11.1% thought vaping during pregnancy was not as harmful as smoking, 51.0% thought it was as harmful, 11.6% thought it would be an increased harm, and 26.2% were unsure.^[306]

As a result of perceiving e-cigarettes as less of a health risk, their usage among pregnant women has grown, which has increased the exposure of unborn children to nicotine and other hazardous substances.^[17]

Perceived health risks in Canada

An online survey conducted in 2020, accessed through Facebook and Reddit, gathered responses from 157 participants.^[307] Of these respondents, 73.08% were under the age of 35, and 65.38% resided in British Columbia.^[307] The survey found that nearly all participants rejected the idea that e-cigarettes were risk-free.^[307] The survey also found that both e-cigarette and tobacco users tend to have a more positive perception of e-cigarettes and vaping compared to non-users.^[307]

Perceived health risks in adolescence in Canada

A significant number of youths feel that vaping for the first time carries no risk.^[308] This perception is influenced by seeing others around them engaging in the activity.^[308] According to a national school-based survey conducted between 2021 and 2022, 48% of Canadian students in grades seven to 12 believed that habitual vaping with nicotine, and 21% believed that habitual vaping without nicotine, posed significant risks.^[309]

Perceived health risks in the United States

A 2015 PHE report noted that in the US, 82% of respondents considered vaping was a safer option than smoking, but this number declined to 51% by 2014.^[310]

Perceived health risks in adolescence in the United States

A 2016 study in the US found that, for US adolescents, fruit-flavored e-cigarettes were perceived to be less harmful than tobacco flavored ones.^[303] A 2015 analysis reports that 34.20% (8,433/24,658) of American youth sampled believe that e-cigarettes are less harmful than cigarettes, and 45% (11,096/24,658) are not sure.^[291]

Wait for review. See here.

Perceived health risks in the United Kingdom

Action on Smoking and Health in the UK found that in 2015, compared to the year before, more people thought that e-cigarettes are equally harmful or even more harmful than smoking, increased from 15% in 2014 to 22% in 2015.^[311] Among smokers who are aware of e-cigarettes but have not tried them, that thought that e-cigarettes are equally harmful or even more harmful than smoking, almost increased by two-fold from 12% in 2014 to 22% in 2015.^[311]

In 2018, under 50% of adults in the UK believe vaping is less harmful than smoking.^[312] In 2021 in the UK, about 32% of adults of respondents believed that e-cigarettes were either equally or more harmful than smoking tobacco, an increase from 7% in 2013.^[313] In 2021 in the UK, about 30% of respondents believed e-cigarettes to be less harmful than smoking and 12% thought they were a lot less harmful, whereas 24% expressed uncertainty.^[313] In 2021, data from the Smoking Toolkit Study in England showed that 34.1% of adult smokers believed vaping to be less harmful than smoking.^[314] Meanwhile, 32.1% felt that the dangers of vaping and smoking were roughly equal.^[314] Additionally, 11.9% perceived vaping as more harmful than smoking, and 22.0% were unsure.^[314]

Perceived health risks in adolescence in the United Kingdom

In 2014, researchers from Liverpool John Moores University in North West England have found that children are developing perceptions that are similar to those promoted by e-cigarette marketing.^[298] However, these perceptions are only loosely connected to the often contradictory body of evidence and media reports, which often describe e-cigarettes as safe and effective, dangerous and ineffective, or unlikely to lead to smoking but are responsible for a substantial increase in dual use with traditional cigarettes.^[298] Nicotine is also depicted as both relatively benign and toxic, which adds to the conflicting messages that could be causing confusion among teenagers.^[298] Adolescence in the UK tend to think that e-cigarettes with fruity flavors are not as harmful as those with tobacco flavors.^[292]

According to the 2021 International Tobacco Control Policy Evaluation Project Youth Tobacco and Vaping Survey in England, 40.7% of past 30-day vapers were 'a little' worried about potential future health damage from vaping.^[315] Additionally, 27.2% expressed no worry at all, while 25.1% reported being 'moderately' or 'very' concerned.^[315] Only 6.0% stated they were unsure.^[315]

In the 2021 International Tobacco Control Policy Evaluation Project Youth Tobacco and Vaping Survey conducted in England, 16 to 19-year-olds were asked about the addictiveness of e-cigarettes/vaping.^[316] 50.7% of respondents believed that vaping was 'slightly' or 'somewhat' addictive.^[316] 31.7% considered it to be 'very' or 'extremely' addictive, while 6.3% thought it was 'not at all' addictive.^[316] Additionally, 11.1% reported being uncertain.^[316]

Related media

E-cigarette related media
NIDA Live - The Science of Vaping
Why Teens are Attracted to Vaping
Nora Volkow on Addiction - A Disease of Free Will
Julius Dein Performs A Magic Trick on a Vape
E-cigarette battery explosion injuries

Notes

↑ A 2019 review concluded: "no long term vaping toxicological/safety studies have been done in humans; without these data, saying with certainty that e-cigarettes are safer than combustible cigarettes is impossible."^[11] Early research seemed to indicate that vaping might be safer than traditional cigarettes and provide a different method to give up smoking, though mounting evidence does not substantiate this.^[12] Evidence has not been presented to demonstrate that e-cigarettes are less dangerous than tobacco.^[13] The short-term health effects of e-cigarettes can be severe,^[6] and the short-term harms of e-cigarettes is greater than tobacco products.^[7] E-cigarettes are frequently viewed as a safer alternative to conventional cigarettes; however, evidence to support this perspective has not materialized.^[8] This appears to be due to the presence of toxicants in e-liquid composition, their adverse effects in animal models, association with acute lung injury and cardiovascular disease, and ability to modulate different cell populations in the lung and blood towards pro-inflammatory phenotypes.^[8] A 2020 review noted, "although there is overlap with the toxicity of tobacco, vaping introduces exposures and has effects which are not seen with tobacco. Thus the idea that vaping is a safer, watered-down version of smoking, is scientific nonsense."^[7]
↑ While vitamin E acetate is strongly linked to this outbreak, evidence is not sufficient to rule out the contribution of other chemicals of concern, including chemicals in either THC or non-THC products, in some of the reported vaping-related lung injury cases.^[28] There is likely more than one cause of the outbreak.^[30] The majority of cases in Canada involving lung injuries do not seem to have been connected with the use of THC-infused products.^[29] In 2019, some people diagnosed with a vaping-induced lung injury reported using only nicotine-containing products.^[31] Nicotine e-cigarette use has been linked to the vaping-induced lung injury cases in a small subset of users.^[32] In 2020, the first uptick in vaping-induced lung injury cases had occurred in Utah since the decline of 2019.^[33] This research indicates the recurrent nature of the vaping-induced lung illness epidemic with new occurrences continuing to be reported.^[33]
↑ A 2021 review found "Formaldehyde, acetaldehyde, acrolein, carcinogenic nitrosamines N'-nitrosonornicotine (NNN) and nicotine-derived nitrosamine ketones (NNK) were found in vapors of a variety of e-cigarette products and are all carcinogenic to humans."^[52]
↑ The engineering designs, including the kind of the battery, heating temperature of the solution, and the style of heating element and storage for the solution, typically affects the nature, number, and size of particles generated.^[10]
↑ E-cigarettes were initially marketed as a safe replacement for smoking, but clinical and experimental studies have observed the potentially, lethal consequences of these products.^[80] The industry's marketing approach for these instruments of addiction has been to promote them as a safer alternative to tobacco, a behavioral choice supporting smoking cessation, and as the 'cool' appearance of vaping with flavored products (e.g. tutti frutti, bubble gum, and buttered popcorn etc.).^[81]
↑ E-cigarette aerosol generally contains fewer toxic chemicals than the deadly mix of 7,000 chemicals in smoke from regular cigarettes.^[87]
↑ Due to the subsequent identification of the primary cause of cases in the US, and the considerable decline in cases and deaths since a peak in September 2019, the CDC stopped collecting these data from states as of February 2020.^[28]
↑ Vitamin E acetate is used as an additive, most notably in THCl-containing e-cigarette, or vaping, products.^[28] Vitamin E acetate dilutes THC oil without altering the look or thickness.^[71] Research suggests that when vitamin E acetate is inhaled, it may interfere with normal lung functioning.^[28]
↑ A 2014 review found "Wide ranges in the levels of chemical substances such as tobacco-specific nitrosamines, aldehydes, metals, volatile organic compounds, phenolic compounds, polycyclic aromatic hydrocarbons, flavours, solvent carriers, tobacco alkaloids and drugs have been reported in e-cigarette refill solutions, cartridges, aerosols and environmental emissions."^[53]
↑ A 2014 review found "there is enough heat generated during puffing to cause the fluid to decompose and/or components of the device to pyrolyze, whereby toxic/carcinogenic substances may be formed."^[67]
↑ The term vapor is a misnomer due to the fact that the aerosol generated by e-cigarettes has both a particulate and gas phase.^[44]
↑ E-cigarette aerosol is composed of droplets of e-liquids, which contain mainly propylene glycol, glycerin, nicotine, water, flavorings (if added to e-liquid), preservatives and also small amounts of by-products of thermal decomposition of some of these constituents.^[238]
↑ A 2017 review found "The physical composition of the aerosol can be altered by many factors: the temperature of the metal coil, rate of e-liquid flow through the heated coil, chemical composition of the coil, the coil connection to the power source, the wicking material transporting e-liquid and the hot aerosol contacts."^[239]
↑ A 2017 review found "As e-cig metal components undergo repeated cycles of heating and cooling, traces of these metal components can leech into the e-liquid, causing the device to emit metallic nanoparticles."^[242]

References

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↑ Detailed reference list is located at a separate image page.
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↑ McCubbin, Andrea; Fallin-Bennett, Amanda; Barnett, Janine; Ashford, Kristin (2017). "Perceptions and use of electronic cigarettes in pregnancy". Health Education Research. 32 (1): 22–32. doi:10.1093/her/cyw059. ISSN 0268-1153. PMC 5914445. PMID 28158490.
↑ McNeill 2018, p. 190.
↑ ^307.0 ^307.1 ^307.2 ^307.3 Cheng, Joey; Chen, Dale (27 March 2020). "The perceived health effects of e-cigarette use among adult smokers". BCIT Environmental Public Health Journal. doi:10.47339/ephj.2020.32.
↑ ^308.0 ^308.1 "Consider the Consequences of Vaping". Health Canada. 18 April 2018.
↑ Belon, Ana Paula; Nieuwendyk, Laura; Allen, Tasha; Worrell, Melissa; Nykiforuk, Candace I J (January 2025). "Effective interventions to prevent youth vaping behaviours: a rapid review". BMJ Open. 15 (1): e092380. doi:10.1136/bmjopen-2024-092380. PMC 11784122. PMID 39843384.
↑ McNeill 2015, p. 79.
↑ ^311.0 ^311.1 "Electronic cigarette use among smokers slows as perceptions of harm increase". ASH UK. 22 May 2015.
↑ McNeill 2018, p. 20.
↑ ^313.0 ^313.1 "Electronic Cigarettes". Action on Smoking and Health. December 2021.
↑ ^314.0 ^314.1 ^314.2 An evidence update including health risks and perceptions, 2022 2022, p. 1209, Harm perceptions in England.
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External links

[14] A 2019 review concluded: "no long term vaping toxicological/safety studies have been done in humans; without these data, saying with certainty that e-cigarettes are safer than combustible cigarettes is impossible."^[11] Early research seemed to indicate that vaping might be safer than traditional cigarettes and provide a different method to give up smoking, though mounting evidence does not substantiate this.^[12] Evidence has not been presented to demonstrate that e-cigarettes are less dangerous than tobacco.^[13] The short-term health effects of e-cigarettes can be severe,^[6] and the short-term harms of e-cigarettes is greater than tobacco products.^[7] E-cigarettes are frequently viewed as a safer alternative to conventional cigarettes; however, evidence to support this perspective has not materialized.^[8] This appears to be due to the presence of toxicants in e-liquid composition, their adverse effects in animal models, association with acute lung injury and cardiovascular disease, and ability to modulate different cell populations in the lung and blood towards pro-inflammatory phenotypes.^[8] A 2020 review noted, "although there is overlap with the toxicity of tobacco, vaping introduces exposures and has effects which are not seen with tobacco. Thus the idea that vaping is a safer, watered-down version of smoking, is scientific nonsense."^[7]

[35] While vitamin E acetate is strongly linked to this outbreak, evidence is not sufficient to rule out the contribution of other chemicals of concern, including chemicals in either THC or non-THC products, in some of the reported vaping-related lung injury cases.^[28] There is likely more than one cause of the outbreak.^[30] The majority of cases in Canada involving lung injuries do not seem to have been connected with the use of THC-infused products.^[29] In 2019, some people diagnosed with a vaping-induced lung injury reported using only nicotine-containing products.^[31] Nicotine e-cigarette use has been linked to the vaping-induced lung injury cases in a small subset of users.^[32] In 2020, the first uptick in vaping-induced lung injury cases had occurred in Utah since the decline of 2019.^[33] This research indicates the recurrent nature of the vaping-induced lung illness epidemic with new occurrences continuing to be reported.^[33]

[55] A 2021 review found "Formaldehyde, acetaldehyde, acrolein, carcinogenic nitrosamines N'-nitrosonornicotine (NNN) and nicotine-derived nitrosamine ketones (NNK) were found in vapors of a variety of e-cigarette products and are all carcinogenic to humans."^[52]

[56] The engineering designs, including the kind of the battery, heating temperature of the solution, and the style of heating element and storage for the solution, typically affects the nature, number, and size of particles generated.^[10]

[86] E-cigarettes were initially marketed as a safe replacement for smoking, but clinical and experimental studies have observed the potentially, lethal consequences of these products.^[80] The industry's marketing approach for these instruments of addiction has been to promote them as a safer alternative to tobacco, a behavioral choice supporting smoking cessation, and as the 'cool' appearance of vaping with flavored products (e.g. tutti frutti, bubble gum, and buttered popcorn etc.).^[81]

[93] E-cigarette aerosol generally contains fewer toxic chemicals than the deadly mix of 7,000 chemicals in smoke from regular cigarettes.^[87]

[221] Due to the subsequent identification of the primary cause of cases in the US, and the considerable decline in cases and deaths since a peak in September 2019, the CDC stopped collecting these data from states as of February 2020.^[28]

[224] Vitamin E acetate is used as an additive, most notably in THCl-containing e-cigarette, or vaping, products.^[28] Vitamin E acetate dilutes THC oil without altering the look or thickness.^[71] Research suggests that when vitamin E acetate is inhaled, it may interfere with normal lung functioning.^[28]

[242] A 2014 review found "Wide ranges in the levels of chemical substances such as tobacco-specific nitrosamines, aldehydes, metals, volatile organic compounds, phenolic compounds, polycyclic aromatic hydrocarbons, flavours, solvent carriers, tobacco alkaloids and drugs have been reported in e-cigarette refill solutions, cartridges, aerosols and environmental emissions."^[53]

[243] A 2014 review found "there is enough heat generated during puffing to cause the fluid to decompose and/or components of the device to pyrolyze, whereby toxic/carcinogenic substances may be formed."^[67]

[244] The term vapor is a misnomer due to the fact that the aerosol generated by e-cigarettes has both a particulate and gas phase.^[44]

[250] E-cigarette aerosol is composed of droplets of e-liquids, which contain mainly propylene glycol, glycerin, nicotine, water, flavorings (if added to e-liquid), preservatives and also small amounts of by-products of thermal decomposition of some of these constituents.^[238]

[252] A 2017 review found "The physical composition of the aerosol can be altered by many factors: the temperature of the metal coil, rate of e-liquid flow through the heated coil, chemical composition of the coil, the coil connection to the power source, the wicking material transporting e-liquid and the hot aerosol contacts."^[239]

[256] A 2017 review found "As e-cig metal components undergo repeated cycles of heating and cooling, traces of these metal components can leech into the e-liquid, causing the device to emit metallic nanoparticles."^[242]

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v t e Electronic cigarettes
General topics	Construction pod mod Environmental impact Marketing Regulation Safety Cloud-chasing Composition of the aerosol Vape shop
Brands and companies	Blu Dragonite International Elf Bar Hyde Juul Logic Lost Mary NJOY Openvape Pax Labs Puff Bar Ten Motives V2 Veev Vuse
Controversy	Health effects Positions of medical organizations List of vaping bans in the United States Vaping-associated pulmonary injury 2019–2020 vaping lung illness outbreak Nicotine salt
See also	Flavored tobacco Nicotine poisoning Effects of nicotine on human brain development Nicotine marketing
Category Cigarettes Smoking

Health effects

Overview of benefits and effects

Alternative to smoking

Effects on increased availability of vaping products

Effects on dual use of vaping and smoking

Overview

Metabolic effects

Asthma

Breathing and heart effects

Other effects

Effects on smoking cessation

Overview

Effects

Toxicity

Effects on vaping cessation

Primary-care interventions

Overall risk relative to smoking

Vaping is estimated to be 95% less harmful than smoking claims

Funding for researchers and groups that are supportive of promoting tobacco use

Conflicts of interests and flawed and flimsy evidence

Harm reduction

Regulation

Public health consequences

Adverse effects

Toxicology

Long-term health effects

2019–2020 vaping lung illness outbreak

Pathogens

Microbial toxins

Virulence

E-cigarette aerosol

Composition

Second-hand exposure

Third-hand exposure

Effects on pregnancy and infants

Environmental impact

History of e-cigarette research and vaping industry strategies

Summary of ethical concerns

Public perception

Overview

Perceived health risks

Perceived misconceptions regarding safety

Perceived health risks in various countries

Perceived health risks in adolescence in various countries

Perceived health risks regarding pregnant women

Perceived health risks in Canada

Perceived health risks in adolescence in Canada

Perceived health risks in the United States

Perceived health risks in adolescence in the United States

Perceived health risks in the United Kingdom

Perceived health risks in adolescence in the United Kingdom

Related media

Notes

References

Bibliography

Further reading

External links