essay about e cigarette or vaping

The youth vaping epidemic: Addressing the rise of e-cigarettes in schools

Subscribe to the brown center on education policy newsletter, nandeeni patel and np nandeeni patel intern, the brown center on education policy - the brookings institution diana quintero diana quintero former senior research analyst, brown center on education policy - the brookings institution, ph.d. student - vanderbilt university.

November 22, 2019

Last December, the U.S. surgeon general raised an alarm regarding the rise in e-cigarette use among the nation’s youth, saying it has increased “at a rate of epidemic proportions.” According to the 2019 National Youth Tobacco Survey , over 5 million youth are currently using e-cigarettes, primarily the JUUL brand, with nearly 1 million youth using the product daily. This substantial increase in teenage vaping is seriously impacting middle and high schools across America.

Teen vaping has gained a significant amount of media attention since President Trump expressed concern about vaping’s public health effects in a September meeting with the FDA. While Trump had suggested a ban on flavored e-cigarettes, it seems that he has backed away from that idea due to political fallout among voters .

Vaping is on the rise in schools

Of the youth population, 27.5% regularly use e-cigarettes, approximately 22 percentage points higher than high schoolers who smoke normal cigarettes. These numbers are alarming because vaping has various types of negative impacts on health. First , e-cigarettes have been linked to severe lung and heart diseases. Second , e-cigarettes with high levels of nicotine can put youth at risk for developing a nicotine addiction which subsequently hinders brain development. Third, e-cigarettes expose youth users to harmful substances, like heavy metals, and are a gateway to smoking cigarettes.

E-cigarettes are causing public health and disciplinary concerns in schools nationwide. Teenagers are being hospitalized for vaping-related diseases, with at least one confirmed death . Teachers and school administrators are trying, yet failing, to prevent students from vaping in classrooms and on school campuses. Administrators are struggling to combat vaping with both punitive and restorative disciplinary measures , and students continue to vape even when facing penalties as serious as suspension. With the number of youth e-cigarette users increasing in the last decade and roughly doubling since 2017 , there may be a need for new policies that could standardize an approach to combating teenage vaping and help curb the impact on students.

President Trump proposed two routes to tackle vaping: a ban on flavored e-cigarettes , and raising the minimum age of purchase on e-cigarettes from 18 to 21. According to recent reporting , Trump has delayed a flavor ban. In response to Trump’s inaction, the House Energy and Commerce Committee passed a bill on Tuesday that would ban flavored tobacco products, raise the minimum age of purchase to 21, and restrict online sales of tobacco products. Despite the bill in the House, Trump is meeting with vaping industry executives and public health advocates. It is unclear how vaping regulations will unfold, but it is worthwhile to examine potential plans and their implications on students.

Examining a potential ban of flavored e-cigarettes

Major vaping companies, like JUUL Labs, have pushed against the flavor ban, which may have influenced Trump’s sudden decision to pull back from the policy. JUUL, which controls three-fourths of the e-cigarette market and has a forecasted 2019 revenue of $3.4 billion , is being investigated by the Food and Drug Administration (FDA) for allegedly illegally advertising its products as less harmful than regular cigarettes. Consequently , JUUL altered its leadership and marketing practices by suspending all advertising in the U.S. and replacing its CEO.

Banning the sale of flavored e-cigarettes would have hefty implications on vaping companies since they employ thousands of small shop owners and hardware designers. Banning the legal sale of flavored vaping products would also create a robust black market for e-cigarettes. A black market for vapes could be lethal for youth who find themselves smoking from cartridges cut with cheaper substances.

Trump faced pressures from the vaping lobby, which flocked to the nation’s capital claiming, among other things, that flavored e-cigarettes help smokers quit regular cigarettes. It is unproven , however, if there are health benefits to a regular smoker who instead becomes a long-term vaper. Research further suggests that while e-cigarette use was associated with high rates of smoking cessation, more than 80% of smokers who entered a randomized trial to stop smoking with the help of e-cigarettes continued to smoke e-cigarettes a year later. This is especially concerning given that smoking e-cigarettes has a negative impact on health.

Should the age limit be increased?

Whether by congressional action or Trump’s executive authority, the age minimum to purchase e-cigarettes can be changed from 18 to 21. Some vaping advocates believe that youth vape because of the nicotine in e-cigarettes. While the nicotine content in e-cigarettes can get students addicted to vaping, our analysis of the 2018 National Youth Tobacco Survey indicates that the most students report vaping for the flavor (about 35%) and because their family and friends use e-cigarettes (about 30%). Increasing the age of purchase to 21 would not address either of those incentives to vape.

Changing the age limit to 21 might fail to prevent many minors from getting their hands on e-cigarettes; in fact, 19% of youth report first trying an e-cigarette before the age of 13. Starting at the age of 13, rates of youth vaping in each age group increase. In 2018, 22% of 16-year-olds and 24% of 17-year-olds reported smoking an e-cigarette. This is an increase from 2017, when 11% of 16-year-olds and 14% of 17-year-olds reported smoking an e-cigarette. This shows that students are gaining access to and using e-cigarette products at an age well below the current age limit of 18. Further, over 70% of youth e-cigarette users report buying e-cigarettes from people rather than a shop, and 27% of frequent users reported living with someone who smoked. Youth vapers are typically not going to shops to buy vapes, they are buying vapes from their peers. Thus, minors who vape may still have access, although slightly restricted, to flavored e-cigarettes from friends and family who are over the age of 21.

We cannot know what will happen to e-cigarettes if the minimum age increases, but we can look to the experience of increasing the minimum age on alcohol for some suggestive evidence. According to the 2017 Youth Risk Behavior Survey, 30% of youth drank some amount of alcohol while 14% of youth engaged in binge drinking. Though raising the age limit for purchasing alcohol helped reduce youth alcohol consumption , youth consumption of alcohol persists.

State and local action

Federal action to stop the teenage vaping epidemic will likely fall short on some, if not most, metrics. Consequently, the onus will fall on state governments, boards of education, and local school districts to combat the issue of teen vaping. Several localities have already taken vaping into their own hands. For example, four states have banned vaping on school grounds, seven states have enacted or will enact a ban on flavored vaping products, and 18 states have raised the legal smoking age from 18 to 21 in the past three years. While the numbers show that vaping has increased drastically even with these state-level bans placed in populous states like New York and Texas, the effect of these state policies is largely unknown.

Beyond traditional tactics like monitoring bathrooms and hallways to confiscate vaping devices, states could also take a new approach to fighting the e-cigarette epidemic, like offering grants to schools to invest in on-site counseling. South Portland High School has been addressing teen vaping by offering mental health services and guiding students away from the social influences that encourage vaping. This school—and others, like Arrowhead High School in Milwaukee—have also been getting students involved in their anti-vaping campaign via peer-to-peer education.

The teenage vaping crisis calls for innovative solutions. In collaboration with federal and state action, local actors can look at the FDA’s Youth Tobacco Prevention Plan for insight on ways to initiate community-supported approaches that restrict access to vaping products, curb teenage-focused marketing tactics, and educate teenagers about the harmful, long-term effects of vaping.

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Conclusions about the effects of electronic cigarettes remain the same

An updated Cochrane Review provides an independent, rigorous assessment of the best available evidence to date about electronic cigarettes for quitting smoking.

Scroll to the bottom of this article for a round-up of media coverage

The conclusions of this updated Review are unchanged since the last review was published two years ago: electronic cigarettes may help smokers stop their smoking, and the included studies did not find any serious side effects associated with their use for up to two years.

Many studies are now underway which may help us understand more about their effects in the future.

The first Cochrane Review, published in the Cochrane Library in December 2014, showed that electronic cigarettes may be an aid to smokers in stopping their smoking. The updated Review did not find any new randomized controlled trials (RCTs) with long-term outcomes looking at the effectiveness of electronic cigarettes in helping people to stop smoking. However, this is an active area of research, with a large number of ongoing studies that will add to the evidence in the next few years.   

Smoking is a significant global health problem. Despite many smokers wanting to stop, they often find it difficult to succeed in the long term. One of the most effective and widely used strategies to help combat the cravings associated with nicotine addiction is to deliver nicotine by patches and chewing gum.

Electronic cigarettes have been around in some form for a number of years, but over the past few years their popularity has increased significantly, and they have begun to look and feel less like conventional cigarettes. Unlike chewing gum and patches, they mimic the experience of cigarette smoking because they are hand-held and generate a smoke-like vapour when used.  They help to recreate similar sensations of smoking without exposing users or others to the smoke from conventional cigarettes, and can be used to provide smokers with nicotine. Though they are used by many smokers, little is still known about how effective they are at helping people stop smoking.

This version of the updated Cochrane Review includes no new RCTs. The original Review included two RCTs involving more than 600 participants, and found that electronic cigarettes containing nicotine may increase the chances of stopping smoking within six to 12 months, compared to using an electronic cigarette without nicotine. The researchers could not determine whether using electronic cigarettes was better than a nicotine patch in helping people stop smoking, because there were not enough people taking part in the study.

This updated Review now includes observational data from an additional 11 studies.  Of the studies which measured side effects, none found any serious side effects of using electronic cigarettes for up to two years. The studies showed that throat and mouth irritation are the most commonly reported side effects in the short to medium term (up to two years).

The lead author of this Cochrane Review, Jamie Hartmann-Boyce from the Cochrane Tobacco Addiction Group, said, “The randomized evidence on smoking cessation is unchanged since the last version of the Review. We are encouraged to find many studies are now underway, particularly as electronic cigarettes are an evolving technology. Since the last version of the Review, 11 new observational and uncontrolled studies have been published. In terms of quitting, these can’t provide the same information we get from randomized controlled trials, but they contribute further information on the side effects of using electronic cigarettes to quit smoking. None detected any serious side effects, but longer term data are needed.”

Read this Press Release in French, Spanish or Polish .

Editor’s notes Full citation: Hartmann-Boyce J, McRobbie H, Bullen C, Begh R, Stead LF, Hajek P. Electronic cigarettes for smoking cessation . Cochrane Database of Systematic Reviews 2016, Issue 9. Art. No.: CD010216. DOI: 10.1002/14651858.CD010216.pub3.

Cochrane Review Author contact details : [email protected]

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Jo Anthony Senior Media and Communications Officer, Cochrane M +44(0) 7582 726 634 E  [email protected] or [email protected]

About Cochrane Cochrane is a global independent network of researchers, professionals, patients, carers, and people interested in health. Cochrane produces reviews which study all of the best available evidence generated through research and make it easier to inform decisions about health. These are called systematic reviews. Cochrane is a not-for-profit organization with collaborators from more than 130 countries working together to produce credible, accessible health information that is free from commercial sponsorship and other conflicts of interest. Our work is recognized as representing an international gold standard for high quality, trusted information.

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Selected Media Coverage:

E-cigarettes can help smokers quit, says study in The Guardian . Why can't scientists agree on e-cigarettes? blog post in The Guardian . E-Cigs Might Help Some Quit Smoking, New Study Reveals on Consumer Reports .

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The Risks of Another Epidemic: Teenage Vaping

“We’re stepping backward from all the advances we’ve made in tobacco control,” one investigator said.

By Jane E. Brody

While most of us strive to avoid inhaling aerosols that could harbor a deadly virus, millions of teens and young adults are deliberately bathing their lungs in aerosols rich in chemicals with known or suspected health hazards.

I’m referring to vaping (or “ juuling ”): the use of e-cigarettes that is hooking young people on a highly addictive drug — nicotine — and will be likely to keep them hooked for decades. Meanwhile, e-cigarettes and other vaping devices are legally sold with few restrictions while producers and sellers reap the monetary rewards. Although many states prohibit e-cigarette sales to persons younger than 18 or 21, youngsters have little trouble accessing the products online or from friends and relatives.

In just one year, from 2017 to 2018, vaping by high school seniors increased more than “for any substance we’ve ever monitored in 45 years, and the next year it rose again almost as much,” said Richard Miech, principal investigator for the national survey Monitoring the Future.

By 2019, a quarter of 12th graders were vaping nicotine, nearly half of them daily. Daily vaping rose in all three grades surveyed — eighth, 10th and 12th — “with accompanying increases in the proportions of youth who are physically addicted to nicotine,” Dr. Miech and colleagues reported in The New England Journal of Medicine last year.

Although self-reported use of e-cigarettes by high school and middle school students decreased over the past year, Dr. Robert R. Redfield, director of the Centers for Disease Control and Prevention, cautioned, “Youth e-cigarette use remains an epidemic.”

“We’re stepping backward from all the advances we’ve made in tobacco control,” Dr. Miech, professor at the Institute for Social Research at the University of Michigan, said in an interview. “I’m worried that we will eventually return to the tobacco situation of yore. There’s evidence that kids who vape are four to five times more likely the next year to experiment with cigarettes for the first time.”

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Vaping – Top 3 Pros and Cons

Vaping is the act of using e-cigarettes , which were first introduced in the United States around 2006. [ 5 ]

E-cigarettes are battery-powered devices that heat a liquid into an aerosol vapor for inhalation . The liquid used in e-cigarettes is also known as e-liquid or vape juice. The main components are generally flavoring, nicotine , and water, along with vegetable glycerin and propylene glycol , which distribute the flavor and nicotine in the liquid and create the vapor. Popular flavorings include mint , mango , and tobacco . [ 3 ] [ 4 ] [ 44 ] [ 45 ]

E-cigarettes are also known as “e-cigs,” “e-hookahs,” “mods,” “vape pens,” “vapes,” “vaporizers,” “e-pipes,” and “electronic nicotine delivery systems (ENDS).” Some e-cigarettes are made to resemble regular cigarettes, cigars, or pipes, while others look like pens or USB flash drives.  [ 7 ] [ 42 ] [ 43 ]

The JUUL brand of e-cigarettes, a vaporizer shaped like a USB flash drive , launched in 2015 and captured nearly 75% of the market in 2018, becoming so popular that vaping is often referred to as “juuling.” Juul’s market popularity has since declined to 42% in 2020. [ 7 ] [ 8 ] [ 9 ] [ 51 ]

The U.S. Food and Drug Administration (FDA) has regulated e-cigarettes as a tobacco product since 2016. On Sep. 11, 2019, President Donald Trump’s administration announced plans to have the FDA end sales of non-tobacco e-cigarette flavors such as mint or menthol in response to concerns over teen vaping. E-cigarette manufacturers were required to request FDA permission to keep flavored products on the market. The FDA had until Sep. 9, 2021 to make a decision. [ 6 ][ 46 ] [ 49 ]

On Sep. 9, 2021, Acting FDA Commissioner Janet Woodcock and Director of the FDA’s Center for Tobacco Products Mitch Zeller announced that the FDA had made decisions on 93% of the 6.5 million submitted applications for “deemed” new tobacco products (“‘deemed’ new” means the FDA newly has authority to review the products but the products may already be on the market), including denying 946,000 vaping products “because their applications lacked sufficient evidence that they have a benefit to adult smokers to overcome the public health threat posed by the well-documented, alarming levels of youth use.” [ 55 ] [ 56 ] [ 57 ]

On Oct. 12, 2021, the FDA authorized the Vuse e-cigarette and cartridges, marketed by R.J. Reynolds one of the world’s largest cigarette manufacturers. The move is the first time the FDA authorized any vaping product. According to a statement from the FDA, the organization “determined that the potential benefit to smokers who switch completely or significantly reduce their cigarette use, would outweigh the risk to youth.” [ 58 ]

On June 23, 2022, the FDA ordered Juul to stop selling “all of their products currently marketed in the United States.” The order included removing products currently on the market, including Juul devices (vape pens) and pods (cartridges). The following day, June 24, 2022, a federal appeals court temporarily put the ban on hold while the court reviewed Juul’s appeal. On Sep. 6, 2022, Juul settled a lawsuit brought by almost 36 states and Puerto Rico , in which Juul was accused of marketing to minors. Juul admitted no wrongdoing in settling the lawsuit, but the company will have to pay $438.5 million, stop marketing to youth, stop funding education in schools, and stop misrepresenting the amount of nicotine in the products. [ 61 ] [ 62 ] [ 63 ]

On June, 21, 2024, the FDA approved four types of menthol -flavored vapes made by NJOY. The approval makes the vapes the first flavored e-cigarettes that can be legally sold in the United States. The move comes amid a debate about whether to ban traditional menthol cigarettes at the federal level. [ 64 ]

Nearly 11 million American adults used  e-cigarettes in 2018, more than half of whom were under age 35. One in five high school students used e-cigarettes to vape nicotine in 2018. E-cigarettes were the fourth most popular tobacco products with 4% of retail sales, behind traditional cigarettes (83%), chewing/smokeless tobacco (8%), and cigars (5%) as of Feb. 2019. The global e-cigarette and vape market was worth $15.04 billion in 2020. [ 1 ][ 2 ][ 8 ] [ 50 ]

According to the Centers for Disease Control (CDC), 9.7% of current cigarette smokers were also current vapers, though 49.4% of current smokers had vaped at some point. Of former smokers who had quit within the last year, 25.2% were current vapers and 57.3% had tried vaping. Of former smokers who quit one to four years ago, 17.3% were current vapers and and 48.6% had tried vaping. Of former smokers who quit five or more years ago, 1.7% were current vapers and 9% had tried vaping. And of people who have never smoked, 1.5% were current vapers and 6.5% had tried vaping. 18-29 year olds were more likely to say they vaped (17%) than smoked cigarettes, while every older age group was more likely to smoke than vape. [ 52 ] [ 54 ]

Is Vaping with E-Cigarettes Safe?

Pro 1 E-cigarettes help adults quit smoking and lowers youth smoking rates. Cigarette smokers who picked up vaping are 67% more likely to quit smoking. A New England Journal of Medicine study found that e-cigarettes are twice as effective at getting people to quit smoking as traditional nicotine replacements such as the patch and gum. E-cigarettes caused a 50% increase in the rate of people using a product designed to help people quit smoking. [ 14 ]   [ 15 ] [ 48 ]  “Smokers who switch to vaping remove almost all the risks smoking poses to their health,” according to Peter Hajek, professor of clinical psychology at Queen Mary University London. [ 13 ] Vaping has likely contributed to record low levels of youth cigarette smoking, which hit a record-low of just 1.9% of high school students in 2023, down from 19.8% in 2006 (the year e-cigarettes were introduced in the United States). [ 19 ] [ 20 ] [ 53 ] [ 65 ] Further, a report from Public Health England found no evidence that vaping is an entry into smoking traditional cigarettes for young people. [ 21 ] Read More

Pro 2 Vaping is a safer way to ingest tobacco. A U.K. government report stated that the “best estimates show e-cigarettes are 95% less harmful to your health than normal cigarettes.” [ 16 ] “Combustible cigarettes are the most harmful form of nicotine delivery,” according to Matthew Carpenter, co-director of the Tobacco Research Program at the Hollings Cancer Center. [ 17 ] E-cigarettes are safer for indoor use. Researchers found that the level of nicotine on surfaces in the homes of e-cigarette users was nearly 200 times lower than in the homes of traditional cigarette smokers. Nicotine left behind on surfaces can turn into carcinogens; the amount of nicotine found where vapers live was similar to the trace amounts in the homes of nonsmokers. [ 1 ]   [ 18 ] Traditional cigarettes are known to cause health problems such as lung cancer, heart disease, and stroke. Worldwide, smoking is the top cause of preventable death, responsible for over seven million deaths each year. [ 10 ] The National Academies of Science, Engineering, and Medicine found conclusive evidence that switching to e-cigarettes reduces exposure to toxicants and carcinogens. Burning a traditional cigarette releases noxious gases such as carbon monoxide. Cigarette smoke contains tar, which accounts for most of the carcinogens associated with smoking. E-cigarettes don’t have those gases or tar. [ 11 ] [ 12 ] Read More

Pro 3 E-cigarettes reduce health care costs, create jobs, and help the economy. “Promoting electronic cigarettes to smokers should be a public health priority. Given that the direct medical costs of smoking are estimated to be more than $130 billion per year, along with $150 billion annually in productivity losses from premature deaths, getting more smokers to switch would result in significant cost savings — as well as almost half a million lives saved each year,” argues Sally Satel, a psychiatrist specializing in addiction and resident scholar at the American Enterprise Institute. [ 22 ] Grover Norquist and Paul Blair, both of Americans for Tax Reform, stated, “e-cigarettes and vapor products are the Uber of the product industry. They’re a disruptive and innovative technology… Thousands of good-paying jobs are being created by an industry that is probably going to save hundreds of thousands of lives.” [ 23 ] Plus, the harm reduction from smokers switching to vaping could save $48 billion in annual Medicaid spending. [ 24 ] Juul created more than 1,200 jobs just in 2018. A letter signed by a coalition of anti-regulation groups warned that efforts to limit the e-cigarette industry would destroy tens of thousands of jobs for manufacturers of the devices and the stores that sell them. [ 7 ] [ 25 ] Read More

Con 1 Vaping among kids is skyrocketing: addicting a new generation to nicotine and introducing them to smoking. Marijuana vaping by teens doubled between 2013 and 2020, and the number of minors who stated they’d vaped marijuana in the past 30 days rose from 1.6% to 8.4% in the same time. [ 59 ] Former U.S. Surgeon General Jerome Adams declared youth e-cigarette use an “epidemic,” noting a 900% increase in vaping by middle and high school students between 2011 and 2015. [ 2 ] As of 2023, 10% of high school students used e-cigarettes, the most-used tobacco product among the age group, followed by cigarettes (1.9%) and cigars (1.8%). Teens who use e-cigarettes are four times more likely to try regular cigarettes than their peers who never used tobacco, and 21.8% of youth cigarette use may be attributable to initiation through vaping. [ 26 ] [ 53 ] [ 65 ] “The tobacco industry is well aware that flavored tobacco products [such as e-cigarettes] appeal to youth and has taken advantage of this by marketing them in a wide range of fruit and candy flavors,” says Nancy Brown, CEO of the American Heart Association. [ 30 ] Read More

Con 2 Vaping causes serious health risks, including depression, lung disease, and stroke. Nicotine use by young people may increase the risk of addiction to other drugs and impair prefrontal brain development, which can lead to ADD and disrupt impulse control. Adult vapers are also more than twice as likely to be diagnosed as depressed than their non-vaping peers. [ 12 ] [ 27 ] [ 28 ] [ 29 ] [ 60 ] The CDC has confirmed six vaping-related deaths and over 450 possible cases of lung illness associated with e-cigarettes. People who use e-cigarettes have a 71% increased risk of stroke and 40% higher risk of heart disease, as compared to nonusers. Studies have shown that e-cigarettes can cause arterial stiffness and cardiovascular harm, and may increase the odds of a heart attack by 42%. [ 31 ] [ 32 ] [ 33 ] [ 47 ] Researchers who found increased risk of blood clots from e-cigarettes wrote, “these devices do emit considerable levels of toxicants, some of which are shared/overlap with tobacco smoking; and thus their harm should not be underestimated.” [ 33 ] Scientists at Johns Hopkins Bloomberg School of Public Health found that e-cigarettes leak toxic metals, possibly from the heating coils, that are associated with health problems such as kidney disease, respiratory irritation, shortness of breath, and more. [ 34 ] Some ingredients in the liquids used in e-cigarettes change composition when they are heated, leading to inhalation of harmful compounds such as formaldehyde, which is carcinogenic. [ 35 ] Read More

Con 3 E-cigarettes can catch fire and even explode. E-cigarette explosions have led to the loss of body parts (such as an eye, tongue, or tooth), third degree burns, holes in the roof of the mouth, and death. [ 36 ] Researchers at George Mason University found that 2,035 people sought emergency room treatment for burn or explosion injuries from e-cigarettes between 2015 and 2017, and believe there were more injuries that went untreated. They also found more than 40 times the number of injuries reported by the FDA between 2009 and 2015. [ 36 ] [ 37 ] Airlines prohibit e-cigarettes in checked baggage due to the possibility of their lithium batteries catching fire. In Jan. 2019, a passenger’s e-cigarette overheated and caught fire in the airplane cabin. That same month, a Texas man died when debris from an e-cigarette explosion tore his carotid artery. In 2018, a man in Florida was killed by shrapnel from his e-cigarette exploding. [ 38 ] [ 39 ]   [ 40 ] The U.S. Fire Administration (USFA) found 195 reports of e-cigarette explosions and fires including 133 acute injuries, of which 29% were severe. The USFA stated, “No other consumer product that is typically used so close to the human body contains the lithium-ion battery that is the root cause of the incidents.” [ 41 ] Read More

Discussion Questions

1. Is vaping safe? Explain your answer.

2. Should vaping restrictions or prohibitions be placed on teens? Why or why not?

3. While this article focuses on nicotine e-cigarettes, consider the safety of marijuana vaping.

Take Action

1. Consider Consumer Advocates for Smoke-free Alternatives Association’s take on vaping as a cigarette alternative

2. Learn about e-cigarettes at Encyclopaedia Britannica.

3. Analyze the science of vaping at the American Heart Association .

4. Consider how you felt about the issue before reading this article. After reading the pros and cons on this topic, has your thinking changed? If so, how? List two to three ways. If your thoughts have not changed, list two to three ways your better understanding of the “other side of the issue” now helps you better argue your position.

5. Push for the position and policies you support by writing US national senators and representatives .

ProCon/Encyclopaedia Britannica, Inc. 325 N. LaSalle Street, Suite 200 Chicago, Illinois 60654 USA

Natalie Leppard Managing Editor [email protected]

© 2023 Encyclopaedia Britannica, Inc. All rights reserved

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The electronic cigarette ( e-cigarette ), for many considered as a safe alternative to conventional cigarettes, has revolutionised the tobacco industry in the last decades. In e-cigarettes , tobacco combustion is replaced by e-liquid heating, leading some manufacturers to propose that e-cigarettes have less harmful respiratory effects than tobacco consumption. Other innovative features such as the adjustment of nicotine content and the choice of pleasant flavours have won over many users. Nevertheless, the safety of e-cigarette consumption and its potential as a smoking cessation method remain controversial due to limited evidence. Moreover, it has been reported that the heating process itself can lead to the formation of new decomposition compounds of questionable toxicity. Numerous in vivo and in vitro studies have been performed to better understand the impact of these new inhalable compounds on human health. Results of toxicological analyses suggest that e-cigarettes can be safer than conventional cigarettes, although harmful effects from short-term e-cigarette use have been described. Worryingly, the potential long-term effects of e-cigarette consumption have been scarcely investigated. In this review, we take stock of the main findings in this field and their consequences for human health including coronavirus disease 2019 (COVID-19).

Electronic nicotine dispensing systems (ENDS), commonly known as electronic cigarettes or e-cigarettes , have been popularly considered a less harmful alternative to conventional cigarette smoking since they first appeared on the market more than a decade ago. E-cigarettes are electronic devices, essentially consisting of a cartridge, filled with an e-liquid, a heating element/atomiser necessary to heat the e-liquid to create a vapour that can be inhaled through a mouthpiece, and a rechargeable battery (Fig.  1 ) [ 1 , 2 ]. Both the electronic devices and the different e-liquids are easily available in shops or online stores.

Effect of the heating process on aerosol composition. Main harmful effects documented. Several compounds detected in e-cigarette aerosols are not present in e-liquid s and the device material also seems to contribute to the presence of metal and silicate particles in the aerosols. The heating conditions especially on humectants, flavourings and the low-quality material used have been identified as the generator of the new compounds in aerosols. Some compounds generated from humectants (propylene glycol and glycerol) and flavourings, have been associated with clear airways impact, inflammation, impairment of cardiovascular function and toxicity. In addition, some of them are carcinogens or potential carcinogens

The e-liquid typically contains humectants and flavourings, with or without nicotine; once vapourised by the atomiser, the aerosol (vapour) provides a sensation similar to tobacco smoking, but purportedly without harmful effects [ 3 ]. However, it has been reported that the heating process can lead to the generation of new decomposition compounds that may be hazardous [ 4 , 5 ]. The levels of nicotine, which is the key addictive component of tobacco, can also vary between the commercially available e-liquids, and even nicotine-free options are available. For this particular reason, e-cigarettes are often viewed as a smoking cessation tool, given that those with nicotine can prevent smoking craving, yet this idea has not been fully demonstrated [ 2 , 6 , 7 ].

Because e-cigarettes are combustion-free, and because most of the damaging and well-known effects of tobacco are derived from this reaction, there is a common and widely spread assumption that e-cigarette consumption or “vaping” is safer than conventional cigarette smoking. However, are they risk-free? Is there sufficient toxicological data on all the components employed in e-liquids ? Do we really know the composition of the inhaled vapour during the heating process and its impact on health? Can e-cigarettes be used to curb tobacco use? Do their consumption impact on coronavirus disease 2019 (COVID-19)? In the present review, we have attempted to clarify these questions based on the existing scientific literature, and we have compiled new insights related with the toxicity derived from the use of these devices.

Effect of e-cigarette vapour versus conventional cigarette exposure: in vivo and in vitro effects

Numerous studies have been performed to evaluate the safety/toxicity of e-cigarette use both in vivo and in in vitro cell culture.

One of the first studies in humans involved the analysis of 9 volunteers that consumed e-cigarettes , with or without nicotine, in a ventilated room for 2 h [ 8 ]. Pollutants in indoor air, exhaled nitric oxide (NO) and urinary metabolite profiles were analysed. The results of this acute experiment revealed that e-cigarettes are not emission-free, and ultrafine particles formed from propylene glycol (PG) could be detected in the lungs. The study also suggested that the presence of nicotine in e-cigarettes increased the levels of NO exhaled from consumers and provoked marked airway inflammation; however, no differences were found in the levels of exhaled carbon monoxide (CO), an oxidative stress marker, before and after e-cigarette consumption [ 8 ]. A more recent human study detected significantly higher levels of metabolites of hazardous compounds including benzene, ethylene oxide, acrylonitrile, acrolein and acrylamide in the urine of adolescent dual users ( e-cigarettes and conventional tobacco consumers) than in adolescent e-cigarette -only users (Table 1 ) [ 9 ]. Moreover, the urine levels of metabolites of acrylonitrile, acrolein, propylene oxide, acrylamide and crotonaldehyde, all of which are detrimental for human health, were significantly higher in e-cigarette -only users than in non-smoker controls, reaching up to twice the registered values of those from non-smoker subjects (Table 1 ) [ 9 ]. In line with these observations, dysregulation of lung homeostasis has been documented in non-smokers subjected to acute inhalation of e-cigarette aerosols [ 10 ].

Little is known about the effect of vaping on the immune system. Interestingly, both traditional and e-cigarette consumption by non-smokers was found to provoke short-term effects on platelet function, increasing platelet activation (levels of soluble CD40 ligand and the adhesion molecule P-selectin) and platelet aggregation, although to a lesser extent with e-cigarettes [ 11 ]. As found with platelets, the exposure of neutrophils to e-cigarette aerosol resulted in increased CD11b and CD66b expression being both markers of neutrophil activation [ 12 ]. Additionally, increased oxidative stress, vascular endothelial damage, impaired endothelial function, and changes in vascular tone have all been reported in different human studies on vaping [ 13 , 14 , 15 , 16 , 17 ]. In this context, it is widely accepted that platelet and leukocyte activation as well as endothelial dysfunction are associated with atherogenesis and cardiovascular morbidity [ 18 , 19 ]. In line with these observations the potential association of daily e-cigarettes consumption and the increased risk of myocardial infarction remains controversial but benefits may occur when switching from tobacco to chronic e-cigarette use in blood pressure regulation, endothelial function and vascular stiffness (reviewed in [ 20 ]). Nevertheless, whether or not e-cigarette vaping has cardiovascular consequences requires further investigation.

More recently, in August 2019, the US Centers for Disease Control and Prevention (CDC) declared an outbreak of the e-cigarette or vaping product use-associated lung injury (EVALI) which caused several deaths in young population (reviewed in [ 20 ]). Indeed, computed tomography (CT scan) revealed local inflammation that impaired gas exchange caused by aerosolised oils from e-cigarettes [ 21 ]. However, most of the reported cases of lung injury were associated with use of e-cigarettes for tetrahydrocannabinol (THC) consumption as well as vitamin E additives [ 20 ] and not necessarily attributable to other e-cigarette components.

On the other hand, in a comparative study of mice subjected to either lab air, e-cigarette aerosol or cigarette smoke (CS) for 3 days (6 h-exposure per day), those exposed to e-cigarette aerosols showed significant increases in interleukin (IL)-6 but normal lung parenchyma with no evidence of apoptotic activity or elevations in IL-1β or tumour necrosis factor-α (TNFα) [ 22 ]. By contrast, animals exposed to CS showed lung inflammatory cell infiltration and elevations in inflammatory marker expression such as IL-6, IL-1β and TNFα [ 22 ]. Beyond airway disease, exposure to aerosols from e-liquids with or without nicotine has also been also associated with neurotoxicity in an early-life murine model [ 23 ].

Results from in vitro studies are in general agreement with the limited number of in vivo studies. For example, in an analysis using primary human umbilical vein endothelial cells (HUVEC) exposed to 11 commercially-available vapours, 5 were found to be acutely cytotoxic, and only 3 of those contained nicotine [ 24 ]. In addition, 5 of the 11 vapours tested (including 4 that were cytotoxic) reduced HUVEC proliferation and one of them increased the production of intracellular reactive oxygen species (ROS) [ 24 ]. Three of the most cytotoxic vapours—with effects similar to those of conventional high-nicotine CS extracts—also caused comparable morphological changes [ 24 ]. Endothelial cell migration is an important mechanism of vascular repair than can be disrupted in smokers due to endothelial dysfunction [ 25 , 26 ]. In a comparative study of CS and e-cigarette aerosols, Taylor et al . found that exposure of HUVEC to e-cigarette aqueous extracts for 20 h did not affect migration in a scratch wound assay [ 27 ], whereas equivalent cells exposed to CS extract showed a significant inhibition in migration that was concentration dependent [ 27 ].

In cultured human airway epithelial cells, both e-cigarette aerosol and CS extract induced IL-8/CXCL8 (neutrophil chemoattractant) release [ 28 ]. In contrast, while CS extract reduced epithelial barrier integrity (determined by the translocation of dextran from the apical to the basolateral side of the cell layer), e-cigarette aerosol did not, suggesting that only CS extract negatively affected host defence [ 28 ]. Moreover, Higham et al . also found that e-cigarette aerosol caused IL-8/CXCL8 and matrix metallopeptidase 9 (MMP-9) release together with enhanced activity of elastase from neutrophils [ 12 ] which might facilitate neutrophil migration to the site of inflammation [ 12 ].

In a comparative study, repeated exposure of human gingival fibroblasts to CS condensate or to nicotine-rich or nicotine-free e-vapour condensates led to alterations in morphology, suppression of proliferation and induction of apoptosis, with changes in all three parameters greater in cells exposed to CS condensate [ 29 ]. Likewise, both e-cigarette aerosol and CS extract increased cell death in adenocarcinomic human alveolar basal epithelial cells (A549 cells), and again the effect was more damaging with CS extract than with e-cigarette aerosol (detrimental effects found at 2 mg/mL of CS extract vs. 64 mg/mL of e-cigarette extract) [ 22 ], which is in agreement with another study examining battery output voltage and cytotoxicity [ 30 ].

All this evidence would suggest that e-cigarettes are potentially less harmful than conventional cigarettes (Fig.  2 ) [ 11 , 14 , 22 , 24 , 27 , 28 , 29 ]. Importantly, however, most of these studies have investigated only short-term effects [ 10 , 14 , 15 , 22 , 27 , 28 , 29 , 31 , 32 ], and the long-term effects of e-cigarette consumption on human health are still unclear and require further study.

Comparison of the degree of harmful effects documented from e-cigarette and conventional cigarette consumption. Human studies, in vivo mice exposure and in vitro studies. All of these effects from e-cigarettes were documented to be lower than those exerted by conventional cigarettes, which may suggest that e-cigarette consumption could be a safer option than conventional tobacco smoking but not a clear safe choice

Consequences of nicotine content

Beyond flavour, one of the major issues in the e-liquid market is the range of nicotine content available. Depending on the manufacturer, the concentration of this alkaloid can be presented as low , medium or high , or expressed as mg/mL or as a percentage (% v/v). The concentrations range from 0 (0%, nicotine-free option) to 20 mg/mL (2.0%)—the maximum nicotine threshold according to directive 2014/40/EU of the European Parliament and the European Union Council [ 33 , 34 ]. Despite this normative, however, some commercial e-liquids have nicotine concentrations close to 54 mg/mL [ 35 ], much higher than the limits established by the European Union.

The mislabelling of nicotine content in e-liquids has been previously addressed [ 8 , 34 ]. For instance, gas chromatography with a flame ionisation detector (GC-FID) revealed inconsistencies in the nicotine content with respect to the manufacturer´s declaration (average of 22 ± 0.8 mg/mL vs. 18 mg/mL) [ 8 ], which equates to a content ~ 22% higher than that indicated in the product label. Of note, several studies have detected nicotine in those e-liquids labelled as nicotine-free [ 5 , 35 , 36 ]. One study detected the presence of nicotine (0.11–6.90 mg/mL) in 5 of 23 nicotine-free labelled e-liquids by nuclear magnetic resonance spectroscopy [ 35 ], and another study found nicotine (average 8.9 mg/mL) in 13.6% (17/125) of the nicotine-free e-liquids as analysed by high performance liquid chromatography (HPLC) [ 36 ]. Among the 17 samples tested in this latter study 14 were identified to be counterfeit or suspected counterfeit. A third study detected nicotine in 7 of 10 nicotine-free refills, although the concentrations were lower than those identified in the previous analyses (0.1–15 µg/mL) [ 5 ]. Not only is there evidence of mislabelling of nicotine content among refills labelled as nicotine-free, but there also seems to be a history of poor labelling accuracy in nicotine-containing e-liquids [ 37 , 38 ].

A comparison of the serum levels of nicotine from e-cigarette or conventional cigarette consumption has been recently reported [ 39 ]. Participants took one vape from an e-cigarette , with at least 12 mg/mL of nicotine, or inhaled a conventional cigarette, every 20 s for 10 min. Blood samples were collected 1, 2, 4, 6, 8, 10, 12 and 15 min after the first puff, and nicotine serum levels were measured by liquid chromatography-mass spectrometry (LC–MS). The results revealed higher serum levels of nicotine in the conventional CS group than in the e-cigarette group (25.9 ± 16.7 ng/mL vs. 11.5 ± 9.8 ng/mL). However, e-cigarettes containing 20 mg/mL of nicotine are more equivalent to normal cigarettes, based on the delivery of approximately 1 mg of nicotine every 5 min [ 40 ].

In this line, a study compared the acute impact of CS vs. e-cigarette vaping with equivalent nicotine content in healthy smokers and non-smokers. Both increased markers of oxidative stress and decreased NO bioavailability, flow-mediated dilation, and vitamin E levels showing no significant differences between tobacco and e-cigarette exposure (reviewed in [ 20 ]). Inasmuch, short-term e-cigarette use in healthy smokers resulted in marked impairment of endothelial function and an increase in arterial stiffness (reviewed in [ 20 ]). Similar effects on endothelial dysfunction and arterial stiffness were found in animals when they were exposed to e-cigarette vapor either for several days or chronically (reviewed in [ 20 ]). In contrast, other studies found acute microvascular endothelial dysfunction, increased oxidative stress and arterial stiffness in smokers after exposure to e-cigarettes with nicotine, but not after e-cigarettes without nicotine (reviewed in [ 20 ]). In women smokers, a study found a significant difference in stiffness after smoking just one tobacco cigarette, but not after use of e-cigarettes (reviewed in [ 20 ]).

It is well known that nicotine is extremely addictive and has a multitude of harmful effects. Nicotine has significant biologic activity and adversely affects several physiological systems including the cardiovascular, respiratory, immunological and reproductive systems, and can also compromise lung and kidney function [ 41 ]. Recently, a sub-chronic whole-body exposure of e-liquid (2 h/day, 5 days/week, 30 days) containing PG alone or PG with nicotine (25 mg/mL) to wild type (WT) animals or knockout (KO) mice in α7 nicotinic acetylcholine receptor (nAChRα7-KO) revealed a partly nAChRα7-dependent lung inflammation [ 42 ]. While sub-chronic exposure to PG/nicotine promote nAChRα7-dependent increased levels of different cytokines and chemokines in the bronchoalveolar lavage fluid (BALF) such as IL-1α, IL-2, IL-9, interferon γ (IFNγ), granulocyte-macrophage colony-stimulating factor (GM-CSF), monocyte chemoattractant protein-1 (MCP-1/CCL2) and regulated on activation, normal T cell expressed and secreted (RANTES/CCL5), the enhanced levels of IL-1β, IL-5 and TNFα were nAChRα7 independent. In general, most of the cytokines detected in BALF were significantly increased in WT mice exposed to PG with nicotine compared to PG alone or air control [ 42 ]. Some of these effects were found to be through nicotine activation of NF-κB signalling albeit in females but not in males. In addition, PG with nicotine caused increased macrophage and CD4 + /CD8 + T-lymphocytes cell counts in BALF compared to air control, but these effects were ameliorated when animals were sub-chronically exposed to PG alone [ 42 ].

Of note, another study indicated that although RANTES/CCL5 and CCR1 mRNA were upregulated in flavour/nicotine-containing e-cigarette users, vaping flavour and nicotine-less e-cigarettes did not significantly dysregulate cytokine and inflammasome activation [ 43 ].

In addition to its toxicological effects on foetus development, nicotine can disrupt brain development in adolescents and young adults [ 44 , 45 , 46 ]. Several studies have also suggested that nicotine is potentially carcinogenic (reviewed in [ 41 ]), but more work is needed to prove its carcinogenicity independently of the combustion products of tobacco [ 47 ]. In this latter regard, no differences were encountered in the frequency of tumour appearance in rats subjected to long-term (2 years) inhalation of nicotine when compared with control rats [ 48 ]. Despite the lack of carcinogenicity evidence, it has been reported that nicotine promotes tumour cell survival by decreasing apoptosis and increasing proliferation [ 49 ], indicating that it may work as a “tumour enhancer”. In a very recent study, chronic administration of nicotine to mice (1 mg/kg every 3 days for a 60-day period) enhanced brain metastasis by skewing the polarity of M2 microglia, which increases metastatic tumour growth [ 50 ]. Assuming that a conventional cigarette contains 0.172–1.702 mg of nicotine [ 51 ], the daily nicotine dose administered to these animals corresponds to 40–400 cigarettes for a 70 kg-adult, which is a dose of an extremely heavy smoker. We would argue that further studies with chronic administration of low doses of nicotine are required to clearly evaluate its impact on carcinogenicity.

In the aforementioned study exposing human gingival fibroblasts to CS condensate or to nicotine-rich or nicotine-free e-vapour condensates [ 29 ], the detrimental effects were greater in cells exposed to nicotine-rich condensate than to nicotine-free condensate, suggesting that the possible injurious effects of nicotine should be considered when purchasing e-refills . It is also noteworthy that among the 3 most cytotoxic vapours for HUVEC evaluated in the Putzhammer et al . study, 2 were nicotine-free, which suggests that nicotine is not the only hazardous component in e-cigarettes [ 24 ] .

The lethal dose of nicotine for an adult is estimated at 30–60 mg [ 52 ]. Given that nicotine easily diffuses from the dermis to the bloodstream, acute nicotine exposure by e-liquid spilling (5 mL of a 20 mg/mL nicotine-containing refill is equivalent to 100 mg of nicotine) can easily be toxic or even deadly [ 8 ]. Thus, devices with rechargeable refills are another issue of concern with e-cigarettes , especially when e-liquids are not sold in child-safe containers, increasing the risk of spilling, swallowing or breathing.

These data overall indicate that the harmful effects of nicotine should not be underestimated. Despite the established regulations, some inaccuracies in nicotine content labelling remain in different brands of e-liquids . Consequently, stricter regulation and a higher quality control in the e-liquid industry are required.

Effect of humectants and their heating-related products

In this particular aspect, again the composition of the e-liquid varies significantly among different commercial brands [ 4 , 35 ]. The most common and major components of e-liquids are PG or 1,2-propanediol, and glycerol or glycerine (propane-1,2,3-triol). Both types of compounds are used as humectants to prevent the e-liquid from drying out [ 2 , 53 ] and are classified by the Food and Drug Administration (FDA) as “Generally Recognised as Safe” [ 54 ]. In fact, they are widely used as alimentary and pharmaceutical products [ 2 ]. In an analysis of 54 commercially available e-liquids , PG and glycerol were detected in almost all samples at concentrations ranging from 0.4% to 98% (average 57%) and from 0.3% to 95% (average 37%), respectively [ 35 ].

With regards to toxicity, little is known about the effects of humectants when they are heated and chronically inhaled. Studies have indicated that PG can induce respiratory irritation and increase the probability of asthma development [ 55 , 56 ], and both PG and glycerol from e-cigarettes might reach concentrations sufficiently high to potentially cause irritation of the airways [ 57 ]. Indeed, the latter study established that one e-cigarette puff results in a PG exposure of 430–603 mg/m 3 , which is higher than the levels reported to cause airway irritation (average 309 mg/m 3 ) based on a human study [ 55 ]. The same study established that one e-cigarette puff results in a glycerol exposure of 348–495 mg/m 3 [ 57 ], which is close to the levels reported to cause airway irritation in rats (662 mg/m 3 ) [ 58 ].

Airway epithelial injury induced by acute vaping of PG and glycerol aerosols (50:50 vol/vol), with or without nicotine, has been reported in two randomised clinical trials in young tobacco smokers [ 32 ]. In vitro, aerosols from glycerol only-containing refills showed cytotoxicity in A549 and human embryonic stem cells, even at a low battery output voltage [ 59 ]. PG was also found to affect early neurodevelopment in a zebrafish model [ 60 ]. Another important issue is that, under heating conditions PG can produce acetaldehyde or formaldehyde (119.2 or 143.7 ng/puff at 20 W, respectively, on average), while glycerol can also generate acrolein (53.0, 1000.0 or 5.9 ng/puff at 20 W, respectively, on average), all carbonyls with a well-documented toxicity [ 61 ]. Although, assuming 15 puffs per e-cigarette unit, carbonyls produced by PG or glycerol heating would be below the maximum levels found in a conventional cigarette combustion (Table 2 ) [ 51 , 62 ]. Nevertheless, further studies are required to properly test the deleterious effects of all these compounds at physiological doses resembling those to which individuals are chronically exposed.

Although PG and glycerol are the major components of e-liquids other components have been detected. When the aerosols of 4 commercially available e-liquids chosen from a top 10 list of “ Best E-Cigarettes of 2014” , were analysed by gas chromatography-mass spectrometry (GC–MS) after heating, numerous compounds were detected, with nearly half of them not previously identified [ 4 ], thus suggesting that the heating process per se generates new compounds of unknown consequence. Of note, the analysis identified formaldehyde, acetaldehyde and acrolein [ 4 ], 3 carbonyl compounds with known high toxicity [ 63 , 64 , 65 , 66 , 67 ]. While no information was given regarding formaldehyde and acetaldehyde concentrations, the authors calculated that one puff could result in an acrolein exposure of 0.003–0.015 μg/mL [ 4 ]. Assuming 40 mL per puff and 15 puffs per e-cigarette unit (according to several manufacturers) [ 4 ], each e-cigarette unit would generate approximately 1.8–9 μg of acrolein, which is less than the levels of acrolein emitted by a conventional tobacco cigarette (18.3–98.2 μg) [ 51 ]. However, given that e-cigarette units of vaping are not well established, users may puff intermittently throughout the whole day. Thus, assuming 400 to 500 puffs per cartridge, users could be exposed to up to 300 μg of acrolein.

In a similar study, acrolein was found in 11 of 12 aerosols tested, with a similar content range (approximately 0.07–4.19 μg per e-cigarette unit) [ 68 ]. In the same study, both formaldehyde and acetaldehyde were detected in all of the aerosols tested, with contents of 0.2–5.61 μg and 0.11–1.36 μg, respectively, per e-cigarette unit [ 68 ]. It is important to point out that the levels of these toxic products in e-cigarette aerosols are significantly lower than those found in CS: 9 times lower for formaldehyde, 450 times lower for acetaldehyde and 15 times lower for acrolein (Table 2 ) [ 62 , 68 ].

Other compounds that have been detected in aerosols include acetamide, a potential human carcinogen [ 5 ], and some aldehydes [ 69 ], although their levels were minimal. Interestingly, the existence of harmful concentrations of diethylene glycol, a known cytotoxic agent, in e-liquid aerosols is contentious with some studies detecting its presence [ 4 , 68 , 70 , 71 , 72 ], and others finding low subtoxic concentrations [ 73 , 74 ]. Similar observations were reported for the content ethylene glycol. In this regard, either it was detected at concentrations that did not exceed the authorised limit [ 73 ], or it was absent from the aerosols produced [ 4 , 71 , 72 ]. Only one study revealed its presence at high concentration in a very low number of samples [ 5 ]. Nevertheless, its presence above 1 mg/g is not allowed by the FDA [ 73 ]. Figure  1 lists the main compounds detected in aerosols derived from humectant heating and their potential damaging effects. It would seem that future studies should analyse the possible toxic effects of humectants and related products at concentrations similar to those that e-cigarette vapers are exposed to reach conclusive results.

Impact of flavouring compounds

The range of e-liquid flavours 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 [ 6 ]. In fact, over 5 million middle- and high-school students were current users of e-cigarettes in 2019 [ 75 ], and appealing flavours have been identified as the primary reason for e-cigarette consumption in 81% of young users [ 76 ]. Since 2016, the FDA regulates the flavours used in the e-cigarette market and has recently published an enforcement policy on unauthorised flavours, including fruit and mint flavours, which are more appealing to young users [ 77 ]. However, the long-term effects of all flavour chemicals used by this industry (which are more than 15,000) remain unknown and they are not usually included in the product label [ 78 ]. Furthermore, there is no safety guarantee since they may harbour potential toxic or irritating properties [ 5 ].

With regards to the multitude of available flavours, some have demonstrated cytotoxicity [ 59 , 79 ]. Bahl et al. evaluated the toxicity of 36 different e-liquids and 29 different flavours on human embryonic stem cells, mouse neural stem cells and human pulmonary fibroblasts using a metabolic activity assay. In general, those e-liquids that were bubblegum-, butterscotch- and caramel-flavoured did not show any overt cytotoxicity even at the highest dose tested. By contrast, those e-liquids with Freedom Smoke Menthol Arctic and Global Smoke Caramel flavours had marked cytotoxic effects on pulmonary fibroblasts and those with Cinnamon Ceylon flavour were the most cytotoxic in all cell lines [ 79 ]. A further study from the same group [ 80 ] revealed that high cytotoxicity is a recurrent feature of cinnamon-flavoured e-liquids. In this line, results from GC–MS and HPLC analyses indicated that cinnamaldehyde (CAD) and 2-methoxycinnamaldehyde, but not dipropylene glycol or vanillin, were mainly responsible for the high cytotoxicity of cinnamon-flavoured e-liquids [ 80 ]. Other flavouring-related compounds that are associated with respiratory complications [ 81 , 82 , 83 ], such as diacetyl, 2,3-pentanedione or acetoin, were found in 47 out of 51 aerosols of flavoured e-liquids tested [ 84 ] . Allen et al . calculated an average of 239 μg of diacetyl per cartridge [ 84 ]. Assuming again 400 puffs per cartridge and 40 mL per puff, is it is possible to estimate an average of 0.015 ppm of diacetyl per puff, which could compromise normal lung function in the long-term [ 85 ].

The cytotoxic and pro-inflammatory effects of different e-cigarette flavouring chemicals were also tested on two human monocytic cell lines—mono mac 6 (MM6) and U937 [ 86 ]. Among the flavouring chemicals tested, CAD was found to be the most toxic and O-vanillin and pentanedione also showed significant cytotoxicity; by contrast, acetoin, diacetyl, maltol, and coumarin did not show any toxicity at the concentrations assayed (10–1000 µM). Of interest, a higher toxicity was evident when combinations of different flavours or mixed equal proportions of e-liquids from 10 differently flavoured e-liquids were tested, suggesting that vaping a single flavour is less toxic than inhaling mixed flavours [ 86 ]. Also, all the tested flavours produced significant levels of ROS in a cell-free ROS production assay. Finally, diacetyl, pentanedione, O-vanillin, maltol, coumarin, and CAD induced significant IL-8 secretion from MM6 and U937 monocytes [ 86 ]. It should be borne in mind, however, that the concentrations assayed were in the supra-physiological range and it is likely that, once inhaled, these concentrations are not reached in the airway space. Indeed, one of the limitations of the study was that human cells are not exposed to e-liquids per se, but rather to the aerosols where the concentrations are lower [ 86 ]. In this line, the maximum concentration tested (1000 µM) would correspond to approximately 80 to 150 ppm, which is far higher than the levels found in aerosols of some of these compounds [ 84 ]. Moreover, on a day-to-day basis, lungs of e-cigarette users are not constantly exposed to these chemicals for 24 h at these concentrations. Similar limitations were found when five of seven flavourings were found to cause cytotoxicity in human bronchial epithelial cells [ 87 ].

Recently, a commonly commercialized crème brûlée -flavoured aerosol was found to contain high concentrations of benzoic acid (86.9 μg/puff), a well-established respiratory irritant [ 88 ]. When human lung epithelial cells (BEAS-2B and H292) were exposed to this aerosol for 1 h, a marked cytotoxicity was observed in BEAS-2B but not in H292 cells, 24 h later. However, increased ROS production was registered in H292 cells [ 88 ].

Therefore, to fully understand the effects of these compounds, it is relevant the cell cultures selected for performing these assays, as well as the use of in vivo models that mimic the real-life situation of chronic e-cigarette vapers to clarify their impact on human health.

The e-cigarette device

While the bulk of studies related to the impact of e-cigarette use on human health has focused on the e-liquid components and the resulting aerosols produced after heating, a few studies have addressed the material of the electronic device and its potential consequences—specifically, the potential presence of metals such as copper, nickel or silver particles in e-liquids and aerosols originating from the filaments and wires and the atomiser [ 89 , 90 , 91 ].

Other important components in the aerosols include silicate particles from the fiberglass wicks or silicone [ 89 , 90 , 91 ]. Many of these products are known to cause abnormalities in respiratory function and respiratory diseases [ 89 , 90 , 91 ], but more in-depth studies are required. Interestingly, the battery output voltage also seems to have an impact on the cytotoxicity of the aerosol vapours, with e-liquids from a higher battery output voltage showing more toxicity to A549 cells [ 30 ].

A recent study compared the acute effects of e-cigarette vapor (with PG/vegetable glycerine plus tobacco flavouring but without nicotine) generated from stainless‐steel atomizer (SS) heating element or from a nickel‐chromium alloy (NC) [ 92 ]. Some rats received a single e-cigarette exposure for 2 h from a NC heating element (60 or 70 W); other rats received a similar exposure of e-cigarette vapor using a SS heating element for the same period of time (60 or 70 W) and, a final group of animals were exposed for 2 h to air. Neither the air‐exposed rats nor those exposed to e-cigarette vapor using SS heating elements developed respiratory distress. In contrast, 80% of the rats exposed to e-cigarette vapor using NC heating units developed clinical acute respiratory distress when a 70‐W power setting was employed. Thus, suggesting that operating units at higher than recommended settings can cause adverse effects. Nevertheless, there is no doubt that the deleterious effects of battery output voltage are not comparable to those exerted by CS extracts [ 30 ] (Figs.  1 and 2 ).

E-cigarettes as a smoking cessation tool

CS contains a large number of substances—about 7000 different constituents in total, with sizes ranging from atoms to particulate matter, and with many hundreds likely responsible for the harmful effects of this habit [ 93 ]. Given that tobacco is being substituted in great part by e-cigarettes with different chemical compositions, manufacturers claim that e -cigarette will not cause lung diseases such as lung cancer, chronic obstructive pulmonary disease, or cardiovascular disorders often associated with conventional cigarette consumption [ 3 , 94 ]. However, the World Health Organisation suggests that e-cigarettes cannot be considered as a viable method to quit smoking, due to a lack of evidence [ 7 , 95 ]. Indeed, the results of studies addressing the use of e-cigarettes as a smoking cessation tool remain controversial [ 96 , 97 , 98 , 99 , 100 ]. Moreover, both FDA and CDC are actively investigating the incidence of severe respiratory symptoms associated with the use of vaping products [ 77 ]. Because many e-liquids contain nicotine, which is well known for its powerful addictive properties [ 41 ], e-cigarette users can easily switch to conventional cigarette smoking, avoiding smoking cessation. Nevertheless, the possibility of vaping nicotine-free e-cigarettes has led to the branding of these devices as smoking cessation tools [ 2 , 6 , 7 ].

In a recently published randomised trial of 886 subjects who were willing to quit smoking [ 100 ], the abstinence rate was found to be twice as high in the e-cigarette group than in the nicotine-replacement group (18.0% vs. 9.9%) after 1 year. Of note, the abstinence rate found in the nicotine-replacement group was lower than what is usually expected with this therapy. Nevertheless, the incidence of throat and mouth irritation was higher in the e-cigarette group than in the nicotine-replacement group (65.3% vs. 51.2%, respectively). Also, the participant adherence to the treatment after 1-year abstinence was significantly higher in the e-cigarette group (80%) than in nicotine-replacement products group (9%) [ 100 ].

On the other hand, it is estimated that COPD could become the third leading cause of death in 2030 [ 101 ]. Given that COPD is generally associated with smoking habits (approximately 15 to 20% of smokers develop COPD) [ 101 ], smoking cessation is imperative among COPD smokers. Published data revealed a clear reduction of conventional cigarette consumption in COPD smokers that switched to e-cigarettes [ 101 ]. Indeed, a significant reduction in exacerbations was observed and, consequently, the ability to perform physical activities was improved when data was compared with those non-vapers COPD smokers. Nevertheless, a longer follow-up of these COPD patients is required to find out whether they have quitted conventional smoking or even vaping, since the final goal under these circumstances is to quit both habits.

Based on the current literature, it seems that several factors have led to the success of e-cigarette use as a smoking cessation tool. First, some e-cigarette flavours positively affect smoking cessation outcomes among smokers [ 102 ]. Second, e-cigarettes have been described to improve smoking cessation rate only among highly-dependent smokers and not among conventional smokers, suggesting that the individual degree of nicotine dependence plays an important role in this process [ 97 ]. Third, the general belief of their relative harmfulness to consumers' health compared with conventional combustible tobacco [ 103 ]. And finally, the exposure to point-of-sale marketing of e-cigarette has also been identified to affect the smoking cessation success [ 96 ].

Implication of e-cigarette consumption in COVID-19 time

Different reports have pointed out that smokers and vapers are more vulnerable to SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus 2) infections or more prone to adverse outcomes if they suffer COVID-19 [ 104 ]. However, while a systematic review indicated that cigarette smoking is probably associated with enhanced damage from COVID-19, a meta-analysis did not, yet the latter had several limitations due to the small sample sizes [ 105 ].

Interestingly, most of these reports linking COVID-19 harmful effects with smoking or vaping, are based on their capability of increasing the expression of angiotensin-converting enzyme 2 (ACE2) in the lung. It is well known that ACE2 is the gate for SARS-CoV-2 entrance to the airways [ 106 ] and it is mainly expressed in type 2 alveolar epithelial cells and alveolar macrophages [ 107 ]. To date, most of the studies in this field indicate that current smokers have higher expression of ACE2 in the airways (reviewed by [ 108 ]) than healthy non-smokers [ 109 , 110 ]. However, while a recent report indicated that e-cigarette vaping also caused nicotine-dependent ACE2 up-regulation [ 42 ], others have revealed that neither acute inhalation of e-cigarette vapour nor e-cigarette users had increased lung ACE2 expression regardless nicotine presence in the e-liquid [ 43 , 110 ].

In regard to these contentions, current knowledge suggests that increased ACE2 expression is not necessarily linked to enhanced susceptibility to SARS-CoV-2 infection and adverse outcome. Indeed, elderly population express lower levels of ACE2 than young people and SARS-CoV-2/ACE2 interaction further decreases ACE2 expression. In fact, most of the deaths provoked by COVID-19 took place in people over 60 years old of age [ 111 ]. Therefore, it is plausible that the increased susceptibility to disease progression and the subsequent fatal outcome in this population is related to poor angiotensin 1-7 (Ang-1-7) generation, the main peptide generated by ACE2, and probably to their inaccessibility to its anti-inflammatory effects. Furthermore, it seems that all the efforts towards increasing ACE2 expression may result in a better resolution of the pneumonic process associated to this pandemic disease.

Nevertheless, additional complications associated to COVID-19 are increased thrombotic events and cytokine storm. In the lungs, e-cigarette consumption has been correlated to toxicity, oxidative stress, and inflammatory response [ 32 , 112 ]. More recently, a study revealed that while the use of nicotine/flavour-containing e-cigarettes led to significant cytokine dysregulation and potential inflammasome activation, none of these effects were detected in non-flavoured and non-nicotine-containing e-cigarettes [ 43 ]. Therefore, taken together these observations, e-cigarette use may still be a potent risk factor for severe COVID-19 development depending on the flavour and nicotine content.

In summary, it seems that either smoking or nicotine vaping may adversely impact on COVID-19 outcome. However, additional follow up studies are required in COVID-19 pandemic to clarify the effect of e-cigarette use on lung and cardiovascular complications derived from SARS-CoV-2 infection.

Conclusions

The harmful effects of CS and their deleterious consequences are both well recognised and widely investigated. However, and based on the studies carried out so far, it seems that e-cigarette consumption is less toxic than tobacco smoking. This does not necessarily mean, however, that e-cigarettes are free from hazardous effects. Indeed, studies investigating their long-term effects on human health are urgently required. In this regard, the main additional studies needed in this field are summarized in Table 3 .

The composition of e-liquids requires stricter regulation, as they can be easily bought online and many incidences of mislabelling have been detected, which can seriously affect consumers’ health. Beyond their unknown long-term effects on human health, the extended list of appealing flavours available seems to attract new “never-smokers”, which is especially worrying among young users. Additionally, there is still a lack of evidence of e-cigarette consumption as a smoking cessation method. Indeed, e-cigarettes containing nicotine may relieve the craving for smoking, but not the conventional cigarette smoking habit.

Interestingly, there is a strong difference of opinion on e-cigarettes between countries. Whereas countries such as Brazil, Uruguay and India have banned the sale of e-cigarettes , others such as the United Kingdom support this device to quit smoking. The increasing number of adolescent users and reported deaths in the United States prompted the government to ban the sale of flavoured e-cigarettes in 2020. The difference in opinion worldwide may be due to different restrictions imposed. For example, while no more than 20 ng/mL of nicotine is allowed in the EU, e-liquids with 59 mg/dL are currently available in the United States. Nevertheless, despite the national restrictions, users can easily access foreign or even counterfeit products online.

In regard to COVID-19 pandemic, the actual literature suggests that nicotine vaping may display adverse outcomes. Therefore, follow up studies are necessary to clarify the impact of e-cigarette consumption on human health in SARS-CoV-2 infection.

In conclusion, e-cigarettes could be a good alternative to conventional tobacco cigarettes, with less side effects; however, a stricter sale control, a proper regulation of the industry including flavour restriction, as well as further toxicological studies, including their chronic effects, are warranted.

Availability of data and materials

Not applicable.

Abbreviations

Angiotensin-converting enzyme 2

Angiotensin 1-7

Bronchoalveolar lavage fluid

Cinnamaldehyde

US Centers for Disease Control and Prevention

Carbon monoxide

Chronic obstructive pulmonary disease

Coronavirus disease 2019

Cigarette smoke

Electronic nicotine dispensing systems

e-cigarette or vaping product use-associated lung injury

Food and Drug Administration

Gas chromatography with a flame ionisation detector

Gas chromatography-mass spectrometry

Granulocyte–macrophage colony-stimulating factor

High performance liquid chromatography

Human umbilical vein endothelial cells

Interleukin

Interferon γ

Liquid chromatography-mass spectrometry

Monocyte chemoattractant protein-1

Matrix metallopeptidase 9

α7 Nicotinic acetylcholine receptor

Nickel‐chromium alloy

Nitric oxide

Propylene glycol

Regulated on activation, normal T cell expressed and secreted

Reactive oxygen species

Severe acute respiratory syndrome coronavirus 2

Stainless‐steel atomizer

Tetrahydrocannabinol

Tumour necrosis factor-α

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Acknowledgements

The authors gratefully acknowledge Dr. Cruz González, Pulmonologist at University Clinic Hospital of Valencia (Valencia, Spain) for her thoughtful suggestions and support.

This work was supported by the Spanish Ministry of Science and Innovation [Grant Number SAF2017-89714-R]; Carlos III Health Institute [Grant Numbers PIE15/00013, PI18/00209]; Generalitat Valenciana [Grant Number PROMETEO/2019/032, Gent T CDEI-04/20-A and AICO/2019/250], and the European Regional Development Fund.

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A systematic review of the effects of e-cigarette use on lung function

• Lucy Honeycutt 1 ,
• Katherine Huerne 1 , 2 ,
• Alanna Miller 1 ,
• Erica Wennberg 1 ,
• Kristian B. Filion 1 , 3 ,
• Roland Grad 1 , 4 ,
• Andrea S. Gershon 5 ,
• Carolyn Ells   ORCID: orcid.org/0000-0002-4593-454X 1 , 2 , 4 ,
• Genevieve Gore 6 ,
• Andrea Benedetti 3 , 7 ,
• Brett Thombs 1 , 3 , 8 &
• Mark J. Eisenberg   ORCID: orcid.org/0000-0002-1296-0661 1 , 3 , 9  

npj Primary Care Respiratory Medicine volume  32 , Article number:  45 ( 2022 ) Cite this article

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• Epidemiology

Given the increasing use of e-cigarettes and uncertainty surrounding their safety, we conducted a systematic review to determine the effects of e-cigarettes on measures of lung function. We systematically searched EMBASE, MEDLINE, and PsycINFO databases via Ovid, the Cochrane CENTRAL database, and the Web of Science Core from 2004 until July 2021, identifying 8856 potentially eligible studies. A total of eight studies (seven studying immediate effects and one long-term effects, 273 total participants) were included. The risk of bias was assessed using the Risk of Bias in Non-randomized Studies—of Interventions (ROBINS-I) and Cochrane risk of bias tools. These studies suggest that vaping increases airway resistance but does not appear to impact forced expiratory volume in one second (FEV 1) , forced vital capacity (FVC), or FEV 1 /FVC ratio. However, given the limited size and follow-up duration of these studies, larger, long-term studies are required to further determine the effects of e-cigarettes on lung function.

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Introduction.

The first electronic cigarette (e-cigarette) was patented and marketed in 2004 1 . Since then, e-cigarette use (or “vaping”) has grown exponentially across the globe 2 . As the use of vaping devices evolves with policy, the consequences of vaping on health are becoming an increasingly important public health issue. E-cigarettes are being studied for harm reduction in individuals who use cigarettes and as a smoking cessation aid, as they are believed to be less harmful to health than smoking 3 . However, there is increasing evidence demonstrating adverse respiratory effects of vaping compared to vaping abstinence. In particular, an outbreak of E-Cigarette and Vaping-Associated Lung Illness (EVALI) brought the short-term respiratory consequences of vaping into question, especially if cannabis or THC-containing products are used 4 . Other short-term respiratory changes that have been linked to vaping include increased airway resistance 5 , breathing difficulty 6 , and transient lung inflammation 7 . Vaping has also been associated with chronic respiratory conditions such as asthma 8 and chronic bronchitis 9 . Despite these reports, the short- and long-term respiratory safety of vaping is still largely unknown. Several small studies have examined the effects of e-cigarettes on lung function, including measures such as forced expiratory volume in one second (FEV 1 ), forced vital capacity (FVC), and airway resistance. However, no evidence syntheses have been completed on this topic. Therefore, we conducted a systematic review to determine the effects of vaping on measures of lung function.

Our systematic review was conducted following a protocol developed prior to initiating the review, which was registered on the PROSPERO register of systematic reviews ( CRD42021227121 ) 10 . This systematic review is reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines 11 .

Search strategy and study selection

Using a search strategy (Supplementary Tables 1 – 5 ) developed by an experienced health sciences librarian (G.G.), we systematically searched EMBASE, MEDLINE, and PsycINFO databases via Ovid, the Cochrane CENTRAL database, and the Web of Science Core from 2004 (the year of the first e-cigarette patent) until July 12, 2021. We additionally conducted a gray literature search by searching the websites of key governmental and public health organizations (the World Health Organization, Health Canada, the US Centers for Disease Control and Prevention, the US Food and Drug Administration, the Canadian Center on Substance Use and Addiction, the European Centre for Disease Prevention and Control, and the European Public Health Association). Additional articles were identified by manually searching the reference lists of included publications as well as SCOPUS and Google Scholar (first ten pages). Articles were included if they reported quantitative primary data on changes in lung function associated with vaping, defined as the use of any device that functions by transforming an e-liquid to an aerosol using metal coils, among human participants of any age. Studies of cells and those conducted in animals were excluded. Studies using heat-not-burn devices were also excluded, as these do not meet the above definition of vaping. Eligible studies included randomized controlled trials (RCTs), non-randomized studies of interventions (NRSIs), and cohort studies; cross-sectional studies and case reports were excluded. We included studies that used non-users of both vaping devices and conventional cigarettes as a comparison group and those that used a pre- and post-design in which individuals acted as their own controls. Inclusion was not restricted by language or country of publication. Abstracts and conference proceedings were included if sufficient data could be extracted from these publications.

Search results were downloaded from databases into reference management software (EndNote X9) or manually added (e.g., for gray literature results). Duplicates were removed in EndNote and entries were uploaded to Covidence (Veritas Health Innovation, Melbourne, Australia), a systematic review software. Two reviewers (L.H. and K.H.) independently screened the titles and abstracts of all identified publications for eligibility. Citations considered potentially eligible by either reviewer, based on the pre-specified review inclusion/exclusion criteria (Supplementary Table 6 ), were retrieved for full-text screening and assessed for inclusion. The reasons for exclusion after full-text review were annotated in Covidence and any disagreements were resolved by consensus or a third reviewer (A.H-L.).

Data extraction

Two independent reviewers (L.H and K.H.) extracted methodological, demographic, and outcome data from included studies in duplicate; disagreements were detected in Covidence and were resolved by consensus or, if necessary, by a third reviewer (A.H-L.). Extracted data included study characteristics (first author, journal, year of publication, years(s) of data collection, funding, data source, study design, recruitment strategy, duration of follow-up, country of origin, sample size); population characteristics (sex, gender, age, race, ethnicity, socioeconomic status, dose/frequency of e-cigarette use, conventional cigarette smoking status, smoked cannabis use); and vaping behavior, including the type of vaping device used (e.g., disposable e-cigarette vs. pod device such as JUUL), vaping products used (e.g., nicotine cartridges exclusively vs. THC cartridges exclusively vs. dual use of nicotine and THC products), and source of the vaping product (informal [i.e., friends, family members, or dealers] vs. commercial [i.e., vape shops, stores, dispensaries]).

Initially, extracted outcomes of primary interest were respiratory signs and symptoms, as these are important to patients and are the early signs of respiratory disease. Secondary outcomes included: findings on lung function; Computed tomography (CT) findings of emphysema, airway remodeling, and small airway loss; respiratory-related quality of life and exercise limitations; incidence and/or prevalence of respiratory disease as well as exacerbations of previous respiratory disease; and health care resource use including respiratory disease-related ambulatory care, emergency department visits, and hospitalization. Given the limited number of studies available and the heterogeneity of the data extracted from these studies, no meta-analysis was conducted.

Risk of bias

The risk of bias in included publications was assessed independently by two reviewers (L.H. and K.H.), and discrepancies were resolved by consensus or, if necessary, by a third reviewer (A.H-L.). The risk of bias of included non-randomized studies (pre-post studies, NRSI with non-vaping reference group, cohort study) was assessed using the Risk of Bias in Non-randomized Studies—of Interventions (ROBINS-I) tool 12 . The ROBINS-I tool evaluates intervention-specific outcomes for a study through seven domains which assess the risk of bias pre-intervention, at-intervention, and post-intervention. For each outcome of interest extracted from an included study, the risk of bias within each domain was reported as “low”, “moderate”, “serious”, or “critical”. Included RCTs were assessed using the Cochrane Collaboration’s Tool for Assessing Risk of Bias (ROB V1) 13 . Similar to ROBINS-I, this tool evaluates the risk of bias through the assessment of five domains; for each outcome of interest extracted from an included study, the risk of bias for each domain was reported as “low risk of bias”, “high risk of bias”, or “unclear risk of bias.” All eligible publications were included in the qualitative synthesis regardless of their assessed risk of bias.

Reporting summary

Further information on research design is available in the Nature Research Reporting Summary linked to this article.

As our search did not identify studies which focused on the broad outcomes detailed above, we chose to limit our focus to studies on lung function. Our database searches identified 14,307 potentially eligible studies (Fig. 1 ). After duplicates were removed, 8856 titles and abstracts were assessed. After this initial screening, 44 full texts were retrieved and reviewed in further detail, yielding eight studies eligible for inclusion.

PRISMA flow diagram of included studies assessing the effect of e-cigarettes on lung function.

Study and participant characteristics

Of the eight included studies (273 total participants), seven 14 , 15 , 16 , 17 , 18 , 19 , 20 involved short-term exposure to e-cigarettes with immediate outcome assessment, and the remaining study followed vapers and non-vapers over 3.5 years 21 (Table 1 ). This prospective cohort study examined 21 participants (12 nonsmokers and nine vapers) at means of 12 (standard deviation: 1), 24 (2), and 42 (2) months after baseline 21 . Of the seven short-term studies, four were NRSIs (three pre-post studies 14 , 15 , 16 and one NRSI with a non-vaping reference group 20 ) and three were RCTs 17 , 18 , 19 . Among these seven studies, two included 70–80 participants 14 , 15 and five included 10–30 participants 16 , 17 , 18 , 19 , 20 . Exposures varied in terms of e-cigarettes, e-liquids, and vaping session timings. Most studies did not expand on their definition of “non-smoker/non-vaper” 15 , 16 , 18 , 19 , 20 , 21 , but two studies clarified that these participants were never-smokers 14 , 17 . One of these two studies further elaborated that participants had no exposure to tobacco products or e-cigarettes 17 . Few studies gave detailed information on the type of e-cigarette used. Three studies reported a specific brand or product (Blu 17 , eGo 16 , Joytech elips-C series 18 , Puff bar 20 ). Polosa et al. listed some of the various e-cigarettes used by participants throughout the longitudinal study, including standard refillable (eGo style products) and more advanced refillable (Provari, Innokin, Joytech, eVIC, Avatar Puff) 21 . The remaining studies did not report a specific brand, though one study described the e-cigarette used as a “1 st generation e-cigarette popular in Greece” 15 . All studies clarified whether the e-cigarettes used during the study contained nicotine.

The included RCTs ( n  = 3) 17 , 18 , 19 had an unclear risk of bias, with each study demonstrating an unclear risk of bias in 3+ domains (Table 2 ). This was primarily due to missing information in the manuscripts required to make an adequate judgment, such as a lack of detail surrounding randomization. The risk associated with the blinding of participants and personnel was judged to be low for all 3 included RCTs. These studies were not blinded, and one was placebo-controlled. However, it was judged that this lack of blinding would not influence measures of lung function. Of the included non-randomized studies ( n  = 5) 14 , 15 , 16 , 20 , 21 , four 14 , 15 , 16 , 20 were judged to be at moderate risk of bias and one 21 was found to have a serious risk of bias (Table 3 ). The most consistent source of bias in these studies was bias due to confounding, with only one 16 study judged to have a low risk of bias due to confounding. Of the remaining four studies, three 14 , 15 , 20 were found to have a moderate risk of bias due to confounding and one 21 was found to be at serious risk of bias due to confounding, with important confounding variables not accounted for in the design or analysis.

Effects of E-cigarette use on lung function

Seven studies 14 , 15 , 16 , 17 , 18 , 19 , 20 reported immediate measures of lung function after short-term exposure to e-cigarettes (Table 4 ), including FEV 1 , FVC, and FEV 1 /FVC. Two studies, Boulay et al. and Staudt. et al. suggested no changes in FEV 1 or FEV 1 /FVC after vaping among nonsmokers 17 , 19 . Kizhakke Puliyakote et al. observed lower baseline FEV 1 and FEV 1 /FVC values among nonsmokers compared to vapers 20 . Coppeta et al. found a decrease in FEV 1 and FEV 1 /FVC among nonsmokers after 1 min of vaping; however, these values returned to baseline after 15 min 16 .

Airway resistance and specific airway conductance after 10 min of vaping were measured in two 14 , 15 of the seven short-term studies (Table 4 ). Both Palamidas et al. 2013 and 2017 suggested that vaping increased airway resistance and decreased specific airway conductance among nonsmokers and smokers with and without respiratory disease. Oxygen saturation was assessed in four studies 15 , 17 , 19 , 20 . Three studies suggested no changes after vaping, with only Palamidas et. al. 2017 suggesting decreased oxygen saturation following vaping among smokers with and without asthma 15 .

Long-term changes (3.5 years) in lung function measurements were assessed in only one small ( n  = 21) study (Polosa 2017) 21 . This study suggested that FEV 1 , FVC, FEV 1 /FVC, and forced mid-expiratory flow (FEF 25-75 ) did not change over time among vapers and non-vapers (Table 5 ).

This systematic review was designed to determine the effect of vaping on measures of lung function. We found that there were only eight studies in the literature assessing this issue, all of which were small, and only one examined longer-term outcomes (3.5 years follow-up). In general, these studies suggest that there are no acute changes associated with vaping. However, airway resistance and conductance may be influenced by e-cigarettes, with two studies reporting changes in these values in multiple population subgroups. It is important to note that there were few studies available for this systematic review and that most of these studies focused on the acute effects of vaping; therefore, these results are suggestive but not definitive, and future research must be conducted in this area. Furthermore, three of the included studies had an unclear risk of bias, four had a moderate risk of bias, and one had a serious risk of bias, which further limits the interpretation of this review’s findings.

In addition to the limitations above, this review lacks subgroup analyses or a meta-analysis. This is due to the heterogeneity of the included studies, both in terms of study design and outcomes. Few studies were eligible for this review due to the variation in study designs and definitions of e-cigarettes and smoking status. For example, some studies included both conventional cigarette smokers and nonsmokers in their definition of “non-vapers” and did not analyze data separately based on conventional smoking status. Other studies used a “sham” vaping session for controls where either an e-cigarette with an empty cartridge (i.e., without e-liquid) or second-hand smoke were used. More commonly, studies were conducted on smokers only, without nonsmokers as a comparison group. Future studies could analyze subgroups based on both smoking and vaping status to allow for a more detailed quantitative analysis.

E-cigarettes are becoming more popular for recreational use and are being studied for harm reduction among smokers as a smoking cessation aid, as they are believed to be less harmful to health than smoking. However, there are limited data available and virtually no long-term studies assessing how prolonged e-cigarette use could impact lung function. As the use of vaping devices evolves and becomes more widespread, the health consequences of vaping are becoming an increasingly important public health issue. This is a knowledge gap that must be addressed. Knowledge of the safety of e-cigarettes, particularly their long-term safety, will inform public health policy and e-cigarette regulations, as well as the guidance clinicians, offer to their patients on smoking harm reduction. For these policies, regulations, and guidelines to be developed, we must understand how e-cigarettes can influence one’s health. This includes establishing the effects of e-cigarettes on clinical outcomes such as respiratory symptoms (cough, dyspnea), measures of lung function, and risk of developing respiratory disease. Further research is required to elucidate the short- and long-term consequences of vaping to determine whether e-cigarettes are truly a “safer” alternative to traditional cigarettes for smoking cessation or for recreational use. Future studies should be long-term, have large sample sizes, and may include different types of e-cigarettes as well as conventional cigarettes for comparison. In addition, it is important for future research to include clinical outcomes as described above. This will allow for better translation of the research findings to help inform clinical decision-making.

Data availability

No additional data were available, as this study is a knowledge synthesis that relied on aggregate, published results available in the public domain. Any inquiries should be directed to the corresponding author.

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Acknowledgements

The authors would like to thank Jenna Glidden and Andrea Hebert-Losier for their assistance with study screening, data abstraction, and risk of bias assessment. The authors would also like to thank Francesca Frati, who peer-reviewed the search strategy. This work was funded by the Canadian Institutes for Health Research (#HEV-172891). The funder of the study had no role in study design, data collection, data analysis, data interpretation, writing of the report, or decision to submit for publication. Dr. Filion is supported by a Senior Research Scholar award from the Fonds de recherche du Québec – Santé and a William Dawson Scholar award from McGill University. Dr. Thombs was supported by a Tier 1 Canada Research Chair.

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Lucy Honeycutt, Katherine Huerne, Alanna Miller, Erica Wennberg, Kristian B. Filion, Roland Grad, Carolyn Ells, Brett Thombs & Mark J. Eisenberg

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Contributions

G.G. performed the search. L.H. and K.H. screened studies, extracted data, and performed a risk of bias assessment of included studies. L.H. drafted the manuscript. All authors contributed to the study design and interpretation of results, revised the manuscript for important intellectual content, and approved the final version of the manuscript. M.J.E. supervised the study and is the guarantor.

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Correspondence to Mark J. Eisenberg .

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Honeycutt, L., Huerne, K., Miller, A. et al. A systematic review of the effects of e-cigarette use on lung function. npj Prim. Care Respir. Med. 32 , 45 (2022). https://doi.org/10.1038/s41533-022-00311-w

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The Impact of E-Cigarettes on the Lung

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E-cigarettes are a relatively new tobacco product that have been sold in the U.S. for about a decade The e-cigarettes currently in the U.S. marketplace have not been systemically reviewed by the Food and Drug Administration to determine their impact on lung health. While much remains to be determined about the lasting health consequences of these products, the American Lung Association is very troubled by the evolving evidence about the impact of e-cigarettes on the lungs.

The Inhalation of Harmful Chemicals Can Cause Irreversible Lung Damage and Lung Disease

In January 2018, the National Academies of Science, Engineering and Medicine 1 released a consensus study report that reviewed over 800 different studies.

That report made clear: using e-cigarettes causes health risks. It concluded that e-cigarettes both contain and emit a number of potentially toxic substances. The Academies' report also states there is moderate evidence that youth who use e-cigarettes are at increased risk for  cough  and wheezing and an increase in asthma exacerbations.

• A study from the University of North Carolina found that the two primary ingredients found in e-cigarettes—propylene glycol and vegetable glycerin—are toxic to cells and that the more ingredients in an e-liquid, the greater the toxicity. 2
• E-cigarettes produce a number of dangerous chemicals including acetaldehyde, acrolein, and formaldehyde. These aldehydes can cause lung disease, as well as cardiovascular (heart) disease. 3
• E-cigarettes also contain acrolein, a herbicide primarily used to kill weeds. It can cause acute lung injury and COPD and may cause asthma and lung cancer. 4
• Both the U.S. Surgeon General and the National Academies of Science, Engineering and Medicine have warned about the risks of inhaling secondhand e-cigarette emissions, which are created when an e-cigarette user exhales the chemical cocktail created by e-cigarettes.
• In 2016, the Surgeon General concluded that secondhand emissions contain, "nicotine; ultrafine particles; flavorings such as diacetyl, a chemical linked to serious lung disease; volatile organic compounds such as benzene, which is found in car exhaust; and heavy metals, such as nickel, tin, and lead."
• The Food and Drug Administration has not found any e-cigarette to be safe and effective in helping people who use tobacco products to quit. If people are ready to quit smoking and using other tobacco products for good, they should call 1-800-QUIT NOW or talk with their doctor about finding the best way to quit using proven methods and FDA-approved treatments and counseling.

NAM Report - https://www.nap.edu/resource/24952/012318ecigaretteConclusionsbyEvidence.pdf

Sassano MF, Davis ES, Keating JE, Zorn BT, Kochar TK, Wolfgang MC, et al. (2018) Evaluation of e-liquid toxicity using an open-source high-throughput screening assay. PLoS Biol 16(3): e2003904. https://doi.org/10.1371/journal.pbio.2003904

Ogunwale, Mumiye A et al. (2017) Aldehyde Detection in Electronic Cigarette Aerosols. ACS omega 2(3): 1207-1214. doi: 10.1021/acsomega.6b00489].

Bein K, Leikauf GD. (2011) Acrolein - a pulmonary hazard. Mol Nutr Food Res 55(9):1342-60. doi: 10.1002/mnfr.201100279.

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Home — Essay Samples — Social Issues — Vaping — Argumentative Essay On Vaping

Argumentative Essay on Vaping

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Vaping Devices (Electronic Cigarettes) DrugFacts

What are vaping devices.

Vaping devices are battery-operated devices that people use to inhale an aerosol, which typically contains nicotine (though not always), flavorings, and other chemicals. They can resemble traditional tobacco cigarettes (cig-a-likes) , cigars, or pipes, or even everyday items like pens or USB memory sticks. Other devices, such as those with fillable tanks, may look different. Regardless of their design and appearance, these devices generally operate in a similar manner and are made of similar components. More than 460 different e-cigarette brands are currently on the market. 1

How do vaping devices work?

Most e-cigarettes consist of four different components, including:

• a cartridge or reservoir or pod, which holds a liquid solution ( e-liquid or e-juice ) containing varying amounts of nicotine, flavorings, and other chemicals
• a heating element (atomizer)
• a power source (usually a battery)
• a mouthpiece that the person uses to inhale

In many e-cigarettes, puffing activates the battery-powered heating device, which vaporizes the liquid in the cartridge. The person then inhales the resulting aerosol or vapor (called vaping ).

Vaping Among Teens

Vaping devices are popular among teens and are now the most commonly used form of nicotine among youth in the United States. Some research shows that many teens do not even realize that vaping cartridges contain nicotine, and assume the pods contain only flavoring. The easy availability of these devices, alluring advertisements, various e-liquid flavors, and the belief that they're safer than cigarettes have helped make them appealing to this age group. In addition, they are easy to hide from teachers and parents because they do not leave behind the stench of tobacco cigarettes, and are often disguised as flash drives. Further, a study of high school students found that one in four teens reported using e-cigarettes for dripping, a practice in which people produce and inhale vapors by placing e-liquid drops directly onto heated atomizer coils. Teens reported the following reasons for dripping: to create thicker vapor (63.5 percent), to improve flavors (38.7 percent), and to produce a stronger throat hit—a pleasurable feeling that the vapor creates when it causes the throat to contract (27.7 percent). 2 More research is needed on the risks of this practice.

In addition to the unknown health effects, early evidence suggests that vaping might serve as an introductory product for preteens and teens who then go on to use other nicotine products, including cigarettes, which are known to cause disease and premature death. A study showed that students who had used e-cigarettes by the time they started 9th grade were more likely than others to start smoking cigarettes and other smokable tobacco products within the next year. 3 Another study supports these findings, showing that high school students who used e-cigarettes in the last month were about 7 times more likely to report that they smoked cigarettes when asked approximately 6 months later, as compared to students who said they didn't use e-cigarettes. Notably, the reverse was not true—students who said they smoked cigarettes were no more likely to report use of e-cigarettes when asked approximately 6 months later. Like the previous study, these results suggest that teens using e-cigarettes are at a greater risk for smoking cigarettes in the future. 4 Another study has shown an association between e-cigarette smoking and progression to smoking actual cigarettes. 5 This study suggests that vaping nicotine might actually encourage cigarette smoking in adolescents.

Additionally, a study of adult smokers in Europe found those who vaped nicotine were less like to have stopped smoking than those who did not. Those who used e-cigarettes also smoked more cigarettes than those who didn’t. 6 In another study of more than 800 people who said they vaped to help them quit traditional cigarette smoking, only nine percent reported having quit when asked a year later. 7 However, more research is still needed to understand if experimenting with e-cigarettes leads to regular use of smokable tobacco.

Under U.S. Food and Drug Administration (FDA) regulations designed to protect the health of young Americans, minors can no longer buy e-cigarettes in stores or online (see "Government Regulation of E-cigarettes"). The FDA now regulates the manufacture, import, packaging, labeling, advertising, promotion, sale, and distribution of e-cigarettes. This includes components and parts of e-cigarettes but excludes accessories. 8

Government Regulation of E-cigarettes

In 2016, the FDA established a  rule  for e-cigarettes and their liquid solutions. Because e-cigarettes contain nicotine derived from tobacco, they are now subject to government regulation as tobacco products. In December 2019, the federal government  raised the legal minimum age  of sale of tobacco products from 18 to 21 years, and in January 2020, the FDA issued a  policy  on the sale of flavored vaping cartridges. 

How does vaping affect the brain?

The nicotine in e-liquids is readily absorbed from the lungs into the bloodstream when a person vapes an e-cigarette. Upon entering the blood, nicotine stimulates the adrenal glands to release the hormone epinephrine (adrenaline). Epinephrine stimulates the central nervous system and increases blood pressure, breathing, and heart rate. As with most addictive substances, nicotine activates the brain’s reward circuits and also increases levels of a chemical messenger in the brain called dopamine , which reinforces rewarding behaviors. Pleasure caused by nicotine’s interaction with the reward circuit motivates some people to use nicotine again and again, despite risks to their health and well-being.

What are the health effects of vaping? Is it safer than smoking tobacco cigarettes?

Research so far suggests that vaping devices might be less harmful than combustible cigarettes when people who regularly smoke switch to them as a complete replacement. But nicotine in any form is a highly addictive drug. Research suggests it can even prime the brain’s reward system, putting vapers at risk for addiction to other drugs. 9

Also, e-cigarette use exposes the lungs to a variety of chemicals, including those added to e-liquids, and other chemicals produced during the heating/vaporizing process. 10 A study of some e-cigarette products found the vapor contains known carcinogens and toxic chemicals, as well as potentially toxic metal nanoparticles from the device itself. The study showed that the e-liquids of certain cig-a-like brands contain high levels of nickel and chromium, which may come from the nichrome heating coils of the vaporizing device. Cig-a-likes may also contain low levels of cadmium, a toxic metal also found in cigarette smoke that can cause breathing problems and disease. 11 More research is needed on the health consequences of repeated exposure to these chemicals. There are also reports of lung illnesses and deaths related to inhalation of certain vaping oils into the lungs, which have no way to filter out toxic ingredients.

Reports of Deaths Related to Vaping

The Food and Drug Administration has alerted the public to thousands of reports of serious lung illnesses associated with vaping, including dozens of deaths . They are working with the Centers for Disease Control and Prevention (CDC) to investigate the cause of these illnesses. Many of the suspect products tested by the states or federal health officials have been identified as vaping products containing THC, the main psychotropic ingredient in marijuana. Some of the patients reported a mixture of THC and nicotine; and some reported vaping nicotine alone. While the CDC and FDA continue to investigate possible other contributing substances, CDC has identified a thickening agent—Vitamin E acetate—as a chemical of concern among people with e-cigarette or vaping associated lung injuries. They recommend that people should not use any product containing Vitamin E acetate, or any vaping products containing THC; particularly from informal sources like friends, family, or in-person and online dealers. They also warn against modifying any products purchased in stores, or using any vaping products bought on the street. People, including health professionals, should r eport any adverse effects of vaping products. The CDC has posted an information page for consumers .

Health Effects for Teens

The teen years are critical for brain development, which continues into young adulthood. Young people who use nicotine products in any form, including e-cigarettes, are uniquely at risk for long-lasting effects. Because nicotine affects the development of the brain's reward system, continued nicotine vaping can not only lead to nicotine addiction, but it also can make other drugs such as cocaine and methamphetamine more pleasurable to a teen's developing brain. 12

Nicotine also affects the development of brain circuits that control attention and learning. Other risks include mood disorders and permanent problems with impulse control—failure to fight an urge or impulse that may harm oneself or others. 12

Can vaping help a person quit smoking?

Some people believe e-cigarettes may help lower nicotine cravings in those who are trying to quit smoking. However, e-cigarettes are not an FDA-approved quit aid, and there is no conclusive scientific evidence on the effectiveness of vaping for long-term smoking cessation. It should be noted that there are seven FDA-approved quit aids that are proven safe and can be effective when used as directed.

Vaping nicotine has not been thoroughly evaluated in scientific studies. For now, not enough data exists on the safety of e-cigarettes, how the health effects compare to traditional cigarettes, and if they are helpful for people trying to quit smoking.

Points to Remember

• People vape with battery-operated devices used to inhale an aerosol, which can contain nicotine, marijuana, flavorings, and other chemicals. In many e-cigarettes, puffing activates the battery-powered heating device, which vaporizes the liquid in the cartridge or reservoir. The person then inhales the resulting aerosol or vapor (called vaping ).
• Vaping is popular among teens. Under U.S. Food and Drug Administration (FDA) regulations designed to protect the health of young Americans, minors can no longer buy e-cigarettes in stores or online.
• Nicotine stimulates the adrenal glands to release the hormone epinephrine (adrenaline) and increases the levels of a chemical messenger in the brain called dopamine . Pleasure caused by nicotine’s interaction with the brain’s reward system motivates some people to use nicotine again and again, despite possible risks to their health and well-being.
• Research so far suggests that vaping is less harmful than combustible cigarettes when people who regularly smoke switch to them as a complete replacement. But e-cigarettes can still damage a person's health.
• Vaping can lead to nicotine addiction and increased risk for addiction to other drugs.
• Vaping also exposes the lungs to a variety of chemicals, including those added to e-liquids, and other chemicals produced during the heating/vaporizing process.
• More research is needed to determine if vaping nicotine can be as effective as smoking cessation aids already approved by the FDA.

For more information about e-cigarettes, visit:

• NIH-funded study finds teens prefer mint and mango vaping flavors (Science Spotlight, November 2019)
• NIDA Live: The Science of Vaping (30:19)  (September 2019)
• NIDA TV Spotlight on Electronic Cigarettes  
• A NIDA Science Spotlight on the association between e-cigarette use and future tobacco cigarette use
• the FDA's webpage, Vaporizers, E-Cigarettes, and other Electronic Nicotine Delivery Systems (ENDS)
• the website, Know the Risks: E-cigarettes & Young People , based on the U.S. Surgeon General's Report on e-cigarette use among youth and young adults; includes various resources such as a parent tip sheet, healthcare provider conversation card, and FAQs
• Notes from the Field: Use of Electronic Cigarettes and Any Tobacco Product Among Middle and High School Students — United States, 2011–2018 (MMRW)  (CDC, November 2018)
• E-Cigarette, or Vaping, Products Visual Dictionary  (CDC)
• Zhu S-H, Sun JY, Bonnevie E, et al. Four hundred and sixty brands of e-cigarettes and counting: Implications for product regulation. Tob Control. 2014;23 Suppl 3:iii3-iii9. doi:10.1136/tobaccocontrol-2014-051670
• Krishnan-Sarin S, Morean M, Kong G, et al. E-Cigarettes and “dripping” among high-school youth. Pediatrics. 2017; 139(3). doi: https://doi.org/10.1542/peds.2016-3224
• Leventhal AM, Strong DR, Kirkpatrick MG, et al. Association of electronic cigarette use with initiation of combustible tobacco product smoking in early adolescence. JAMA. 2015;314(7):700-707. doi:10.1001/jama.2015.8950
• Bold KW, Kong G, Camenga DR, et al. Trajectories of e-cigarette and conventional cigarette use among youth. Pediatrics. December 2017:e20171832. doi:10.1542/peds.2017-1832
• Chaffee BW, Watkins SL, Glantz SA. Electronic cigarette use and progression from experimentation to established smoking. Pediatrics. March 2018:e20173594. doi:10.1542/peds.2017-3594
• Kulik MC, Lisha NE, Glantz SA. E-cigarettes associated with depressed smoking cessation: A cross-sectional study of 28 European Union countries. Am J Prev Med. 2018;54(4):603-609. doi:10.1016/j.amepre.2017.12.017
• Weaver SR, Huang J, Pechacek TF, Heath JW, Ashley DL, Eriksen MP. Are electronic nicotine delivery systems helping cigarette smokers quit? Evidence from a prospective cohort study of U.S. adult smokers, 2015–2016. PLOS ONE. 2018;13(7):e0198047. doi:10.1371/journal.pone.0198047
• Products C for T. Products, Ingredients & Components - Vaporizers, E-Cigarettes, and other Electronic Nicotine Delivery Systems (ENDS). https://www.fda.gov/TobaccoProducts/Labeling/ProductsIngredientsComponents/ucm456610.htm . Accessed April 17, 2017.
• Levine A, Huang Y, Drisaldi B, et al. Molecular mechanism for a gateway drug: Epigenetic changes initiated by nicotine prime gene expression by cocaine. Sci Transl Med. 2011;3(107):107ra109. doi:10.1126/scitranslmed.3003062
• Sleiman M, Logue JM, Montesinos VN, et al. Emissions from electronic cigarettes: Key parameters affecting the release of harmful chemicals. Environ Sci Technol. 2016;50(17):9644-9651. doi:10.1021/acs.est.6b01741
• Hess CA, Olmedo P, Navas-Acien A, Goessler W, Cohen JE, Rule AM. E-cigarettes as a source of toxic and potentially carcinogenic metals. Environ Res. 2017;152:221-225. doi:10.1016/j.envres.2016.09.026
• U.S. Department of Health, and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease, Prevention and Health Promotion, Office on Smoking and Health. E-Cigarette Use Among Youth And Young Adults: A Report of the Surgeon General — Executive Summary. ; 2016. https://e-cigarettes.surgeongeneral.gov/documents/2016_SGR_Exec_Summ_508.pdf . Accessed February 21, 2017.

This publication is available for your use and may be reproduced in its entirety without permission from NIDA. Citation of the source is appreciated, using the following language: Source: National Institute on Drug Abuse; National Institutes of Health; U.S. Department of Health and Human Services.

Discussion: Vaping and E-Cigarettes Essay

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Electronic nicotine delivery systems cause the same harm to the human body as other tobacco products. Plus, polyhydric alcohol solvents kill cell membranes. All this can lead to severe illnesses. If the main harmful effect of conventional cigarettes comes from tar and combustion products, here it comes from solvents (Dinardo & Rome, 2019; National Institute on Drug Abuse (NIDA/NIH), 2018). It is severe harm to health, so creeping because not only the membranes and cells of the lungs are dissolved, but also the brain and heart.

In 2019, the discussion about the negative impact of vaping on health intensified in the United States. In August of that year, the Illinois Department of Public Health reported what was believed to be the first death in the country due to a severe respiratory illness dubbed EVALI. This acronym stands for lung injury associated with the use of e-cigarettes or vaping products. By the end of the year, doctors were already talking about almost forty dead (Irusa et al., 2020). In total, the country’s authorities have identified several thousand cases of such diseases. The age of the dead varies from 17 to 75 years.

Consequently, e-cigarettes must be subject to laws governing the sale and distribution of traditional tobacco products. Making them available to young people is dangerous for the reasons mentioned above. The absence of tar and an unpleasant odor is the only external differences between a regular cigarette and a vape, while in reality, all the harm is contained within the composition of the products themselves and the inhaled vapor (Kennedy et al., 2022). Sales should also be restricted in some cases to persons over the age of 18. As smoking can affect the lungs and some other chronic diseases, the damage to health is already proven and evident. At the legislative level, it is recommended that people be able to buy a vape only if, after a medical examination, the doctor concludes based on which the risks of illness from vaping will be reduced. According to the certificates, electronic cigarettes will be sold, reducing their consumption.

Dinardo, P., & Rome, E. S. (2019). Vaping: The new wave of nicotine addiction . Cleveland Clinic Journal of Medicine, 86 (12), 789-798. Web.

Irusa, K. F., Vence, B., & Donovan, T. (2020). Potential oral health effects of e‐cigarettes and vaping: A review and case reports . Journal of Esthetic and Restorative Dentistry, 32 (3), 260-264. Web.

Kennedy, V. Jendian, M. A. & Norwood, R. (2022). Think Critical Thinking About Social Problems . Kendall Hunt Publishing.

National Institute on Drug Abuse (NIDA/NIH). (2018). Why Teens are Attracted to Vaping [Video]. YouTube. Web.

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A toxic, plastic problem: E-cigarette waste and the environment

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Tobacco and the environment

3 ways JUUL harms the environment

Vaping, still at epidemic levels among youth with about one in five high school students using e-cigarettes in 2020, generates a significant amount of toxic and plastic waste. Many popular e-cigarettes, like JUUL, are pod-based with single-use plastic cartridges containing nicotine. Generating even more waste are disposable e-cigarettes like Puff Bar, which are designed entirely for one-time use and have skyrocketed in popularity with a 1,000% increase in use among high school students between 2019 and 2020.

With a 399.73% increase in retail e-cigarette sales (excluding internet sales and tobacco-specialty stores) from 2015 through 2020, the environmental consequences of e-cigarette waste are enormous. Instead of taking responsibility for the disposal of their products, tobacco companies engage in clean-up initiatives designed to make them appear “green” — just one of many tactics designed to overhaul their reputations (read the Truth Initiative report “ Seeing Through Big Tobacco’s Spin ”).

Almost half (49.1%) of young people don’t know what to do with used e-cigarette pods and disposable devices.

More than half (51%) of young e-cigarette users reported disposing of used e-cigarette pods or empty disposables in the trash, 17% in a regular recycling bin not designed for e-cigarette waste, and 10% reported they simply throw them on the ground, according to Truth Initiative research conducted in 2020. Almost half (49.1%) of young people don’t know what to do with used e-cigarette pods and disposable devices.

Their actions should come as no surprise as e-cigarette manufacturers fail to provide consumers with guidance or take responsibility for appropriate disposal methods. In a separate study conducted by Truth Initiative in 2019, almost half (46.9%) of e-cigarette device owners said that the e-cigarette device they used currently did not provide any disposal information, such as where to send used batteries or empty pods. Additionally, when e-cigarette device owners were asked about e-cigarette waste disposal, the majority (73.7%) believed that it was difficult to find e-cigarette drop off sites.

How e-cigarette waste hurts the environment

E-cigarettes not only pose substantial health risks to youth and young adults, they pose a significant environmental threat (see the Truth Initiative fact sheet on Tobacco and the Environment ).

E-cigarette waste is potentially a more serious environmental threat than cigarette butts since e-cigarettes introduce plastic, nicotine salts, heavy metals, lead, mercury, and flammable lithium-ion batteries into waterways, soil, and to wildlife.

Unlike cigarette butts, e-cigarette waste won’t biodegrade even under severe conditions. E-cigarettes left on the street eventually break down into microplastics and chemicals that flow into the storm drains to pollute our waterways and wildlife.

DISPOSING OF USED E-CIGARETTES AND ACCESSORIES

How do you recycle a juul.

Many young e-cigarette users reported throwing away, improperly recycling, or littering the devices. Only 15% of young e-cigarette users reported disposing of empty pods or disposable vapes by dropping them off or sending them for electronic recycling.

According to a survey conducted from February to June 2020, e-cigarette users reported how they disposed of empty pods, disposable e-cigarettes, batteries or other vape pieces:

• More than half of respondents (51%) said that they throw empty pods or empty disposable vapes in the regular trash
• 17% of young people disposed of empty pods and disposable vapes by putting them in regular recycling not designed for e-cigarette waste
• 10% disposed of used pods or disposable vapes by littering on the ground.

Respondents also reported keeping or selling the devices, or returning them to a vape shop.

YOUNG PEOPLE UNDERSTAND THE NEGATIVE ENVIRONMENTAL IMPACT OF E-CIGARETTE WASTE

Are e-cigarettes bad for the environtment.

In a separate study conducted in October 2019, researchers found that young people clearly understand that e-cigarette waste is bad for the environment. The majority of respondents between 15-34 recognized that empty e-cigarettes, pods, cartridges and refills are litter (86.9%) and that e-cigarettes are not biodegradable (65.7%). They also recognized the danger of throwing e-cigarette waste in the trash (75.8%). Most respondents acknowledged that e-cigarettes and related materials contain substances that are toxic to humans (84.1%) and harmful to animals (89.8%)

Young respondents clearly recognized the dangers of e-cigarette waste to humans and the environment and want an appropriate method to recycle. Of the 544 young people who owned e-cigarette devices, 75.7% said that they considered recycling e-cigarettes.

E-CIGARETTE USERS THEMSELVES ARE LESS AWARE OF ENVIRONMENTAL IMPACT OF LITTERING

Is juul bad for the environment.

Even though the majority of survey participants knew about the dangers to the environment presented by e-cigarettes, those who had vaped at least once were significantly less informed about the environmental impact of littering e-cigarettes than those who had never vaped. The 966 respondents who had never vaped more often believed that e-cigarette waste was dangerous to throw in trash compared to the 1,083 respondents who had vaped at least once (81.4% vs. 71%). Fewer of those who had vaped at least once (79.3%) believed that e-cigarettes contained toxic substances compared to those who had never vaped (89.6%).

MANY UNAWARE OF HOW TO BEST DISPOSE OF E-CIGARETTE WASTE

How do you dispose of a juul.

Many of those who vape were likely to report issues that kept them from being able to safely dispose of their used and empty e-cigarette products. Of e-cigarette device owners, the majority (73.7%) believed that it was difficult to find e-cigarette drop off sites and almost half (46.9%) said that the e-cigarette device they used currently did not provide any disposal information such as where to send used batteries or empty pods. More than half (57.8%) of those who had used e-cigarettes in the past month found it inconvenient to dispose of e-cigarette waste responsibly.

How to safely dispose of e-cigarettes

Safely disposing of e-cigarettes involves handling the batteries and e-cigarettes appropriately. To dispose of e-cigarettes:

• local waste departments about their household hazardous waste (HHW) program to see if they accept e-cigarettes.
• If HHW is not an option, remove the battery (if possible) and bring the battery to recycling. After the battery has been removed, bring the rest of the e-cigarette to DEA take-back days (see: E-CIGARETTE MANUFACTURERS FAIL TO PROVIDE USERS’ DISPOSAL INFORMATION).

E-CIGARETTE MANUFACTURERS FAIL TO PROVIDE USERS’ DISPOSAL INFORMATION

Can you throw away a juul in the trash.

E-cigarette manufacturers introduced a new tobacco product that soared in popularity with little thought on how to responsibly dispose of the resulting tons of e-cigarette waste. Unlike other electronics, e-cigarette manufacturers do not provide consumers with clear instructions on how to properly handle e-cigarette waste once the e-cigarette or its accessories reaches the “end of life.” They leave the onus of figuring out how to safely dispose of e-cigarettes to the consumer.

Currently, there is no standardized way to recycle e-cigarettes in the U.S. Starting in 2019, the Drug Enforcement Agency (DEA) began accepting e-cigarette devices and cartridges during their annual National Prescription Take Back Day, although the DEA cannot accept devices containing lithium ion batteries. There are also no documented baseline standards for end-of-life disposal by manufacturers, and no requirement in place to hold manufacturers accountable for the post-consumer waste they helped produce or to devise a clear and safe system to dispose of these items as hazardous materials or electronic waste. Guidance exists on best practices on this concept of accountability — known as end-producer responsibility — but isn’t enforced across the industry by any governing body.

Unlike other electronics, e-cigarette manufacturers do not provide consumers with clear instructions on how to properly handle e-cigarette waste once the e-cigarette or its accessories reaches the “end of life.”

PR INSTEAD OF PROBLEM-SOLVING

Can you throw away an e-cigarette.

Instead of accepting responsibility for their product, tobacco companies are using the environmental problems associated with tobacco products as a ploy for positive press attention. Some tobacco companies have included reducing the amount of cigarette butts in the environment as part of their sustainability goals . For example, American Spirit continues its “inspirational” themed environmental messaging in 2021 with a new “Stronger Together” slogan that describes American Spirit and their fans as “stronger together” when working to protect the environment and reaffirms their goal to help recycle a half-billion cigarette butts by 2025. Philip Morris International (PMI) — the makers of Marlboro — claims it wants to reduce plastic litter from its products by 50% from 2021 to 2025 as part of its “Our World Is Not an Ashtray” initiative. Notwithstanding that filters — which are made of plastic — make it easier to smoke, to inhale more deeply, and convince smokers that they are using a “safer” cigarette when in fact smoking filtered cigarettes provides no health protection and may lead to an increased risk of adenocarcinoma of the lung.

PMI also touts clean-up efforts but these efforts barely make a dent in the vast amounts of tobacco litter, given that with up to two-thirds of every smoked cigarette discarded onto the ground, 340 and 680 million kilograms of waste tobacco product litter the world each year. The sheer volume of e-cigarette waste that is created in a year can be estimated by looking at national sales data. Data collected by the CDC Foundation capturing units of e-cigarette sales per month between 2016-2020 showed over 201 million new devices in the US in 2020. Because proper disposal of components and hazardous waste is not easily accessible to the average consumer, this could potentially translate into 201 million pieces of plastic, aluminum, lithium ion, and packaging that ends up in landfill as a result. But more importantly, campaigns like “Our World is Not an Ashtray” are hypocritical at best and deeply misleading to the public. The tobacco industry not only created this new waste stream in the first place, they seem to be trying to cover-up their harmful practices through misdirection and public displays of eco-activism.

ADDRESSING E-CIGARETTE WASTE POLLUTION

E-cigarette pollution.

There is an urgent, overdue need for standardized processes for the disposal of e-cigarette devices, refills and e-liquids. Waste management and hazardous waste disposal plants are not currently equipped to handle e-cigarette waste and federal regulations still have not caught up to the need for guidance on disposal of these types of small electronics containing toxic waste. Federal, state, and/or local governments need to set clear standards on environmentally responsible e-cigarette waste disposal and hold the industry accountable for adhering to them.

There is an urgent, overdue need for standardized processes for the disposal of e-cigarette devices, refills and e-liquids.

NEED FOR INDUSTRY ACCOUNTABILITY

What is being done about e-cigarette pollution.

• The tobacco industry must accept responsibility for e-cigarette waste. The tobacco industry is responsible for producing much more than tobacco products — they are guilty of creating hundreds of thousands of pounds of e-cigarette waste, which presents serious threats to the ecosystem and require a long-term solution. The tobacco industry needs to facilitate the environmentally safe disposal of their products.
• Public awareness of hypocritical tobacco company-sponsored “clean-ups.” The public needs to know that green initiatives sponsored by the tobacco industry are a smokescreen to distract from culpability for creating tobacco waste in the first place.
• E-cigarette manufacturers need to better inform e-cigarette users of the environmental impact of littering e-cigarettes, since those who had vaped at least once were less aware of the environmental impact of littering e-cigarettes compared to those who had never vaped.

Increasing consumer awareness of the environmental toxicity and dangers posed by discarding e-cigarette waste into landfills and encouraging vapers to quit are the best ways to protect the environment from tobacco product waste.

SURVEY METHODOLOGIES

E-cigarette Brand Tracking Survey (October 2019): Truth Initiative conducted a survey on e-cigarette littering awareness and intentions of 2,049 youth and young adults (age 15-34) to better understand perceptions of environmental impact of e-cigarette waste. Survey respondents included non-smokers, smokers of traditional tobacco products, as well as e-cigarette users.

Media Monitoring Survey (February – June 2020): Truth Initiative collected data on e-cigarette disposal methods over a 17-week period from 3,757 youth and young adults (age 15-24). The survey included a section on e-cigarette waste disposal knowledge and beliefs.

More in harmful effects of tobacco

Nearly half of all cancer deaths in the U.S. are preventable — and smoking is a leading risk factor

Not-so-disposable e-cigarettes: Young people grapple with e-cigarette waste amid lack of safe disposal options

Secondhand smoke and secondhand aerosol

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Immunology & Microbiology

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E-Cigarettes Disrupt Nasal Microbiome, Study Finds

Research reveals that smoking and e-cigarette use disrupt the nasal microbiome..

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The nose plays more roles that just allowing us to smell and shaping our facial profiles. It also acts as a gatekeeper for the respiratory tract, capable of preventing bacteria and other pathogens from leaving the nasal passage and taking residence in the lungs.   

Similar to the microbiome in the gastrointestinal tract and the skin, the precious balance between beneficial bacterial, fungal, and viral colonies in the nose can be disrupted. This imbalance, termed dysbiosis, can lead to an overgrowth of harmful bacteria and predispose people to respiratory diseases, such as chronic obstructive pulmonary disease and asthma.  

Elise Hickman, PhD, a former student in the lab of inhalation toxicologist  Ilona Jaspers, PhD , director of the  UNC Center for Environmental Medicine, Asthma, and Lung Biology  at the UNC School of Medicine, discovered that e-cigarette and cigarette use can cause an imbalance in the nasal microbiome. Their research,  published in  Nicotine & Tobacco Research , could be important in understanding the immunological implications of vaping and smoking.  

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“We found that the composition of the nasal microbiome varies depending on sex, e-cigarette versus cigarette use, and how much of a nicotine biomarker is found in the blood,” said Hickman, who is now a postdoctoral researcher at the  Department of E nvironmental Sciences and Engineering  at the  UNC Gillings School of Public Health . “Our findings warrant further investigation into why and how e-cigarette use dysregulates the immune system in the nasal microbiome and causes imbalance in the respiratory microbiome.”

The Jaspers lab’s  previous research  showed that e-cigarette use can affect the daily operations of the immune system in the nose and make one more susceptible to viral infections like influenza. Knowing that the respiratory microbiome supports respiratory immune defense, Hickman and Jaspers wanted to know if dysbiosis in the nasal microbiome, which is often related to lower airway disease, could be caused by e-cigarette or cigarette use.  

Teaming up with  Matt Wolfgang, PhD , and Cristian Roca from the  Marsico Lung Institute/UNC Cystic Fibrosis Center , Hickman and Jaspers  collected  and analyzed  nasal epithelial lining fluid samples from 20 non-smokers, 28 e-cigarette users, and 19 smokers. They then used genetic sequencing to identify the type and quantity of bacteria in the nasal microbiome.   

Researchers identified different bacteria, some harmful and some protective, depending on whether people used e-cigarettes, smoked regular cigarettes, or neither.  Staphylococcus aureus , a bacterium that can cause pneumonia and other life-threatening infections, was found in greater number in both e-cigarette users and smokers compared to non-smokers.  Lactobacillus iners  – a beneficial bacterium that can protect against respiratory disease – was found more often in smokers than non-smokers.

Surprisingly, researchers found that there were differences in the microbiomes of male and female e-cigarette users. Hickman and Jaspers also found that there were differences in nasal bacteria between people who had high and low levels of cotinine, a metabolite and indicator of nicotine exposure.   

“Taken together, our data identified unique, sex-dependent host immune dysfunction associated with e-cigarette use in the nasal mucosa,” said Jaspers, who is also a  UNC Lineberger Comprehensive Cancer  Center member researching inhaled toxicants and their effects on the respiratory mucosa.  

This research adds to the increasing number of studies demonstrating respiratory health effects associated with e-cigarette use. Considering that there is a growing body of research showing that changes in the nasal microbiome can be related to lung disease and health, dysbiosis in the balance of harmful and protective bacteria in the nose of e-cigarette users should be of concern.   

Reference:  Hickman E, Roca C, Zorn BT, et al. E-cigarette use, cigarette smoking, and sex are associated with nasal microbiome dysbiosis. Nicotine Tobacco Res . Published online July 17, 2024:ntae176. doi:  10.1093/ntr/ntae176

This article has been republished from the following materials . Note: material may have been edited for length and content. For further information, please contact the cited source. Our press release publishing policy can be accessed here .

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Labels that warn about the health harms of smoking, such as this one from the United States, vary across the world. US labels have not changed for many years.

Q&A — Health communications researcher Lucy Popova

The tussle over cigarette warning labels, and the hazy future of vaping

Regulatory hurdles, industry objections and legal fights have gone on for decades over traditional tobacco. What’s in store for the next generation of smoking?

By Clare Watson 08.21.2024

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In 1966, the first warning label appeared on the side of cigarette packs in the United States. Stating “Caution: Cigarette Smoking May Be Hazardous to Your Health,” it was also the first such warning for tobacco in the world. The message had been watered down from what was originally proposed, due to much political pressure from the tobacco industry, and the labels haven’t changed much since; they were last updated in 1984. New, more graphic designs created in 2020 have not yet been released, held up by legal challenges.

Many other countries have gone on to add graphic, full-color warning images, for instance of decaying teeth , gangrenous toes and patients dying of lung cancer, to cigarette packets, as well as explicit statements around the negative health effects. Countries have also enlarged those labels so they now mostly cover cigarette packs, added toll-free quit-line numbers to connect smokers to support services, and moved to plain, branding-free packaging . In April, Canada became the first country to put health warnings on individual cigarettes.

Despite these warning disparities, smoking rates have steadily dropped around the world since the 1990s due to a raft of tobacco control policies — not just warning labels but other measures too, such as tobacco taxes and bans on smoking indoors or in public places. As recently as 2021, 11.5 percent of Americans aged 18 and older smoked cigarettes, as well as 11 percent of Canadians aged 15 and older. It’s difficult for researchers to disentangle the real-world effects of cigarette warning labels because tobacco-control policies are often introduced as a whole package.

Over the last decade or so, a new public health challenge has emerged: e-cigarettes. Marketed as tools to help smokers quit, these devices aerosolize often-flavored liquids along with nicotine. Evidence around the short- and long-term health effects of vaping is still evolving but, concerningly, data suggest that youth who vape are more likely to start smoking . More than 40 countries have banned the sale of e-cigarettes, and many more restrict their use and regulate sales, especially to minors.

So far, the only warning labels introduced for e-cigarettes warn of nicotine’s addictiveness. But increasing e-cigarette use has health-policy analysts, behavioral scientists , epidemiologists and communications researchers asking whether warning labels could help to curb vaping.

To learn how effective cigarette warning labels have been in helping to reduce smoking, and what measures are likely needed to curb the epidemic of youth vaping , Knowable Magazine spoke with health communications researcher Lucy Popova of Georgia State University, coauthor of an article about warning labels in the 2024 Annual Review of Public Health . This conversation has been edited for length and clarity.

Let’s start by talking about cigarette warning labels. Why does the US lag so far behind the rest of the world in its implementation of stronger, larger warning labels for cigarettes?

Originally, the US did try to go for the most striking images, like the rest of the world. This is how warning labels work. You show alarming pictures depicting the health harms of cigarettes on the packs, and smokers are more likely to notice them, think about them and remember them.

But a legal saga that’s been going on since 2009 has delayed their implementation in the US. In 2009, Congress gave the US Food and Drug Administration a directive to create pictorial warnings for cigarettes. Those were supposed to come into effect in 2012, but tobacco companies sued. In one case, the judge ruled that pictorial warnings weren’t purely factual; that the images were emotional, and people could misinterpret their meaning.

Graphic warning labels are designed to communicate information in a memorable way, and you cannot divorce information and emotion when you talk about smoking causing cancer. Still, the FDA agreed and said they would come up with more factual pictures. It took them eight years, but in 2020 they finally did. Those new warnings, a set of 11 labels, were slated to appear on cigarette packs in 2021, but again, tobacco companies sued, arguing that the First Amendment means the US government cannot compel companies to say things they don’t want to say.

In March this year, the 5th Circuit Court of Appeals concluded that the FDA’s labels are, in fact, consistent with the First Amendment and can be mandated. These labels include colorful images showing the harms of smoking, and would bring the US in line with many other countries.

But when the new labels will appear on cigarette packs is uncertain. There are a few pending legal claims that the court still needs to decide on, and the eventual rulings will likely be appealed. So we’re still in the same holding pattern to see if cigarette warnings will finally be updated in the US for the first time in 40 years.

Cigarette warning labels in the United States have not changed since 1984. Legal challenges by the tobacco industry have held up the implementation of new graphic designs created in 2020, shown here, but a recent court ruling may bring their rollout closer.

CREDIT: FDA.GOV

What about other countries? Has the tobacco industry had the same influence there?

Basically, any efforts to strengthen cigarette warning labels have been met with legal challenges from the tobacco industry. So far, most countries have succeeded in defeating those challenges. Unfortunately, even the threat of legal action creates delays, because lawmakers might take longer to prepare their policies to make sure those policies can withstand challenges in court. That was the case with the FDA; that’s why they took eight years to come up with a second set of warning labels. In the meantime, tobacco companies continue selling their products.

What evidence do we have that warning labels actually work to deter smokers or curb smoking rates?

There’s quite a substantial body of evidence, ranging from lab studies to observational, population-level studies. Lab studies are controlled experiments that randomize people into groups and show them different warnings, or give smokers cigarette packs with or without warning labels. If we see a difference between the groups, we can be quite confident in attributing this difference to our intervention, the warning labels, because people are randomized.

What’s missing from those studies, however, is how those labels impact behavior in the real world.

We do have a lot of studies, though, where researchers looked at the effects of policy changes . So when countries such as Canada introduce larger or more colorful warning labels and other countries like the US don’t, we can do cross-country comparisons and find that, yes, indeed, warning labels work — in most cases.

Occasionally, those studies don’t find effects . But as a whole, research shows that when smokers see cigarette warning labels, they think more about harms, perceive cigarettes as more harmful, think more about quitting, and it does change behavior; they do try to quit. Or, they might put out a cigarette earlier because they’re looking at the pack and thinking, “I’m damaging my lungs right now.” And that can eventually lead to smoking cessation.

New warning labels on cigarette packs and individual cigarettes in Canada. They began coming into effect in 2024, for king-size cigarettes. The rollout will continue in 2025.

It’s much harder to find data on initiation rates, on people who would’ve otherwise started smoking but didn’t. And it’s hard to argue that the reductions we see in smoking rates is because of warning labels. Countries usually pass a whole package of policies — not just warning labels: increasing taxes and strengthening policies on smoke-free places at the same time. They might run education campaigns about how harmful smoking is. Or individual provinces in Canada, for example, passed their own laws to ban flavors such as menthol before the federal government did. And you do see smoking rates going down but you don’t know what measures were the cause. In total, the evidence indicates warnings on cigarette packs are effective when used with other policies, and all the policies working together is definitely better than one.

What happens to the effect of warning labels over time? Does their effect wane and if so, what have countries done to counteract this?

It definitely does wane. People get desensitized. You see an image again and again, and after a while, it no longer bothers you. So countries develop whole series of graphic warnings and the World Health Organization recommends rotating them. But tobacco companies argue that they can’t rotate them quickly, that it’s not economical to change their packaging.

Confronting people with scary images about health harms isn’t the only way warning labels work, though. Putting large warning labels on cigarette packs also makes the product less attractive. Some countries, such as Turkey, Benin and Nepal, have warnings that cover 90 percent or more of cigarette packs. So from the standpoint of making the pack less appealing, bigger warnings do serve that purpose.

In the case of Canada adding warnings on individual cigarettes , the idea is to keep reminding smokers each time they pull out a cigarette of the harms of smoking. The more exposures you have to the message, the more it’s going to sink in.

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If countries have to keep revising their warning labels so they remain effective, will this continue until warning labels cover practically the whole pack and every cigarette? Will warning labels eventually reach their limit — and what happens then?

That’s why warning labels are just one of the many policies that work towards what scientists and policymakers call “ the end game ” — that is, having less than 5 percent of all groups and the population smoking tobacco. Warning labels are not the only thing that’s going to get us there; it’s a bunch of other policies.

New Zealand, for example, passed laws in 2022 to raise the legal purchasing age of cigarettes annually, which would have led to the first smoke-free generation. Those laws were meant to take effect in 2027 and the age limit would have risen each year so that some people simply never reach the age where they can legally buy cigarettes, and after a time, it becomes illegal for everyone. But the new government repealed those laws earlier this year. The UK passed a similar bill in April 2024.

New Zealand was also looking at reducing the amount of nicotine in cigarettes to non-addictive levels so it’s easier for people to quit and harder for them to get addicted. That would have been quite a game-changer, and we’ll see if that happens in other countries. The US has been considering this policy; it’s been on the FDA’s docket for two years.

Again, cigarette warning labels will help along the way. They de-normalize tobacco, reminding people of the long-term health effects and that this is not a safe product — it kills half the people who don’t quit.

What does the history of cigarette warning labels tell us about health warnings for e-cigarettes? What are the challenges you foresee there?

In the 1960s, when the first cigarette warning labels were introduced in the US, we had a really big body of evidence showing all the negative health effects of cigarettes, such as the fact that smoking causes cancer. And even then, with all that evidence, we weren’t able to put strong messaging on the packs.

The first health warning on a cigarette pack was rolled out in 1966, in the United States. In this historic photo, Dr. Daniel Horn, director of the Public Health Service’s National Clearinghouse for Smoking and Health, shows off the new warning. Horn’s research had linked cigarette use to cancer.

CREDIT: BETTMANN / GETTY IMAGES

With e-cigarettes, because they’ve been around for only a short time, we don’t have this overwhelming body of evidence showing their negative health effects. We know they irritate the lungs and affect the cardiovascular system, and that they contain nicotine and harmful chemicals — sometimes at higher levels than in cigarettes.

Most countries — probably with one eye towards potential legal challenges — have so far put warnings on e-cigarettes that just deal with the nicotine, informing people that these products contain nicotine and nicotine is addictive. We haven’t seen much resistance from tobacco companies about the warning labels on e-cigarettes, mostly because it’s hard to come up with something more benign than “nicotine is an addictive chemical.”

Communicating addiction is much harder than communicating about harms, because people don’t think it applies to them. Most people, when they start smoking, think they are only going to smoke a bit. Our research shows that people generally recognize the harms of smoking and appreciate they might get cancer. But when you ask them about addiction , they say, “I’m not going to get addicted. I’m the one in control.” So this warning, that e-cigarettes contain nicotine and it’s addictive, doesn’t dissuade people from vaping. And that’s partly why we haven’t seen much pushback from tobacco companies.

One of the other challenges is the debate over whether we should be careful in communicating about the harms of e-cigarettes because e-cigarettes might be an “off-ramp” for adult smokers who cannot otherwise quit, helping them switch to less harmful products. But from what we’ve seen so far, e-cigarettes have had such an oversized impact on youths , as opposed to helping smokers quit.

Statistics from the United States’ National Youth Tobacco Survey from 2023. Vaping and other tobacco use decreased from 2022-2023 among high school students, but a similar decrease was not observed among middle-school students. Overall, 7.7 percent of youth (2.13 million) use e-cigarettes.

Some smokers do switch to e-cigarettes and that might be good for them, but a lot don’t, and many people become dual users. Researchers find that in controlled lab studies , e-cigarettes help smokers quit, but this is a tightly controlled environment where smokers also get behavioral therapy and receive support.

In the real world, most studies show that e-cigarettes don’t help people quit smoking . And now we’re faced with this epidemic of kids vaping. With e-cigarettes, people just carry them in their pocket, they use them all the time, and that creates way higher levels of addiction. So some people find them harder to quit than cigarettes.

Another challenge is lobbying. Tobacco companies tell governments e-cigarettes help smokers quit — even though none of them applied for that approval pathway, in the US at least. In the US, companies can apply for any product to be considered a smoking cessation tool if they can show evidence that they do in fact help in that way. But despite the industry’s lobbying messages, no company has gone down that route yet.

Can warning labels on vapes really be effective if we don’t fully know what the long-term health impacts are?

As the evidence evolves, governments, guided by health advisory bodies, will have to decide at what point we have enough information to put warning labels on e-cigarettes, about specific health effects. And they might not even be needed. Research shows messaging about harmful chemicals in a product is very effective too, because people are really good at connecting the dots. When they hear about harmful chemicals in e-cigarettes — like formaldehyde — they jump straight to thinking it’s going to badly affect them, and they don’t want to use those products. So that might be the way to move forward with more effective warnings earlier on.

But there are so many ways to address the problem of youth e-cigarette use. The US has mostly been running educational campaigns, such as the Real Cost campaign . When we talk to kids in our studies , they tell us they see those ads, they remember them, and they recognize vaping has all these harms. So warning labels aren’t the only thing that will work.

And from a cost-benefit perspective, it takes a lot of effort to put a new warning label on a product. It’s definitely worth doing, but at the same time, resources might be better spent on very effective educational campaigns.

This short video from the FDA’s Real Cost Campaign aims to deter youth from vaping by informing them that cigarettes contain formaldehyde.

CREDIT: THE REAL COST

Are you optimistic that these policies, educational campaigns and possibly warning labels for e-cigarettes, will work?

It’s easy to be pessimistic when you see the resistance from the tobacco industry to public health policies. But at the same time, you have to remember how far we’ve come. I remember people smoking on airplanes, when smoking was much more accepted, whereas today smoking rates are under 10 percent in countries such as Australia , Peru and Sweden . So we are getting there. The tobacco industry is not going away; it will probably morph into something else. But I am optimistic that smoking rates will continue to drop.

As for e-cigarettes, the future will show us how effective policies are.

If you were in charge, what strategies aside from warning labels would you recommend to reduce the harms of vaping?

One thing is to actually regulate the production, distribution and sales of e-cigarettes, because we don’t know what’s in them. And getting rid of all the flavored tobacco, and flavored e-cigarettes , that would be a big step. If there were no flavors, there would be a lot less smoking and vaping.

We could also use influencers on social media to promote being tobacco-free, in the same way that tobacco companies have used influencers to promote their products. We know that works; they influence kids. We need to stay one step ahead of the tobacco industry on e-cigarettes — or, at least, not fall too far behind.

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The BMA is urging the UK government to stop a “growing epidemic of vape use in the UK” by tightening regulations of e-cigarette products and restricting access to them. The association is concerned about increased vaping rates, particularly among children and young people and those who have never smoked tobacco.

Some 7.6% of 11-17 year olds are now vaping either regularly or occasionally, up from 1.3% in 2014, and 11% of adults in Great Britain currently use vapes, up from 4.2% in 2014. 1

In the king’s speech last month the new Labour government reintroduced a bill aimed at tackling smoking and youth vaping, but it has not given details of any …

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With 1 in 10 High School Youth Using E-Cigarettes, New Campaign Empowers Parents to Start the Conversation Early to Protect Their Kids

As students go back to school, the american lung association and the ad council inspire parents to talk to their kids about the risks of vaping.

NEW YORK, NY (AUGUST 27, 2024) – Today, the American Lung Association and the Ad Council are launching a new national campaign to help parents of kids 10-14 years old understand that they‘re the best person to talk to their children about the dangers of vaping. The campaign includes "You're The Best Person” creative assets in broadcast, radio, digital, social, out-of-home and print, developed pro bono by creative agency Hill Holliday.

According to the American Lung Association, 2.1 million kids use e-cigarettes and 4,000 kids start vaping every day. Despite the prevalence of youth vaping, many parents aren’t aware of the risks associated with e-cigarettes , such as, o ne vape pod can contain the same amount of nicotine as a pack of cigarettes, and nicotine exposure during adolescence can harm the developing brain and lead to a lifetime of addiction to tobacco products.

“Youth vaping continues to be a serious public health concern across the U.S., and it is disheartening that so many teens are addicted to these dangerous products,” said Harold Wimmer, president and CEO of the American Lung Association. “Based on our decades of experience in tobacco control, we know that it is key to prevent youth from starting to use tobacco products in the first place. That’s why this new campaign in partnership with the Ad Council is critical in our work to educate parents and protect teens from the health impacts of vaping.”

Developed by creative agency Hill Holliday, new “You’re The Best Person” creative highlights the nostalgic ways that Gen X and Millennial parents received health-related messages growing up to reinforce the idea that parents are the best people to speak to their kids about tough topics like vaping. The “Narrator” and “Sitcom” videos highlight how parents can start these conversations, including emphasizing the importance of talking to children in an open and clear dialogue about the dangers of vaping.

“Vaping is one of those issues that’s been normalized. We wanted to point out the real health risks of vaping and do so in a way that someone might even pay attention to,” said Dave Weist, chief creative officer at Hill Holliday. “Still, this campaign is directed to the parents. When it comes to having a conversation about vaping, don’t let someone else do that job. The best person to talk to your kid about vaping is you.”

The PSAs will appear nationwide in time and space donated by the media, across all advertising formats: broadcast, radio, digital, social, out-of-home and print. To further extend the reach of this message and educate parents on how to talk to their kids about the dangers of vaping, the campaign will also feature posts from a diverse roster of social media influencers, including healthcare professionals and family influencers, to reach parents and remind them that they are the best person to talk to their kids about the dangers of vaping.

“Our ongoing partnership with the Lung Association continues to bring critical awareness to the youth vaping crisis nationwide,” said Heidi Arthur, chief campaign development officer at the Ad Council. “Using the power of humor and nostalgia, our latest work reminds parents everywhere that no one can connect with their child like they can – especially when it comes to talking about the dangers of e-cigarettes.”

The campaign encourages parents to visit TalkAboutVaping.org for resources to help them speak to their kids about vaping, including a “Get the Facts” page and step-by-step conversation guide. Since the campaign’s launch in 2020, there have been more than 5.5 million visits to the campaign website. Parents who have seen at least one campaign PSA are 30% more likely to have spoken to their kids about the dangers of vaping, compared to parents who have not seen the campaign PSAs. The campaign has received more than $98.9 million in donated media support and over 10.5 billion impressions across television, radio, print, out-of-home and digital media.

About the American Lung Association The American Lung Association is the leading organization working to save lives by improving lung health and preventing lung disease through education, advocacy and research. The work of the American Lung Association is focused on four strategic imperatives: to defeat lung cancer; to champion clean air for all; to improve the quality of life for those with lung disease and their families; and to create a tobacco-free future. For more information about the American Lung Association, which has a 4-star rating from Charity Navigator and is a Platinum-Level GuideStar Member, call 1-800-LUNGUSA (1-800-586-4872) or visit: Lung.org. To support the work of the American Lung Association, find a local event at Lung.org/events.

About the Ad Council The Ad Council convenes creative storytellers to educate, unite and uplift audiences by opening hearts, inspiring action and accelerating change around the most pressing issues in America. Since the non-profit’s founding, the organization and its partners in advertising, media, marketing and tech have been behind some of the country’s most iconic social impact campaigns – Smokey Bear, A Mind Is a Terrible Thing to Waste, Love Has No Labels, Tear the Paper Ceiling and many more. With a current focus on mental health, gun safety, the opioid epidemic, skill-based hiring and other critical issues, the Ad Council’s national campaigns encompass advertising and media content, ground game and community efforts, trusted messenger and influencer engagement, and employer programs, among other innovative strategies to move the needle on the most important issues of the day. To learn more or get involved, visit AdCouncil.org , join the Ad Council's communities on Facebook , Instagram , LinkedIn and X , and view campaign creative on YouTube .

About Hill Holliday Hill Holliday is proud to be one of the top creative marketing agencies in the country, with over 200 cross disciplinary talents across the network. Since 1968, Hill Holliday has been on a mission to create transformative work that doesn’t just turn heads and stop thumbs, but consistently drives growth. Blending communications planning, media, and technology with superior creative, the agency approaches problems holistically to create work that punches above its media weight. For more about Hill Holliday’s people, work, and culture, visit http://www.hhcc.com

MEDIA CONTACT: Ad Council Ben Dorf [email protected]

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August 28, 2024

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UK doctors urge government to act over 'vaping epidemic'

Leading UK doctors urged the government Wednesday to pass legislation to tackle "a vaping epidemic," in particular among young people, by banning disposable e-cigarettes and all flavors apart from tobacco.

The call came alongside the publication of a British Medical Association (BMA) report which it said was a "blueprint" for the "bold actions needed."

The previous Conservative government unveiled plans earlier this year to eventually phase out smoking, alongside banning disposable e-cigarettes and restricting their flavors and packaging.

The new Labour administration—which swept to power early last month—has revived the draft legislation but is yet to detail its exact approach.

The BMA report noted that vape use among children and young people has increased almost six-fold in the last decade.

It implored the government not to "shy away from taking brave action" in order to "stem the trend."

"There is no denying we are living in a vaping epidemic," Professor David Strain, chair of the BMA's board of science, said in comments accompanying the report's release.

He noted one in 10 ten adults now vape, while calling the six-fold increase in those aged between 11 and 17 who now vape "far more worrying."

"As a doctor, I understand the role vapes can play in helping people to stop smoking, but they have no rightful place in our children and young people's lives," Strain added.

"An industry so obviously targeting children with colors, flavors and branding, to push a product that can lead to nicotine addiction and potential further harms cannot be allowed to happen any longer."

The report recommends banning all disposable vape and non-tobacco flavor sales, as well as using imagery, coloring and branding on packaging and devices.

That would mirror current restrictions on cigarettes.

The BMA also wants curbs on advertising and marketing, and rules keeping vapes behind retail counters and not on display.

Meanwhile, it is recommending government education campaigns on the dangers of vapes to reduce their appeal, especially among youngsters.

"We are calling on ministers to take bold and brave actions that will make a real difference," Penelope Toff, the BMA's public health medicine committee head, said.

A Department of Health and Social Care spokesperson said marketing vapes to children and young people was "utterly unacceptable."

The spokesperson said planned legislation will outlaw the practice while "regulating flavors , packaging, and changing how and where they are displayed in shops."

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