essay smoking and vaping

How bad is vaping and should it be banned?

Professor at the National Drug Research Institute (Melbourne), Curtin University

PhD Candidate (Psychiatry) & Research Assistant, University of Newcastle

Disclosure statement

Nicole Lee works as a consultant in the health sector and a psychologist in private practice. She has previously received funding by Australian and state governments, NHMRC and other bodies for evaluation and research into alcohol and other drug prevention and treatment.

Brigid Clancy is an Associate at 360Edge, a drug and alcohol consultancy company.

University of Newcastle and Curtin University provide funding as members of The Conversation AU.

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Vaping regularly makes headlines, with some campaigning to make e-cigarettes more available to help smokers quit, while others are keen to see vaping products banned, citing dangers, especially for teens.

So just how dangerous is it? We have undertaken an evidence check of vaping research . This included more than 100 sources on tobacco harm reduction, vaping prevalence and health effects, and what other countries are doing in response. Here’s what we found.

How does vaping compare to smoking?

Smoking is harmful. It’s the leading preventable cause of death in Australia. It causes 13% of all deaths , including from lung, mouth, throat and bladder cancer, emphysema, heart attack and stroke, to name just a few. People who smoke regularly and don’t quit lose about ten years of life compared with non-smokers.

Nicotine, a mild stimulant, is the active ingredient in both cigarettes and nicotine vaping products. It’s addictive but isn’t the cause of cancer or the other diseases related to smoking.

Ideally, people wouldn’t be addicted to nicotine, but having a safe supply without the deadly chemicals, for instance by using nicotine patches or gum, is safer than smoking. Making these other sources available is known as “harm reduction”.

Vaping is not risk-free, but several detailed reviews of the evidence plus a consensus of experts have all estimated it’s at least 95% safer to vape nicotine than to smoke tobacco. The risk of cancer from vaping, for example, has been estimated at less than 1%.

These reviews looked at the known dangerous chemicals in cigarettes, and found there were very few and in very small quantities in nicotine vapes. So the argument that we won’t see major health effects for a few more decades is causing more alarm than is necessary.

Is ‘everyone’ vaping these days?

Some are concerned about the use of vaping products by teens, but currently available statistics show very few teens vape regularly. Depending on the study, between 9.6% and 32% of 14-17-year-olds have tried vaping at some point in their lives.

But less than 2% of 14-17-year-olds say they have used vapes in the past year. This number doubled between 2016 and 2019, but is still much lower than the rates of teen smoking (3.2%) and teen alcohol use (32%).

It’s the same pattern we see with drugs other than alcohol: a proportion of people try them but only a very small proportion of those go on to use regularly or for a long time. Nearly 60% of people who try vaping only use once or twice .

Smoking rates in Australia have declined from 24% in 1991 to 11% in 2019 because we have introduced a number of very successful measures such as restricting sales and where people can smoke, putting up prices, introducing plain packaging, and improving education and access to treatment programs.

But it’s getting harder to encourage the remaining smokers to quit with the methods that have worked in the past. Those still smoking tend to be older , more socially disadvantaged , or have mental health problems.

Read more: My teen's vaping. What should I say? 3 expert tips on how to approach 'the talk'

Should we ban vapes?

So we have a bit of a dilemma. Vaping is much safer than smoking, so it would be helpful for adults to have access to it as an alternative to cigarettes. That means we need to make them more available and accessible.

But ideally we don’t want teens who don’t already smoke to start regular vaping. This has led some to call for a “ crackdown ” on vaping.

But we know from a long history of drug prohibition - like alcohol prohibition in the 1920s - that banning or restricting vaping could actually do more harm than good.

Banning drugs doesn’t stop people using them - more than 43% of Australians have tried an illicit drug at least once. And it has very little impact on the availability of drugs.

But prohibition does have a number of unintended consequences, including driving drugs underground and creating a black market or increasing harms as people switch to other drugs, which are often more dangerous.

The black market makes drugs more dangerous because there is no way to control quality. And it makes it easier, not harder, for teens to access them, because there are no restrictions on who can sell or buy them.

Read more: Learning about the health risks of vaping can encourage young vapers to rethink their habit

Are our current laws working?

In 2021, Australia made it illegal to possess and use nicotine vaping products without a prescription. We are the only country in the world to take this path.

The problem is even after more than a year of this law, only 8.6% of people vaping nicotine have a prescription, meaning more than 90% buy them illegally.

Anecdotal reports even suggest an increase in popularity of vaping among teens since these laws were introduced. At best, they are not helping.

It may seem counterintuitive, but the way to reduce the black market is to make quality-controlled vapes and liquids more widely available, but restricted to adults. If people could access vaping products legally they wouldn’t buy them on the black market and the black market would decline.

We also know from many studies on drug education in schools that when kids get accurate, non-sensationalised information about drugs they tend to make healthier decisions. Sensationalised information can have the opposite effect and increase interest in drugs . So better education in schools and for parents and teachers is also needed, so they know how to talk to kids about vaping and what to do if they know someone is vaping.

What have other countries done?

Other countries allow vapes to be legally sold without a prescription, but impose strict quality controls and do not allow the sale of products to people under a minimum age. This is similar to our regulation of cigarettes and alcohol.

The United Kingdom has minimum standards on manufacturing, as well as restrictions on purchase age and where people can vape.

Aotearoa New Zealand introduced a unique plan to reduce smoking rates by imposing a lifetime ban on buying cigarettes. Anyone born after January 1 2009 will never be able to buy cigarettes, so the minimum age you can legally smoke keeps increasing. At the same time, NZ increased access to vaping products under strict regulations on manufacture, purchase and use.

As of late last year, all US states require sellers to have a retail licence, and sales to people under 21 are banned. There are also restrictions on where people can vape.

A recent study modelled the impact of increasing access to nicotine vaping products in Australia. It found it’s likely there would be significant public health benefits by relaxing the current restrictive policies and increasing access to nicotine vaping products for adults.

The question is not whether we should discourage teens from using vaping products or whether we should allow wider accessibility to vaping products for adults as an alternative to smoking. The answer to both those questions is yes.

The key question is how do we do both effectively without one policy jeopardising the outcomes of the other?

If we took a pragmatic harm-reduction approach, as other countries have done, we could use our very successful model of regulation of tobacco products as a template to achieve both outcomes.

Read more: It's safest to avoid e-cigarettes altogether – unless vaping is helping you quit smoking

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Impact of vaping on respiratory health

Linked editorial.

Protecting children from harms of vaping

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• Andrea Jonas , clinical assistant professor
• Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Stanford University, Stanford, CA, USA
• Correspondence to A Jonas andreajonas{at}stanford.edu

Widespread uptake of vaping has signaled a sea change in the future of nicotine consumption. Vaping has grown in popularity over the past decade, in part propelled by innovations in vape pen design and nicotine flavoring. Teens and young adults have seen the biggest uptake in use of vape pens, which have superseded conventional cigarettes as the preferred modality of nicotine consumption. Relatively little is known, however, about the potential effects of chronic vaping on the respiratory system. Further, the role of vaping as a tool of smoking cessation and tobacco harm reduction remains controversial. The 2019 E-cigarette or Vaping Use-Associated Lung Injury (EVALI) outbreak highlighted the potential harms of vaping, and the consequences of long term use remain unknown. Here, we review the growing body of literature investigating the impacts of vaping on respiratory health. We review the clinical manifestations of vaping related lung injury, including the EVALI outbreak, as well as the effects of chronic vaping on respiratory health and covid-19 outcomes. We conclude that vaping is not without risk, and that further investigation is required to establish clear public policy guidance and regulation.

Abbreviations

BAL bronchoalveolar lavage

CBD cannabidiol

CDC Centers for Disease Control and Prevention

DLCO diffusing capacity of the lung for carbon monoxide

EMR electronic medical record

END electronic nicotine delivery systems

EVALI E-cigarette or Vaping product Use-Associated Lung Injury

LLM lipid laden macrophages

THC tetrahydrocannabinol

V/Q ventilation perfusion

Introduction

The introduction of vape pens to international markets in the mid 2000s signaled a sea change in the future of nicotine consumption. Long the mainstay of nicotine use, conventional cigarette smoking was on the decline for decades in the US, 1 2 largely owing to generational shifts in attitudes toward smoking. 3 With the advent of vape pens, trends in nicotine use have reversed, and the past two decades have seen a steady uptake of vaping among young, never smokers. 4 5 6 Vaping is now the preferred modality of nicotine consumption among young people, 7 and 2020 surveys indicate that one in five US high school students currently vape. 8 These trends are reflected internationally, where the prevalence of vape products has grown in both China and the UK. 9 Relatively little is known, however, regarding the health consequences of chronic vape pen use. 10 11 Although vaping was initially heralded as a safer alternative to cigarette smoking, 12 13 the toxic substances found in vape aerosols have raised new questions about the long term safety of vaping. 14 15 16 17 The 2019 E-cigarette or Vaping product Use-Associated Lung Injury (EVALI) outbreak, ultimately linked to vitamin E acetate in THC vapes, raised further concerns about the health effects of vaping, 18 19 20 and has led to increased scientific interest in the health consequences of chronic vaping. This review summarizes the history and epidemiology of vaping, and the clinical manifestations and proposed pathophysiology of lung injury caused by vaping. The public health consequences of widespread vaping remain to be seen and are compounded by young users of vape pens later transitioning to combustible cigarettes. 4 21 22 Deepened scientific understanding and public awareness of the potential harms of vaping are imperative to confront the challenges posed by a new generation of nicotine users.

Sources and selection criteria

We searched PubMed and Ovid Medline databases for the terms “vape”, “vaping”, “e-cigarette”, “electronic cigarette”, “electronic nicotine delivery”, “electronic nicotine device”, “END”, “EVALI”, “lung injury, diagnosis, management, and treatment” to find articles published between January 2000 and December 2021. We also identified references from the Centers for Disease Control and Prevention (CDC) website, as well as relevant review articles and public policy resources. Prioritization was given to peer reviewed articles written in English in moderate-to-high impact journals, consensus statements, guidelines, and included randomized controlled trials, systematic reviews, meta-analyses, and case series. We excluded publications that had a qualitative research design, or for which a conflict of interest in funding could be identified, as defined by any funding source or consulting fee from nicotine manufacturers or distributors. Search terms were chosen to generate a broad selection of literature that reflected historic and current understanding of the effects of vaping on respiratory health.

The origins of vaping

Vaping achieved widespread popularity over the past decade, but its origins date back almost a century and are summarized in figure 1 . The first known patent for an “electric vaporizer” was granted in 1930, intended for aerosolizing medicinal compounds. 23 Subsequent patents and prototypes never made it to market, 24 and it wasn’t until 1979 that the first vape pen was commercialized. Dubbed the “Favor” cigarette, the device was heralded as a smokeless alternative to cigarettes and led to the term “vaping” being coined to differentiate the “new age” method of nicotine consumption from conventional, combustible cigarettes. 25 “Favor” cigarettes did not achieve widespread appeal, in part because of the bitter taste of the aerosolized freebase nicotine; however, the term vaping persisted and would go on to be used by the myriad products that have since been developed.

Timeline of vape pen invention to widespread use (1970s-2020)

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The forerunner of the modern vape pen was developed in Beijing in 2003 and later introduced to US markets around 2006. 26 27 Around this time, the future Juul Laboratories founders developed the precursor of the current Juul vape pen while they were students at the Stanford Byers-Center for Biodesign. 28 Their model included disposable cartridges of flavored nicotine solution (pods) that could be inserted into the vape pen, which itself resembled a USB flash drive. Key to their work was the chemical alteration of freebase nicotine to a benzoate nicotine salt. 29 The lower pH of the nicotine salt resulted in an aerosolized nicotine product that lacked a bitter taste, 30 and enabled manufacturers to expand the range of flavored vape products. 31 Juul Laboratories was founded a decade later and quickly rose to dominate the US market, 32 accounting for an estimated 13-59% of the vape products used among teens by 2020. 6 8 Part of the Juul vape pen’s appeal stems from its discreet design, as well as its ability to deliver nicotine with an efficiency matching that of conventional cigarettes. 33 34 Subsequent generations of vape pens have included innovations such as the tank system, which allowed users to select from the wide range of different vape solutions on the market, rather than the relatively limited selection available in traditional pod based systems. Further customizations include the ability to select different vape pen components such as atomizers, heating coils, and fluid wicks, allowing users to calibrate the way in which the vape aerosol is produced. Tobacco companies have taken note of the shifting demographics of nicotine users, as evidenced in 2018 by Altria’s $12.8bn investment in Juul Laboratories. 35

Vaping terminology

At present, vaping serves as an umbrella term that describes multiple modalities of aerosolized nicotine consumption. Vape pens are alternatively called e-cigarettes, electronic nicotine delivery systems (END), e-cigars, and e-hookahs. Additional vernacular terms have emerged to describe both the various vape pen devices (eg, tank, mod, dab pen), vape solution (eg, e-liquid, vape juice), as well as the act of vaping (eg, ripping, juuling, puffing, hitting). 36 A conventional vape pen is a battery operated handheld device that contains a storage chamber for the vape solution and an internal element for generating the characteristic vape aerosol. Multiple generations of vape pens have entered the market, including single use, disposable varieties, as well as reusable models that have either a refillable fluid reservoir or a disposable cartridge for the vape solution. Aerosol generation entails a heating coil that atomizes the vape solution, and it is increasingly popular for devices to include advanced settings that allow users to adjust features of the aerosolized nicotine delivery. 37 38 Various devices allow for coil temperatures ranging from 110 °C to over 1000 °C, creating a wide range of conditions for thermal degradation of the vape solution itself. 39 40

The sheer number of vape solutions on the market poses a challenge in understanding the impact of vaping on respiratory health. The spectrum of vape solutions available encompasses thousands of varieties of flavors, additives, and nicotine concentrations. 41 Most vape solutions contain an active ingredient, commonly nicotine 42 ; however, alternative agents include tetrahydrocannabinol (THC) or cannabidiol (CBD). Vape solutions are typically composed of a combination of a flavorant, nicotine, and a carrier, commonly propylene glycol or vegetable glycerin, that generates the characteristic smoke appearance of vape aerosols. Some 450 brands of vape now offer more than 8000 flavors, 41 a figure that nearly doubled over a three year period. 43 Such tremendous variety does not account for third party sellers who offer users the option to customize a vape solution blend. Addition of marijuana based products such as THC or CBD requires the use of an oil based vape solution carrier to allow for extraction of the psychoactive elements. Despite THC vaping use in nearly 9% of high schoolers, 44 THC vape solutions are subject to minimal market regulation. Finally, a related modality of THC consumption is termed dabbing, and describes the process of inhaling aerosolized THC wax concentrate.

Epidemiology of vaping

Since the early 2000s, vaping has grown in popularity in the US and elsewhere. 8 45 Most of the 68 million vape pen users are concentrated in China, the US, and Europe. 46 Uptake among young people has been particularly pronounced, and in the US vaping has overtaken cigarettes as the most common modality of nicotine consumption among adolescents and young adults. 47 Studies estimate that 20% of US high school students are regular vape pen users, 6 48 in contrast to the 5% of adults who use vape products. 2 Teen uptake of vaping has been driven in part by a perception of vaping as a safer alternative to cigarettes, 49 50 as well as marketing strategies that target adolescents. 33 Teen use of vape pens is further driven by the low financial cost of initiation, with “starter kits” costing less than $25, 51 as well as easy access through peer sales and inconsistent age verification at in-person and online retailers. 52 After sustained growth in use over the 2010s, recent survey data from 2020 suggest that the number of vape pen users has leveled off among teens, perhaps in part owing to increased perceived risk of vaping after the EVALI outbreak. 8 53 The public health implications of teen vaping are compounded by the prevalence of vaping among never smokers (defined as having smoked fewer than 100 lifetime cigarettes), 54 and subsequent uptake of cigarette smoking among vaping teens. 4 55 Similarly, half of adults who currently vape have never used cigarettes, 2 and concern remains that vaping serves as a gateway to conventional cigarette use, 56 57 although these results have been disputed. 58 59 Despite regulation limiting the sale of flavored vape products, 60 a 2020 survey found that high school students were still predominantly using fruit, mint, menthol, and dessert flavored vape solutions. 48 While most data available surround the use of nicotine-containing vape products, a recent meta-analysis showed growing prevalence of adolescents using cannabis-containing products as well. 61

Vaping as harm reduction

Despite facing ongoing questions about safety, vaping has emerged as a potential tool for harm reduction among cigarette smokers. 12 27 An NHS report determined that vaping nicotine is “around 95% less harmful than cigarettes,” 62 leading to the development of programs that promote vaping as a tool of risk reduction among current smokers. A 2020 Cochrane review found that vaping nicotine assisted with smoking cessation over placebo 63 and recent work found increased rates of cigarette abstinence (18% v 9.9%) among those switching to vaping compared with conventional nicotine replacement (eg, gum, patch, lozenge). 64 US CDC guidance suggests that vaping nicotine may benefit current adult smokers who are able to achieve complete cigarette cessation by switching to vaping. 65 66

The public health benefit of vaping for smoking cessation is counterbalanced by vaping uptake among never smokers, 2 54 and questions surrounding the safety of chronic vaping. 10 11 Controversy surrounding the NHS claim of vaping as 95% safer than cigarettes has emerged, 67 68 and multiple leading health organizations have concluded that vaping is harmful. 42 69 Studies have demonstrated airborne particulate matter in the proximity of active vapers, 70 and concern remains that secondhand exposure to vaped aerosols may cause adverse effects, complicating the notion of vaping as a net gain for public health. 71 72 Uncertainty about the potential chronic consequences of vaping combined with vaping uptake among never smokers has complicated attempts to generate clear policy guidance. 73 74 Further, many smokers may exhibit “dual use” of conventional cigarettes and vape pens simultaneously, further complicating efforts to understand the impact of vape exposure on respiratory health, and the role vape use may play in smoking cessation. 12 We are unable to know with certainty the extent of nicotine uptake among young people that would have been seen in the absence of vaping availability, and it remains possible that some young vape pen users may have started on conventional cigarettes regardless. That said, declining nicotine use over the past several decades would argue that many young vape pen users would have never had nicotine uptake had vape pens not been introduced. 1 2 It remains an open question whether public health measures encouraging vaping for nicotine cessation will benefit current smokers enough to offset the impact of vaping uptake among young, never smokers. 75

Vaping lung injury—clinical presentations

Vaping related lung injury: 2012-19.

The potential health effects of vape pen use are varied and centered on injury to the airways and lung parenchyma. Before the 2019 EVALI outbreak, the medical literature detailed case reports of sporadic vaping related acute lung injury. The first known case was reported in 2012, when a patient presented with cough, diffuse ground glass opacities, and lipid laden macrophages (LLM) on bronchoalveolar lavage (BAL) return in the context of vape pen use. 76 Over the following seven years, an additional 15 cases of vaping related acute lung injury were reported in the literature. These cases included a wide range of diffuse parenchymal lung disease without any clear unifying features, and included cases of eosinophilic pneumonia, 77 78 79 hypersensitivity pneumonitis, 80 organizing pneumonia, 81 82 diffuse alveolar hemorrhage, 83 84 and giant cell foreign body reaction. 85 Although parenchymal lung injury predominated the cases reported, additional cases detailed episodes of status asthmaticus 86 and pneumothoraces 87 attributed to vaping. Non-respiratory vape pen injury has also been described, including cases of nicotine toxicity from vape solution ingestion, 88 89 and injuries sustained owing to vape pen device explosions. 90

The 2019 EVALI outbreak

In the summer of 2019 the EVALI outbreak led to 2807 cases of idiopathic acute lung injury in predominantly young, healthy individuals, which resulted in 68 deaths. 19 91 Epidemiological work to uncover the cause of the outbreak identified an association with vaping, particularly the use of THC-containing products, among affected individuals. CDC criteria for EVALI ( box 1 ) included individuals presenting with respiratory symptoms who had pulmonary infiltrates on imaging in the context of having vaped or dabbed within 90 days of symptom onset, without an alternative identifiable cause. 92 93 After peaking in September 2019, EVALI case numbers steadily declined, 91 likely owing to identification of a link with vaping, and subsequent removal of offending agents from circulation. Regardless, sporadic cases continue to be reported, and a high index of suspicion is required to differentiate EVALI from covid-19 pneumonia. 94 95 A strong association emerged between EVALI cases and the presence of vitamin E acetate in the BAL return of affected individuals 96 ; however, no definitive causal link has been established. Interestingly, the EVALI outbreak was nearly entirely contained within the US with the exception of several dozen cases, at least one of which was caused by an imported US product. 97 98 99 The pattern of cases and lung injury is most suggestive of a vape solution contaminant that was introduced into the distribution pipeline in US markets, leading to a geographically contained pattern of lung injury among users. CDC case criteria for EVALI may have obscured a potential link between viral pneumonia and EVALI, and cases may have been under-recognized following the onset of the covid-19 pandemic.

CDC criteria for establishing EVALI diagnosis

Cdc lung injury surveillance, primary case definitions, confirmed case.

Vape use* in 90 days prior to symptom onset; and

Pulmonary infiltrate on chest radiograph or ground glass opacities on chest computed tomography (CT) scan; and

Absence of pulmonary infection on initial investigation†; and

Absence of alternative plausible diagnosis (eg, cardiac, rheumatological, or neoplastic process).

Probable case

Pulmonary infiltrate on chest radiograph or ground glass opacities on chest CT; and

Infection has been identified; however is not thought to represent the sole cause of lung injury OR minimum criteria** to exclude infection have not been performed but infection is not thought to be the sole cause of lung injury

*Use of e-cigarette, vape pen, or dabbing.

†Minimum criteria for absence of pulmonary infection: negative respiratory viral panel, negative influenza testing (if supported by local epidemiological data), and all other clinically indicated infectious respiratory disease testing is negative.

EVALI—clinical, radiographic, and pathologic features

In the right clinical context, diagnosis of EVALI includes identification of characteristic radiographic and pathologic features. EVALI patients largely fit a pattern of diffuse, acute lung injury in the context of vape pen exposure. A systematic review of 200 reported cases of EVALI showed that those affected were predominantly men in their teens to early 30s, and most (80%) had been using THC-containing products. 100 Presentations included predominantly respiratory (95%), constitutional (87%), and gastrointestinal symptoms (73%). Radiological studies mostly featured diffuse ground glass opacities bilaterally. Of 92 cases that underwent BAL, alveolar fluid samples were most commonly neutrophil predominant, and 81% were additionally positive for LLM on Oil Red O staining. Lung biopsy was not required to achieve the diagnosis; however, of 33 cases that underwent tissue biopsy, common features included organizing pneumonia, inflammation, foamy macrophages, and fibrinous exudates.

EVALI—outcomes

Most patients with EVALI recovered, and prognosis was generally favorable. A systematic review of identified cases found that most patients with confirmed disease required admission to hospital (94%), and a quarter were intubated. 100 Mortality among EVALI patients was low, with estimates around 2-3% across multiple studies. 101 102 103 Mortality was associated with age over 35 and underlying asthma, cardiac disease, or mental health conditions. 103 Notably, the cohorts studied only included patients who presented for medical care, and the samples are likely biased toward a more symptomatic population. It is likely that many individuals experiencing mild symptoms of EVALI did not present for medical care, and would have self-discontinued vaping following extensive media coverage of the outbreak at that time. Although most EVALI survivors recovered well, case series of some individuals show persistent radiographic abnormalities 101 and sustained reductions in DLCO. 104 105 Pulmonary function evaluation of EVALI survivors showed normalization in FEV 1 /FVC on spirometry in some, 106 while others had more variable outcomes. 105 107 108

Vaping induced lung injury—pathophysiology

The causes underlying vaping related acute lung injury remain interesting to clinicians, scientists, and public health officials; multiple mechanisms of injury have been proposed and are summarized in figure 2 . 31 109 110 Despite increased scientific interest in vaping related lung injury following the EVALI outbreak, the pool of data from which to draw meaningful conclusions is limited because of small scale human studies and ongoing conflicts due to tobacco industry funding. 111 Further, insufficient time has elapsed since widespread vaping uptake, and available studies reflect the effects of vaping on lung health over a maximum 10-15 year timespan. The longitudinal effects of vaping may take decades to fully manifest and ongoing prospective work is required to better understand the impacts of vaping on respiratory health.

Schematic illustrating pathophysiology of vaping lung injury

Pro-inflammatory vape aerosol effects

While multiple pathophysiological pathways have been proposed for vaping related lung injury, they all center on the vape aerosol itself as the conduit of lung inflammation. Vape aerosols have been found to harbor a number of toxic substances, including thermal degradation products of the various vape solution components. 112 Mass spectrometry analysis of vape aerosols has identified a variety of oxidative and pro-inflammatory substances including benzene, acrolein, volatile organic compounds, and propylene oxide. 16 17 Vaping additionally leads to airway deposition of ultrafine particles, 14 113 as well as the heavy metals manganese and zinc which are emitted from the vaping coils. 15 114 Fourth generation vape pens allow for high wattage aerosol generation, which can cause airway epithelial injury and tissue hypoxia, 115 116 as well as formaldehyde exposure similar to that of cigarette smoke. 117 Common carrier solutions such as propylene glycol have been associated with increased airway hyper-reactivity among vape pen users, 31 118 119 and have been associated with chronic respiratory conditions among theater workers exposed to aerosolized propylene glycol used in the generation of artificial fog. 120 Nicotine salts used in pod based vape pen solutions, including Juul, have been found to penetrate the cell membrane and have cytotoxic effects. 121

The myriad available vape pen flavors correlate with an expansive list of chemical compounds with potential adverse respiratory effects. Flavorants have come under increased scrutiny in recent years and have been found to contribute to the majority of aldehyde production during vape aerosol production. 122 Compounds such as cinnamaldehyde, 123 124 2,5-dimethylpyrazine (chocolate flavoring), 125 and 2,3-pentanedione 126 are common flavor additives and have been found to contribute to airway inflammation and altered immunological responses. The flavorant diacetyl garnered particular attention after it was identified on mass spectrometry in most vape solutions tested. 127 Diacetyl is most widely associated with an outbreak of diacetyl associated bronchiolitis obliterans (“popcorn lung”) among workers at a microwave popcorn plant in 2002. 128 Identification of diacetyl in vape solutions raises the possibility of development of a similar pattern of bronchiolitis obliterans among individuals who have chronic vape aerosol exposure to diacetyl-containing vape solutions. 129

Studies of vape aerosols have suggested multiple pro-inflammatory effects on the respiratory system. This includes increased airway resistance, 130 impaired response to infection, 131 and impaired mucociliary clearance. 132 Vape aerosols have further been found to induce oxidative stress in lung epithelial cells, 133 and to both induce DNA damage and impair DNA repair, consistent with a potential carcinogenic effect. 134 Mice chronically exposed to vape aerosols developed increased airway hyper-reactivity and parenchymal changes consistent with chronic obstructive pulmonary disease. 135 Human studies have been more limited, but reveal increased airway edema and friability among vape pen users, as well as altered gene transcription and decreased innate immunity. 136 137 138 Upregulation of neutrophil elastase and matrix metalloproteases among vape users suggests increased proteolysis, potentially putting those patients at risk of chronic respiratory conditions. 139

THC-containing products

Of particular interest during the 2019 EVALI outbreak was the high prevalence of THC use among EVALI cases, 19 raising questions about a novel mechanism of lung injury specific to THC-containing vape solutions. These solutions differ from conventional nicotine based products because of the need for a carrier capable of emulsifying the lipid based THC component. In this context, additional vape solution ingredients rose to attention as potential culprits—namely, THC itself, which has been found to degrade to methacrolein and benzene, 140 as well as vitamin E acetate which was found to be a common oil based diluent. 141

Vitamin E acetate has garnered increasing attention as a potential culprit in the pathophysiology of the EVALI outbreak. Vitamin E acetate was found in 94% of BAL samples collected from EVALI patients, compared with none identified in unaffected vape pen users. 96 Thermal degradation of vitamin E acetate under conditions similar to those in THC vape pens has shown production of ketene, alkene, and benzene, which may mediate epithelial lung injury when inhaled. 39 Previous work had found that vitamin E acetate impairs pulmonary surfactant function, 142 and subsequent studies have shown a dose dependent adverse effect on lung parenchyma by vitamin E acetate, including toxicity to type II pneumocytes, and increased inflammatory cytokines. 143 Mice exposed to aerosols containing vitamin E acetate developed LLM and increased alveolar protein content, suggesting epithelial injury. 140 143

The pathophysiological insult underlying vaping related lung injury may be multitudinous, including potentially compound effects from multiple ingredients comprising a vape aerosol. The heterogeneity of available vape solutions on the market further complicates efforts to pinpoint particular elements of the vape aerosol that may be pathogenic, as no two users are likely to be exposed to the same combination of vape solution products. Further, vape users may be exposed to vape solutions containing terpenes, medium chain triglycerides, or coconut oil, the effects of which on respiratory epithelium remain under investigation. 144

Lipid laden macrophages

Lipid laden alveolar macrophages have risen to prominence as potential markers of vaping related lung injury. Alveolar macrophages describe a scavenger white blood cell responsible for clearing alveolar spaces of particulate matter and modulating the inflammatory response in the lung parenchyma. 145 LLM describe alveolar macrophages that have phagocytosed fat containing deposits, as seen on Oil Red O staining, and have been described in a wide variety of pulmonary conditions, including aspiration, lipoid pneumonia, organizing pneumonia, and medication induced pneumonitis. 146 147 During the EVALI outbreak, LLM were identified in the alveolar spaces of affected patients, both in the BAL fluid and on both transbronchial and surgical lung biopsies. 148 149 Of 52 EVALI cases reported in the literature who underwent BAL, LLM were identified in over 80%. 19 100 101 148 149 150 151 152 153 Accordingly, attention turned to LLM as not only a potential marker of lung injury in EVALI, but as a possible contributor to lung inflammation itself. This concern was compounded by the frequent reported use of oil based THC vape products among EVALI patients, raising the possibility of lipid deposits in the alveolus resulting from inhalation of THC-containing vape aerosols. 154 The combination of LLM, acute lung injury, and inhalational exposure to an oil based substance raised the concern for exogenous lipoid pneumonia. 152 153 However, further evaluation of the radiographic and histopathologic findings failed to identify cardinal features that would support a diagnosis of exogenous lipoid pneumonia—namely, low attenuation areas on CT imaging and foreign body giant cells on histopathology. 155 156 However, differences in the particle size and distribution between vape aerosol exposure and traditional causes of lipoid pneumonia (ie, aspiration of a large volume of an oil-containing substance), could reasonably lead to differences in radiographic appearance, although this would not account for the lack of characteristic histopathologic features on biopsy that would support a diagnosis of lipoid pneumonia.

Recent work suggests that LLM reflect a non-specific marker of vaping, rather than a marker of lung injury. One study found that LLM were not unique to EVALI and could be identified in healthy vape pen users, as well as conventional cigarette smokers, but not in never smokers. 157 Interestingly, this work showed increased cytokines IL-4 and IL-10 among healthy vape users, suggesting that cigarette and vape pen use are associated with a pro-inflammatory state in the lung. 157 An alternative theory supports LLM presence reflecting macrophage clearance of intra-alveolar cell debris rather than exogenous lipid exposure. 149 150 Such a pattern would be in keeping with the role of alveolar macrophages as modulating the inflammatory response in the lung parenchyma. 158 Taken together, available data would support LLM serving as a non-specific marker of vape product use, rather than playing a direct role in vaping related lung injury pathogenesis. 102

Clinical aspects

A high index of suspicion is required in establishing a diagnosis of vaping related lung injury, and a general approach is summarized in figure 3 . Clinicians may consider the diagnosis when faced with a patient with new respiratory symptoms in the context of vape pen use, without an alternative cause to account for their symptoms. Suspicion should be especially high if respiratory complaints are coupled with constitutional and gastrointestinal symptoms. Patients may present with non-specific markers indicative of an ongoing inflammatory process: fevers, leukocytosis, elevated C reactive protein, or elevated erythrocyte sedimentation rate. 19

Flowchart outlining the procedure for diagnosing a vaping related lung injury

Vaping related lung injury is a diagnosis of exclusion. Chest imaging via radiograph or CT may identify a variety of patterns, although diffuse ground glass opacities remain the most common radiographic finding. Generally, patients with an abnormal chest radiograph should undergo a chest CT for further evaluation of possible vaping related lung injury.

Exclusion of infectious causes is recommended. Testing should include evaluation for bacterial and viral causes of pneumonia, as deemed appropriate by clinical judgment and epidemiological data. Exclusion of common viral causes of pneumonia is imperative, particularly influenza and SARS-CoV-2. Bronchoscopy with BAL should be considered on a case-by-case basis for those with more severe disease and may be helpful to identify patients with vaping mediated eosinophilic lung injury. Further, lung biopsy may be beneficial to exclude alternative causes of lung injury in severe cases. 92

No definitive therapy has been identified for the treatment of vaping related lung injury, and data are limited to case reports and public health guidance on the topic. Management includes supportive care and strong consideration for systemic corticosteroids for severe cases of vaping related lung injury. CDC guidance encourages consideration of systemic corticosteroids for patients requiring admission to hospital, or those with higher risk factors for adverse outcomes, including age over 50, immunosuppressed status, or underlying cardiopulmonary disease. 100 Further, given case reports of vaping mediated acute eosinophilic pneumonia, steroids should be implemented in those patients who have undergone a confirmatory BAL. 77 79

Additional therapeutic options include empiric antibiotics and/or antivirals, depending on the clinical scenario. For patients requiring admission to hospital, prompt subspecialty consultation with a pulmonologist can help guide management. Outpatient follow-up with chest imaging and spirometry is recommended, as well as referral to a pulmonologist. Counseling regarding vaping cessation is also a core component in the post-discharge care for this patient population. Interventions specific to vaping cessation remain under investigation; however, literature supports the use of behavioral counseling and/or pharmacotherapy to support nicotine cessation efforts. 66

Health outcomes among vape pen users

Health outcomes among chronic vape pen users remains an open question. To date, no large scale prospective cohort studies exist that can establish a causal link between vape use and adverse respiratory outcomes. One small scale prospective cohort study did not identify any spirometric or radiographic changes among vape pen users over a 3.5 year period. 159 Given that vaping remains a relatively novel phenomenon, many users will have a less than 10 “pack year” history of vape pen use, arguably too brief an exposure period to reflect the potential harmful nature of chronic vaping. Studies encompassing a longer period of observation of vape pen users have not yet taken place, although advances in electronic medical record (EMR) data collection on vaping habits make such work within reach.

Current understanding of the health effects of vaping is largely limited to case reports of acute lung injury, and health surveys drawing associations between vaping exposure and patient reported outcomes. Within these limitations, however, early work suggests a correlation between vape pen use and poorer cardiopulmonary outcomes. Survey studies of teens who regularly vape found increased frequencies of respiratory symptoms, including productive cough, that were independent of smoking status. 160 161 These findings were corroborated in a survey series identifying more severe asthma symptoms and more days of school missed owing to asthma among vape pen users, regardless of cigarette smoking status. 162 163 164 Studies among adults have shown a similar pattern, with increased prevalence of chronic respiratory conditions (ie, asthma or chronic obstructive pulmonary disease) among vape pen users, 165 166 and higher risk of myocardial infarction and stroke, but lower risk of diabetes. 167

The effects of vaping on lung function as determined by spirometric studies are more varied. Reported studies have assessed lung function after a brief exposure to vape aerosols, varying from 5-60 minutes in duration, and no longer term observational cohort studies exist. While some studies have shown increased airway resistance after vaping exposure, 130 168 169 others have shown no change in lung function. 137 170 171 The cumulative exposure of habitual vape pen users to vape aerosols is much longer than the period evaluated in these studies, and the impact of vaping on longer term respiratory heath remains to be seen. Recent work evaluating ventilation-perfusion matching among chronic vapers compared with healthy controls found increased ventilation-perfusion mismatch, despite normal spirometry in both groups. 172 Such work reinforces the notion that changes in spirometry are a feature of more advanced airways disease, and early studies, although inconsistent, may foreshadow future respiratory impairment in chronic vapers.

Covid-19 and vaping

The covid-19 pandemic brought renewed attention to the potential health impacts of vaping. Studies investigating the role of vaping in covid-19 prevalence and outcomes have been limited by the small size of the populations studied and results have been inconsistent. Early work noted a geographic association in the US between vaping prevalence and covid-19 cases, 173 and a subsequent survey study found that a covid-19 diagnosis was five times more likely among teens who had ever vaped. 174 In contrast, a UK survey study found no association between vaping status and covid-19 infection rates, although captured a much smaller population of vape pen users. 175 Reports of nicotine use upregulating the angiotensin converting enzyme 2 (ACE-2) receptor, 176 which serves as the binding site for SARS-CoV-2 entry, raised the possibility of increased susceptibility to covid-19 among chronic nicotine vape pen users. 177 178 Further, vape use associated with sharing devices and frequent touching of the mouth and face were posited as potential confounders contributing to increased prevalence of covid-19 in this population. 179

Covid-19 outcomes among chronic vape pen users remain an open question. While smoking has been associated with progression to more severe infections, 180 181 no investigation has been performed to date among vaping cohorts. The young average age of chronic vape pen users may prove a protective factor, as risk of severe covid-19 infection has been shown to increase with age. 182 Regardless, a prudent recommendation remains to abstain from vaping to mitigate risk of progression to severe covid-19 infection. 183

Increased awareness of respiratory health brought about by covid-19 and EVALI is galvanizing the changing patterns in vape pen use. 184 Survey studies have consistently shown trends toward decreasing use among adolescents and young adults. 174 185 186 In one study, up to two thirds of participants endorsed decreasing or quitting vaping owing to a combination of factors including difficulty purchasing vape products during the pandemic, concerns about vaping effects on lung health, and difficulty concealing vape use while living with family. 174 Such results are reflected in nationwide trends that show halting growth in vaping use among high school students. 8 These trends are encouraging in that public health interventions countering nicotine use among teens may be meeting some measure of success.

Clinical impact—collecting and recording a vaping history

Vaping history in electronic medical records.

Efforts to prevent, diagnose, and treat vaping related lung injury begin with the ability of our healthcare system to identify vape users. Since vaping related lung injury remains a diagnosis of exclusion, clinicians must have a high index of suspicion when confronted with idiopathic lung injury in a patient with vaping exposure. Unlike cigarette use, vape pen use is not built into most EMR systems, and is not included in meaningful use criteria for EMRs. 187 Retrospective analysis of outpatient visits showed that a vaping history was collected in less than 0.1% of patients in 2015, 188 although this number has been increasing. 189 190 In part augmented by EMR frameworks that prompt collection of data on vaping history, more recent estimates indicate that a vaping history is being collected in up to 6% of patients. 191 Compared with the widespread use of vaping, particularly among adolescent and young adult populations, this number remains low. Considering generational trends in nicotine use, vaping will likely eventually overcome cigarettes as the most common mode of nicotine use, raising the importance of collecting a vaping related history. Further, EMR integration of vaping history is imperative to allow for retrospective, large scale analyses of vape exposure on longitudinal health outcomes at a population level.

Practical considerations—gathering a vaping history

As vaping becomes more common, the clinician’s ability to accurately collect a vaping history and identify patients who may benefit from nicotine cessation programs becomes more important. Reassuringly, gathering a vaping history is not dissimilar to asking about smoking and use of other tobacco products, and is summarized in box 2 . Collecting a vaping history is of particular importance for providers caring for adolescents and young adults who are among the highest risk demographics for vape pen use. Adolescents and young adults may be reluctant to share their vaping history, particularly if they are using THC-containing or CBD-containing vape solutions. Familiarity with vernacular terms to describe vaping, assuming a non-judgmental approach, and asking parents or guardians to step away during history taking will help to break down these barriers. 192

Practical guide to collecting a vaping history

Ask with empathy.

Young adults may be reluctant to share history of vaping use. Familiarity with vaping terminology, asking in a non-judgmental manner, and asking in a confidential space may help.

Ask what they are vaping

Vape products— vape pens commonly contain nicotine or an alternative active ingredient, such as THC or CBD. Providers may also inquire about flavorants, or other vape solution additives, that their patient is consuming, particularly if vaping related lung injury is suspected.

Source— ask where they source their product from. Sources may include commercially available products, third party distributors, or friends or local contacts.

Ask how they are vaping

Device— What style of device are they using?

Frequency— How many times a day do they use their vape pen (with frequent use considered >5 times a day)? Alternatively, providers may inquire how long it takes to deplete a vape solution cartridge (with use of one or more pods a day considered heavy use).

Nicotine concentration— For individuals consuming nicotine-containing products, clinicians may inquire about concentration and frequency of use, as this may allow for development of a nicotine replacement therapy plan.

Ask about other inhaled products

Clinicians should ask patients who vape about use of other inhaled products, particularly cigarettes. Further, clinicians may ask about use of water pipes, heat-not-burn devices, THC-containing products, or dabbing.

The following provides a practical guide on considerations when collecting a vaping history. Of note, collecting a partial history is preferable to no history at all, and simply recording whether a patient is vaping or not adds valuable information to the medical record.

Vape use— age at time of vaping onset and frequency of vape pen use. Vape pen use >5 times a day would be considered frequent. Alternatively, clinicians may inquire how long it takes to deplete a vape solution pod (use of one or more pods a day would be considered heavy use), or how frequently users are refilling their vape pens for refillable models.

Vape products— given significant variation in vape solutions available on the market, and variable risk profiles of the multitude of additives, inquiring as to which products a patient is using may add useful information. Further, clinicians may inquire about use of nicotine versus THC-containing vape solutions, and whether said products are commercially available or are customized by third party sellers.

Concurrent smoking— simultaneous use of multiple inhaled products is common among vape users, including concurrent use of conventional cigarettes, water pipes, heat-not-burn devices, and THC-containing or CBD-containing products. Among those using marijuana products, gathering a history regarding the type of product use, the device, and the modality of aerosol generation may be warranted. Gathering such detailed information may be challenging in the face of rapidly evolving product availability and changing popular terminology. Lastly, clinicians may wish to inquire about “dabbing”—the practice of inhaling heated butane hash oil, a concentrated THC wax—which may also be associated with lung injury. 193

Future directions

Our understanding of the effects of vaping on respiratory health is in its early stages and multiple trials are under way. Future work requires enhanced understanding of the effects of vape aerosols on lung biology, such as ongoing investigations into biomarkers of oxidative stress and inflammation among vape users (clinicaltrials.gov NCT03823885 ). Additional studies seek to elucidate the relation between vape aerosol exposure and cardiopulmonary outcomes among vape pen users ( NCT03863509 , NCT05199480 ), while an ongoing prospective cohort study will allow for longitudinal assessment of airway reactivity and spirometric changes among chronic vape pen users ( NCT04395274 ).

Public health and policy interventions are vital in supporting both our understanding of vaping on respiratory health and curbing the vaping epidemic among teens. Ongoing, large scale randomized controlled studies seek to assess the impact of the FDA’s “The Real Cost” advertisement campaign for vaping prevention ( NCT04836455 ) and another trial is assessing the impact of a vaping prevention curriculum among adolescents ( NCT04843501 ). Current trials are seeking to understand the potential for various therapies as tools for vaping cessation, including nicotine patches ( NCT04974580 ), varenicline ( NCT04602494 ), and text message intervention ( NCT04919590 ).

Finally, evaluation of vaping as a potential tool for harm reduction among current cigarette smokers is undergoing further evaluation ( NCT03235505 ), which will add to the body of work and eventually lead to clear policy guidance.

Several guidelines on the management of vaping related lung injury have been published and are summarized in table 1 . 194 195 196 Given the relatively small number of cases, the fact that vaping related lung injury remains a newer clinical entity, and the lack of clinical trials on the topic, guideline recommendations reflect best practices and expert opinion. Further, published guidelines focus on the diagnosis and management of EVALI, and no guidelines exist to date for the management of vaping related lung injury more generally.

Summary of clinical guidelines

• View inline

Conclusions

Vaping has grown in popularity internationally over the past decade, in part propelled by innovations in vape pen design and nicotine flavoring. Teens and young adults have seen the biggest uptake in use of vape pens, which have superseded conventional cigarettes as the preferred modality of nicotine consumption. Despite their widespread popularity, relatively little is known about the potential effects of chronic vaping on the respiratory system, and a growing body of literature supports the notion that vaping is not without risk. The 2019 EVALI outbreak highlighted the potential harms of vaping, and the consequences of long term use remain unknown.

Discussions regarding the potential harms of vaping are reminiscent of scientific debates about the health effects of cigarette use in the 1940s. Interesting parallels persist, including the fact that only a minority of conventional cigarette users develop acute lung injury, yet the health impact of sustained, longitudinal cigarette use is unquestioned. The true impact of vaping on respiratory health will manifest over the coming decades, but in the interval a prudent and time tested recommendation remains to abstain from consumption of inhaled nicotine and other products.

Questions for future research

How does chronic vape aerosol exposure affect respiratory health?

Does use of vape pens affect respiratory physiology (airway resistance, V/Q matching, etc) in those with underlying lung disease?

What is the role for vape pen use in promoting smoking cessation?

What is the significance of pulmonary alveolar macrophages in the pathophysiology of vaping related lung injury?

Are particular populations more susceptible to vaping related lung injury (ie, by sex, demographic, underlying comorbidity, or age)?

Series explanation: State of the Art Reviews are commissioned on the basis of their relevance to academics and specialists in the US and internationally. For this reason they are written predominantly by US authors

Contributors: AJ conceived of, researched, and wrote the piece. She is the guarantor.

Competing interests: I have read and understood the BMJ policy on declaration of interests and declare the following interests: AJ receives consulting fees from DawnLight, Inc for work unrelated to this piece.

Patient involvement: No patients were directly involved in the creation of this article.

Provenance and peer review: Commissioned; externally peer reviewed.

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National Institute of Environmental Health Sciences

Your environment. your health., smoking and vaping, what is niehs doing, further reading, introduction.

The smoke from the tobacco in conventional cigarettes and the vapor produced by electronic cigarettes both contain thousands of chemicals, of which many are hazardous to our health.

The link between smoking and disease , particularly lung cancer and cardiovascular disease, is well understood. Cigarette smoking remains the leading cause of preventable death in the United States.

E-cigarettes initially resembled traditional cigarettes and were introduced as a smoking cessation tool for people who smoked cigarettes made with tobacco. Their appearance and use has changed over the past two decades. Under an umbrella term of “electronic nicotine delivery systems (ENDS),” products referred to here as e-cigarettes may also be called vapes, vaporizers, vape pens, hookah pens, e-cigs, e-cigars, and e-pipes.

The 2021 National Youth Tobacco Survey found that more than 2 million middle and high school kids used e-cigarettes , and most used a flavored product. There is public health concern about the popularity of e-cigarette products, especially the flavored variety with kids.

Over the decades, NIEHS researchers have identified many ways that cigarette smoke negatively affects health. Some findings follow.

Asthma . Cigarette smoke contains formaldehyde, lead, tar, nicotine, and other chemicals, many of which act as irritants and worsen symptoms in people with asthma and allergies. Studies have found that smoking decreases the effectiveness of inhalers used to treat asthma. 1

Autoimmune diseases are caused by the body’s immune system attacking healthy cells. Studies have shown cigarette smoke to be a risk factor in the development of rheumatoid arthritis, an autoimmune disease that affects joints. 2

Male fertility . NIEHS-funded researchers discovered cigarette smoking is linked to sperm abnormalities that may limit men’s fertility. They found smokers had lower sperm volume and total sperm count. 3

Maternal smoking and children . Studies have shown that there is no safe level or safe trimester for maternal smoking during pregnancy. 4  Maternal smoking has also been associated with childhood obesity and preterm birth. 5

E-Cigarettes

A short history of e-cigarettes.

2006: When e-cigarettes first appeared in the U.S., they resembled cigarettes and were primarily used as a tool for people who wanted to quit smoking.

2010: Developers started modifying vaping liquid to add flavors, such as fruit and mint. Bigger batteries and settings gave users control over the heating coil, allowing them to alter the amount of aerosol delivered.

2015: New devices reduced the larger vaporizers to small devices that resembled a USB drive. The chemistry of the liquid was also changed, allowing the concentration of nicotine to double.

2016: The U.S. Food and Drug Administration (FDA) began to regulate e-cigarettes as new tobacco products. The market was soon flooded with disposable devices that came in many flavors, shapes, and colors that were attractive to young people.

2019: An outbreak of EVALI (E-cigarette, or Vaping Product, Use Associated Lung Injury), a severe and potentially lethal lung disease, led to 2,807 hospitalizations and 68 deaths . The outbreak was eventually attributed to a chemical added to some vaping devices.

2020: FDA issued a partial ban on some flavors because of their appeal to youth.

How They Work

E-cigarette work by heating a liquid, which typically contains nicotine, to generate an aerosol or vapor that users inhale. This is commonly known as vaping. Vaping owes its popularity, particularly among teens and young adults, to easy availability, targeted marketing, and creative flavors.

Are They Safe?

Over the years, the safety of e-cigarettes has been called into question. 6  While an understanding of the health effects of vaping remains incomplete, 7  studies have shown that e-cigarettes may harm human health. 8  For example, studies associate e-cigarette use with asthma and COPD. 9  Other studies linked vaping with cardiopulmonary illnesses. 10

Smoking, Vaping, and COVID-19

The evidence supports a role for both e-cigarettes and cigarette smoking in increasing the risk of hospital admission, disease severity, and death related to COVID-19. 11  A study of college students showed that dual use of nicotine products — e-cigarettes and conventional cigarettes together — increased COVID-19-related risks. 12

Toxic metal exposure, from tobacco smoke and elsewhere, may also be considered a potential risk factor for COVID-19 severity. 13

Smoking status and intensity of smoking were associated with hospitalizations and ICU admission in patients with COVID-19. 14  Smokers with COVID-19 are more likely to require ventilation, have a major cardiovascular event, or to die, regardless of their sociodemographic or medical history. 15  Men who smoke are more likely to die from COVID-19 than women. 16

• Polosa R, Thomson NC. 2013. Smoking and asthma: dangerous liaisons. Eur Respir J 41(3):716-726. [ Abstract Polosa R, Thomson NC. 2013. Smoking and asthma: dangerous liaisons. Eur Respir J 41(3):716-726. ]
• Chang K, Yang SM, Kim SH, Han KH, Park SJ, Shin JI. 2014. Smoking and rheumatoid arthritis. Int J Mol Sci 15(12):22279-22295. [ Abstract Chang K, Yang SM, Kim SH, Han KH, Park SJ, Shin JI. 2014. Smoking and rheumatoid arthritis. Int J Mol Sci 15(12):22279-22295. ]
• Tang Q, Pan F, Wu X, Nichols CE, Wang X, Xia Y, London SJ, Wu W. 2019. Semen quality and cigarette smoking in a cohort of healthy fertile men. Environ Epidem 3(4):e055. [ Abstract Tang Q, Pan F, Wu X, Nichols CE, Wang X, Xia Y, London SJ, Wu W. 2019. Semen quality and cigarette smoking in a cohort of healthy fertile men. Environ Epidem 3(4):e055. ]
• Liu B, Xu G, Sun Y, Qiu X, Ryckman KK, Yu Y, Snetselaar LG, Bao W. 2020. Maternal cigarette smoking before and during pregnancy and the risk of preterm birth: A dose-response analysis of 25 million mother-infant pairs. PLoS Med. 17(8):e1003158. [ Abstract Liu B, Xu G, Sun Y, Qiu X, Ryckman KK, Yu Y, Snetselaar LG, Bao W. 2020. Maternal cigarette smoking before and during pregnancy and the risk of preterm birth: A dose-response analysis of 25 million mother-infant pairs. PLoS Med. 17(8):e1003158. ]
• VVrijheid M, Fossati S, Maitre L, Márquez S, Roumeliotaki T, Agier L, Andrusaityte S, Cadiou S, Casas M, de Castro M, Dedele A, Donaire-Gonzalez D, Grazuleviciene R, Haug LS, McEachan R, Meltzer HM, Papadopouplou E, Robinson O, Sakhi AK, Siroux V, Sunyer J, Schwarze PE, Tamayo-Uria I, Urquiza J, Vafeiadi M, Valentin A, Warembourg C, Wright J, Nieuwenhuijsen MJ, Thomsen C, Basagaña X, Slama R, Chatzi L. 2020. Early-life environmental exposures and childhood obesity: An exposome-wide approach. Environ Health Perspect. Jun;128(6):67009. [ Abstract VVrijheid M, Fossati S, Maitre L, Márquez S, Roumeliotaki T, Agier L, Andrusaityte S, Cadiou S, Casas M, de Castro M, Dedele A, Donaire-Gonzalez D, Grazuleviciene R, Haug LS, McEachan R, Meltzer HM, Papadopouplou E, Robinson O, Sakhi AK, Siroux V, Sunyer J, Schwarze PE, Tamayo-Uria I, Urquiza J, Vafeiadi M, Valentin A, Warembourg C, Wright J, Nieuwenhuijsen MJ, Thomsen C, Basagaña X, Slama R, Chatzi L. 2020. Early-life environmental exposures and childhood obesity: An exposome-wide approach. Environ Health Perspect. Jun;128(6):67009. ]
• Gordon T, Karey E, Rebuli ME, Escobar YH, Jaspers I, Chen LC. 2022. E-cigarette toxicology. Annual Review of Pharmacology and Toxicology. 62:1, 301-322. [ Abstract Gordon T, Karey E, Rebuli ME, Escobar YH, Jaspers I, Chen LC. 2022. E-cigarette toxicology. Annual Review of Pharmacology and Toxicology. 62:1, 301-322. ]
• Bonner E, Chang Y, Christie E, Colvin V, Cunningham B, Elson D, Ghetu C, Huizenga J, Hutton SJ, Kolluri SK, Maggio S, Moran I, Parker B, Rericha Y, Rivera BN, Samon S, Schwichtenberg T, Shankar P, Simonich MT, Wilson LB, Tanguay RL. 2021. The chemistry and toxicology of vaping. Pharmacol Ther. 225:107837. [ Abstract Bonner E, Chang Y, Christie E, Colvin V, Cunningham B, Elson D, Ghetu C, Huizenga J, Hutton SJ, Kolluri SK, Maggio S, Moran I, Parker B, Rericha Y, Rivera BN, Samon S, Schwichtenberg T, Shankar P, Simonich MT, Wilson LB, Tanguay RL. 2021. The chemistry and toxicology of vaping. Pharmacol Ther. 225:107837. ]
• Tehrani MW, Newmeyer MN, Rule AM, Prasse C. 2021. Characterizing the chemical landscape in commercial e-cigarette liquids and aerosols by liquid chromatography-high-resolution mass spectrometry. Chem Res Toxicol. 34(10):2216-2226. [ Abstract Tehrani MW, Newmeyer MN, Rule AM, Prasse C. 2021. Characterizing the chemical landscape in commercial e-cigarette liquids and aerosols by liquid chromatography-high-resolution mass spectrometry. Chem Res Toxicol. 34(10):2216-2226. ]
• Wills TA, Soneji SS, Choi K, Jaspers I, Tam EK. 2021. E-cigarette use and respiratory disorders: an integrative review of converging evidence from epidemiological and laboratory studies. Eur Respir J. 57(1):1901815. [ Abstract Wills TA, Soneji SS, Choi K, Jaspers I, Tam EK. 2021. E-cigarette use and respiratory disorders: an integrative review of converging evidence from epidemiological and laboratory studies. Eur Respir J. 57(1):1901815. ]
• Benowitz NL, Goniewicz ML, Halpern-Felsher B, Krishnan-Sarin S, Ling PM, O'Connor RJ, Pentz MA, Robertson RM, Bhatnagar A. 2022. Tobacco product use and the risks of SARS-CoV-2 infection and COVID-19: current understanding and recommendations for future research. Lancet Respir Med. 10(9):900-915. [ Abstract Benowitz NL, Goniewicz ML, Halpern-Felsher B, Krishnan-Sarin S, Ling PM, O'Connor RJ, Pentz MA, Robertson RM, Bhatnagar A. 2022. Tobacco product use and the risks of SARS-CoV-2 infection and COVID-19: current understanding and recommendations for future research. Lancet Respir Med. 10(9):900-915. ]
• Merianos AL, Russell AM, Mahabee-Gittens EM, Barry AE, Yang M, Lin HC. 2022. Assessment of exclusive, dual, and polytobacco e-cigarette use and COVID-19 outcomes among college students. Am J Health Promot. 36(3):421-428. [ Abstract Merianos AL, Russell AM, Mahabee-Gittens EM, Barry AE, Yang M, Lin HC. 2022. Assessment of exclusive, dual, and polytobacco e-cigarette use and COVID-19 outcomes among college students. Am J Health Promot. 36(3):421-428. ]
• Skalny AV, Lima TRR, Ke T, Zhou JC, Bornhorst J, Alekseenko SI, Aaseth J, Anesti O, Sarigiannis DA, Tsatsakis A, Aschner M, Tinkov AA. 2020. Toxic metal exposure as a possible risk factor for COVID-19 and other respiratory infectious diseases. Food and Chemical Toxicology, Volume 146, 111809, ISSN 0278-6915. [ Abstract Skalny AV, Lima TRR, Ke T, Zhou JC, Bornhorst J, Alekseenko SI, Aaseth J, Anesti O, Sarigiannis DA, Tsatsakis A, Aschner M, Tinkov AA. 2020. Toxic metal exposure as a possible risk factor for COVID-19 and other respiratory infectious diseases. Food and Chemical Toxicology, Volume 146, 111809, ISSN 0278-6915. ]
• Mahabee-Gittens EM, Mendy A, Merianos AL. 2021. Assessment of severe COVID-19 outcomes using measures of smoking status and smoking intensity. Int J Environ Res Public Health. 18(17):8939. [ Abstract Mahabee-Gittens EM, Mendy A, Merianos AL. 2021. Assessment of severe COVID-19 outcomes using measures of smoking status and smoking intensity. Int J Environ Res Public Health. 18(17):8939. ]
• Poudel R, Daniels LB, DeFilippis AP, Hamburg NM, Khan Y, Keith RJ, Kumar RS, Strokes AC, Robertson RM, Bhatnagar A. 2022. Smoking is associated with increased risk of cardiovascular events, disease severity, and mortality among patients hospitalized for SARS-CoV-2 infections. PLoS One. 17(7):e0270763. [ Abstract Poudel R, Daniels LB, DeFilippis AP, Hamburg NM, Khan Y, Keith RJ, Kumar RS, Strokes AC, Robertson RM, Bhatnagar A. 2022. Smoking is associated with increased risk of cardiovascular events, disease severity, and mortality among patients hospitalized for SARS-CoV-2 infections. PLoS One. 17(7):e0270763. ]
• Khalil A, Dhingra R, Al-Mulki J, Hassoun M, Alexis N. 2021. Questioning the sex-specific differences in the association of smoking on the survival rate of hospitalized COVID-19 patients. PLoS One. 16(8):e0255692. [ Abstract Khalil A, Dhingra R, Al-Mulki J, Hassoun M, Alexis N. 2021. Questioning the sex-specific differences in the association of smoking on the survival rate of hospitalized COVID-19 patients. PLoS One. 16(8):e0255692. ]

NIEHS scientists are conducting the E-Cigs and Smoking Study , to develop new biomarkers, or indicators of what is normal or abnormal in our bodies, for both tobacco smoke exposure and e-cigarette use.

Toxic Metals

Another NIEHS-funded study, Exposure to Metals from E-Cigarettes (EMIT), has shown that e-cigarettes expose users to toxic metals such as arsenic and lead. A related study showed that exposure to ethyl maltol and copper in e-cigarettes caused the cells that line the surface of the lungs to die. 17

Other studies have shown that e-cigarettes are potential sources of exposure to chromium, nickel, manganese and zinc. 18  These and other metals are particularly toxic to the heart and vascular system. 19  This “neurotoxicity” can result in inflammation and impair cells’ ability to rid themselves of toxins, called oxidative stress. 20  Most metal levels found in the tissue of e-cigarette users were similar or higher than levels of the same metals found in users of conventional cigarettes. 21

A 2023 study measured and compared metal aerosol concentrations by device type and common flavors. Metals and metalloids measured included: aluminum, arsenic, cobalt, chromium, copper, iron, manganese, nickel, lead, antimony, tin, and zinc. The study revealed wide variability in aerosol metal concentrations among different e-cigarette device types, brands, and flavors. Tobacco-flavored aerosols contained the highest metal concentrations. Metal concentration differences among types of devices appears to be related to the coil composition or power within the device.

NIEHS and E-Cigarette Education

NIEHS and the University of North Carolina at Chapel Hill Center for Public Engagement with Science are bringing the science of e-cigarettes and other environmental health topics to the most likely demographic to take up using the products: K-12 students.

The NIEHS-funded Environmental Health Sciences Center at the University of Rochester developed a learning kit for students called “Are Flavored E-cigarettes Harmful?” The lesson demonstrates how flavor compounds affect lung cells. The kit is based on published research studies from the laboratory of Irfan Rahman, Ph.D. , who investigates the health effects of flavoring chemicals.

• Durrani K, El Din SA, Sun Y, Rule AM, Bressler J. 2021. Ethyl maltol enhances copper mediated cytotoxicity in lung epithelial cells. Toxicol Appl Pharmacol. Jan 1;410:115354. [ Abstract Durrani K, El Din SA, Sun Y, Rule AM, Bressler J. 2021. Ethyl maltol enhances copper mediated cytotoxicity in lung epithelial cells. Toxicol Appl Pharmacol. Jan 1;410:115354. ]
• Olmedo P, Goessler W, Tanda S, Grau-Perez M, Jarmul S, Aherrera A, Chen R, Hilpert M, Cohen JE, Navas-Acien A, Rule AM. 2018. Metal concentrations in e-cigarette liquid and aerosol samples: The contribution of metallic coils. Environmental Health Perspectives 126:2 CID: 027010. [ Abstract Olmedo P, Goessler W, Tanda S, Grau-Perez M, Jarmul S, Aherrera A, Chen R, Hilpert M, Cohen JE, Navas-Acien A, Rule AM. 2018. Metal concentrations in e-cigarette liquid and aerosol samples: The contribution of metallic coils. Environmental Health Perspectives 126:2 CID: 027010. ] [ Full Text Olmedo P, Goessler W, Tanda S, Grau-Perez M, Jarmul S, Aherrera A, Chen R, Hilpert M, Cohen JE, Navas-Acien A, Rule AM. 2018. Metal concentrations in e-cigarette liquid and aerosol samples: The contribution of metallic coils. Environmental Health Perspectives 126:2 CID: 027010. ]
• Navas-Acien A, Martinez-Morata I, Hilpert M, Rule A, Shimbo D, LoIacono NJ. 2020. Early cardiovascular risk in e-cigarette users: The potential role of metals. Curr Environ Health Rep. 7(4):353-361. [ Abstract Navas-Acien A, Martinez-Morata I, Hilpert M, Rule A, Shimbo D, LoIacono NJ. 2020. Early cardiovascular risk in e-cigarette users: The potential role of metals. Curr Environ Health Rep. 7(4):353-361. ]
• Ruszkiewicz JA, Zhang Z, Gonçalves FM, Tizabi Y, Zelikoff JT, Aschner M. 2020. Neurotoxicity of e-cigarettes. Food Chem Toxicol. 138:111245. [ Abstract Ruszkiewicz JA, Zhang Z, Gonçalves FM, Tizabi Y, Zelikoff JT, Aschner M. 2020. Neurotoxicity of e-cigarettes. Food Chem Toxicol. 138:111245. ]
• Zhao D, Aravindakshan A, Hilpert M, Olmedo P, Rule AM, Navas-Acien A, Aherrera A. 2020. Metal/metalloid levels in electronic cigarette liquids, aerosols, and human biosamples: A systematic review. Environmental Health Perspectives 128:3. [ Abstract Zhao D, Aravindakshan A, Hilpert M, Olmedo P, Rule AM, Navas-Acien A, Aherrera A. 2020. Metal/metalloid levels in electronic cigarette liquids, aerosols, and human biosamples: A systematic review. Environmental Health Perspectives 128:3. ]

Stories from the Environmental Factor (NIEHS Newsletter)

• Vaping’s respiratory effects traced by leading basic researcher (April 2023)
• E-cigarettes Expose Users to Toxic Metals Such As Arsenic, Lead (February 2022)

Additional Resources

• Facts on E-Cigarette Use Among Youth and Young Adults – Information from the U.S. Surgeon General
• E-Cigarettes, Vapes, and other Electronic Nicotine Delivery Systems – Information from the Food and Drug Administration
• Secondhand Smoke: Questions and Answers – Information from the National Cancer Institute
• Secondhand Smoke and Smoke-free Homes – Information from the U.S. Environmental Protection Agency
• Smoking and Tobacco Use – Information from the Centers for Disease Control and Prevention
• Vaping and E-Cigarettes: A Toolkit for Working With Youth – Available in English and Spanish, an FDA toolkit for professionals working with youth

Related Health Topics

• Indoor Air Quality
• Formaldehyde

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Studying vaping behavior to improve public health

At the Center for the Study of Tobacco Products, psychologists partner with chemists, engineers and other researchers to understand how e-cigarettes work—insights that will inform future regulation

Vol. 51, No. 5 Print version: page 72

• Substance Use, Abuse, and Addiction
• Forensics, Law, and Public Safety

How much nicotine is in an electronic cigarette? That depends on your address. In the European Union, regulations require e-cigarette liquids to contain no more than 20 mg per mL. In the United States, the liquid might contain two or even three times as much nicotine. Now, American legislators are considering similar regulations limiting the nicotine in vaping liquid in an effort to protect public health.

That would be a big mistake, says Tom Eissenberg, PhD, a professor of psychology at Virginia Commonwealth University (VCU) and co-principal investigator at VCU’s Center for the Study of Tobacco Products (CSTP). “On its surface, it makes sense. But such regulation won’t achieve its intended goal, and will probably harm people,” he says.

The reasons have to do with the way e-cigarettes are designed. The devices use a heating element to aerosolize an inhalable liquid containing nicotine, solvents and, often, flavorings. But the devices are available in different wattages, and some devices allow users to turn up the power settings, which results in more vapor and a bigger hit of nicotine. “Users can get around the restrictions on nicotine by increasing the power,” explains Alison Breland, PhD, an assistant research professor of health psychology at VCU and co-principal investigator at the CSTP.

Research from the CSTP team suggests that when nicotine levels in e-cigarette liquid are low, users are likely to ramp up a device’s power to compensate. In the process, the overheated liquids break down into harmful by-products such as the carcinogen formaldehyde. In other words, limiting nicotine levels without understanding how that might affect user behavior could backfire in a dangerous way.

“Limiting nicotine drives addicted people to use high-powered vaping devices, which emit more nicotine and more toxicants,” Eissenberg says. “It’s an example of a regulation that should have been tested in a laboratory first.”

That’s where the CSTP comes in. The multidisciplinary center’s central mission: to test the likely outcomes of potential regulations and provide the U.S. Food and Drug Administration (FDA) with data to inform future regulatory action. It’s a collaborative effort, with more than three dozen faculty and staff from psychology, engineering, chemistry, public health and other fields.

“We want to understand what these products do, how much nicotine and other toxicants they deliver, and how users’ behavior influences what they’re exposed to,” Breland says. “The FDA can put regulations in place to protect public health, but they’re looking for scientific evidence to back them up. Our goal is to give the FDA information to help them make the right regulations.”

Threading the needle

The popularity of e-cigarettes in the U.S. marketplace is soaring—especially among young people. The number of high school students who reported vaping nicotine in the past month rose sharply between 2017 and 2019, according to preliminary data from the University of Michigan’s long-running Monitoring the Future survey (Miech, R., et al., The New England Journal of Medicine , Vol. 381, No. 15, 2019). That report found, for instance, that more than a quarter of 12th graders reported past-month vaping in 2019, compared with 11% two years earlier. Another 2019 study found 27.5% of high school students and 10.5% of middle schoolers reported they had used e-cigarettes (Cullen, K.A., et al., JAMA , Vol. 322, No. 21, 2019).

At the same time, a spate of lung injuries and deaths associated with vaping has brought increased public attention to these products and highlighted how little researchers still know about their potential impact on users’ health, and how they should be regulated.

Proponents maintain that e-cigarettes are a less harmful alternative to traditional cigarettes since they can contain fewer dangerous contaminants than tobacco smoke and may serve as a transitional product to help smokers eventually quit nicotine altogether. But others raise concerns that e-cigarettes could be harmful if they undermine people’s attempts to quit smoking, or encourage nonsmokers to start using nicotine.

“We are all trying to thread this needle of having products on the market that are hopefully lower harm than combustible cigarettes, [but not] enticing to naive users,” says Andrew Barnes, PhD, an associate professor of health behavior and policy at VCU and a member of the research team.

Hoping to help regulators strike that balance, the team is tackling a broad set of questions about how e-cigarettes work, how much nicotine and toxicants they deliver, and how people are using them. To answer those questions, the VCU team has partnered with researchers at institutions including the American University of Beirut in Lebanon, Johns Hopkins University, the University of Arkansas for Medical Sciences, the University of Southern California and the University of Oklahoma Health Sciences Center.

The collaboration developed in the aftermath of a 2009 law granting the FDA authority to regulate tobacco. Realizing the agency needed science to guide its regulatory efforts, the FDA joined with the National Institutes of Health (NIH) to create the Tobacco Centers of Regulatory Science (TCORS) at research institutions throughout the country. Eissenberg had been studying tobacco products since 1999, and he jumped at the chance to get involved. In 2013, the CSTP was launched with a five-year, $18.3 million TCORS grant.

In its first five years, the center focused on studying how e-cigarettes and tobacco products function and how people use them. With its second round of funding—a five-year, $19.7 million TCORS grant awarded in 2018—the researchers are building on that earlier work to predict the effects of potential regulations, such as those limiting e-cigarette nicotine levels or power settings.

Predicting the outcomes of e-cigarette regulations is tricky, because the devices and their users vary so much. The amount of nicotine and toxicants that an e-cigarette delivers depends on a combination of the device design, the content of the liquid, and user behaviors such as the rate at which users puff and how long they inhale. Putting together all of those pieces requires a transdisciplinary effort, and the CSTP has embraced the team approach. In 2018, the center won the APA Prize for Interdisciplinary Team Research, which included $5,000 to put toward their continuing research efforts.

While engineers and analytical chemists have examined the designs of different kinds of e-cigarettes and developed specialized equipment to measure the exact length, volume and rate of people’s puffs, psychologists focus on factors that influence individual behavior, as Breland, Eissenberg and colleagues described in a 2019 article about their multidisciplinary model (Breland, A., et al., American Psychologist , Vol. 74, No. 3, 2019).

Psychology is no more important than other disciplines in the partnership, Eissenberg stresses, but it does bring an essential perspective to the research. “Addiction is a disease of behavior, and psychologists should be on any team that is involved with trying to understand and regulate an addictive behavior,” he says.

Potential for abuse

In one key example of the importance of behavioral research, the team found that experienced e-cigarette users are able to get more nicotine from a puff of an advanced-generation e-cigarette than they’d typically get from a tobacco cigarette (Hiler, M., et al., Experimental and Clinical Psychopharmacology , Vol. 25, No. 5, 2017). The earliest e-cigarettes had previously been found to emit little if any nicotine, Breland says, but this study showed that newer devices are a different story. “That was a key finding, showing that these later-generation devices have the ability to deliver quite a lot of nicotine.”

The nicotine delivery rate is known as “nicotine flux,” and it’s something the research team is very interested in, Breland says. As far as public health is concerned, it’s what ends up in a user’s body that counts. For that reason, regulating nicotine flux could be more effective than regulating the amount of nicotine that can go into the device, as the European Union has done.

The team is now undertaking lab studies to see what happens when nicotine flux is limited. They’re studying physical responses, such as the frequency and volume of puffs and how much nicotine is delivered to the bloodstream, as well as emotional and behavioral factors, such as how well different products relieve cravings and how pleasant they are to use.

“Those things end up being more important than you might imagine. If a product doesn’t reduce cravings, people won’t use it. On the other hand, if you have a product people love, you’re looking at the potential for abuse,” Breland says.

Some team members are taking other approaches to studying “abuse liability,” or the potential for people to become dependent on e-cigarettes. In one study, Barnes and Caroline Cobb, PhD, an assistant professor of psychology at VCU, have recruited smokers and e-cigarette users to vape various products in their lab. As one indicator of abuse liability, the researchers will measure how hard participants are willing to work—by pressing a space bar key—to earn puffs from a given e-cigarette condition. The premise is that participants will work harder (press the key more often) to access more desirable conditions.

“Our preliminary data show people are working harder for the low-nicotine and high-watt condition,” Barnes says, suggesting that such a combination—in which higher wattage results in higher nicotine flux—may present a greater risk of addiction.

Ultimately, the researchers hope to identify a nicotine flux range that would deliver nicotine fast enough to satisfy smokers (so that they would be more inclined to switch from tobacco to less harmful e-cigarettes), but not so satisfying that it would increase their nicotine cravings or hook new users. The goal, Eissenberg adds, is that the FDA could require e-cigarettes to operate within that range. “We’re trying to find the sweet spot for nicotine delivery,” he says.

Another CSTP team member, Joanna Cohen, PhD, of the Bloomberg School of Public Health at Johns Hopkins University, has launched a survey of 1,200 e-cigarette users. Participants will be surveyed every three months about their use of e-cigarettes and other tobacco products to understand how their behaviors are changing as regulatory changes occur.

The survey will ask how users are reacting to the federal ban on fruit and mint flavors in e-cigarettes that use cartridges (like the JUUL vaping device). Will users vape less? Or will they switch to potentially more harm-ful combustible cigarettes or open-system e-cigarettes that allow them to add their own flavors?

Understanding such responses is critical for ensuring regulations benefit public health without creating unintended consequences, Cohen says. “That allows regulators to close policy loopholes, maximize the individual and public health benefits from their policies and minimize the harms.”

The CSTP researchers aren’t privy to the FDA’s future regulatory plans, Breland says, but the team has made some recommendations based on their findings so far. One is the recommendation to restrict open-system vaping devices. In open systems, people can pour in any liquid they like, meaning it can contain any amount of nicotine, additives or flavor compounds. The power settings in such devices also vary widely, some reaching as high as 200 watts. Closed systems use premeasured pods of nicotine liquid, and operate at about 8 watts—meaning users can’t turn up the power to levels that will overheat the liquid and produce dangerous by-products.

“In closed systems, users pop in a pod of liquid that ideally has some quality control and could be regulated in a way that users know what’s going into it. People can’t modify the liquid, and their ability to modify the power settings is very limited,” Breland says. Those limits mean it’s much more practical to regulate nicotine flux within a closed system.

For now, though, e-cigarettes and their nicotine liquids vary dramatically in design, power and nicotine flux, making the industry a bit like the Wild West, Eissenberg says. “I see that continuing unless someone gets ahold of it and reins it in.” But he’s buoyed by the fact that the FDA is looking to the research to guide its decisions. “Data will drive effective regulation,” he adds. 

Further reading

Reasons for Transition From Electronic Cigarette Use to Cigarette Smoking Among Young Adult College Students Hiler, M., et al., Journal of Adolescent Health , 2020

What Factors Reliably Predict Electronic Cigarette Nicotine Delivery? Blank, M.D., et al., Tobacco Control , 2019

Electronic Cigarettes: What Are They and What Do They Do? Breland, A., et al., Annals of the New York Academy of Sciences , 2017

Joanna Broder contributed to this report.

“Lab Work” illuminates the work of psychologists in research labs. To read previous installments, go to the Monitor and search for “Lab Work.”

Recommended Reading

Research foci.

The Center for the Study of Tobacco Products is:

• Studying how e-cigarette emissions of nicotine and toxicants will be influenced by various regulatory actions.
• Collecting behavioral data to test hypotheses about e-cigarette use to predict how potential regulatory action might affect user behavior.
• Predicting how various regulatory actions will affect the potential for people to misuse or become dependent on e-cigarettes.

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National Center for Chronic Disease Prevention and Health Promotion (US) Office on Smoking and Health. E-Cigarette Use Among Youth and Young Adults: A Report of the Surgeon General [Internet]. Atlanta (GA): Centers for Disease Control and Prevention (US); 2016.

E-Cigarette Use Among Youth and Young Adults: A Report of the Surgeon General [Internet].

Chapter 1 introduction, conclusions, and historical background relative to e-cigarettes.

• Introduction

Although conventional cigarette smoking has declined markedly over the past several decades among youth and young adults in the United States ( U.S. Department of Health and Human Services [USDHHS] 2012 ), there have been substantial increases in the use of emerging tobacco products among these populations in recent years ( Centers for Disease Control and Prevention [CDC] 2015c ). Among these increases has been a dramatic rise in electronic cigarette (e-cigarette) use among youth and young adults. It is crucial that the progress made in reducing cigarette smoking among youth and young adults not be compromised by the initiation and use of e-cigarettes. This Surgeon General’s report focuses on the history, epidemiology, and health effects of e-cigarette use among youth and young adults; the companies involved with marketing and promoting these products; and existing and proposed public health policies regarding the use of these products by youth and young adults.

E-cigarettes include a diverse group of devices that allow users to inhale an aerosol, which typically contains nicotine, flavorings, and other additives. E-cigarettes vary widely in design and appearance, but generally operate in a similar manner and are composed of similar components ( Figure 1.1 ). A key challenge for surveillance of the products and understanding their patterns of use is the diverse and nonstandard nomenclature for the devices ( Alexander et al. 2016 ). These devices are referred to, by the companies themselves, and by consumers, as “e-cigarettes,” “e-cigs,” “cigalikes,” “e-hookahs,” “mods,” “vape pens,” “vapes,” and “tank systems.” In this report, the term “e-cigarette” is used to represent all of the various products in this rapidly diversifying product category. The terms may differ by geographic region or simply by the prevailing preferences among young users. For example, some refer to all cigarette-shaped products as “e-cigarettes” or as “cigalikes,” and some may refer to the pen-style e-cigarettes as “hookah pens” or “vape pens” ( Richtel 2014 ; Lempert et al. 2016 ).

Diversity of e-cigarette products. Source: Photo by Mandie Mills, CDC.

This report focuses on research conducted among youth and young adults because of the implications of e-cigarette use in this population, particularly the potential for future public health problems. Understanding e-cigarette use among young persons is critical because previous research suggests that about 9 in 10 adult smokers first try conventional cigarettes during adolescence ( USDHHS 2012 ). Similarly, youth e-cigarette experimentation and use could also extend into adulthood; however, e-cigarette use in this population has not been examined in previous reports of the Surgeon General. The first Surgeon General’s report on the health consequences of smoking was published in 1964; of the subsequent reports, those published in 1994 and 2012 focused solely on youth and young adults ( USDHHS 1994 , 2012 ). More recently, the 2012 report documented the evidence regarding tobacco use among youth and young adults, concluding that declines in cigarette smoking had slowed and that decreases in the use of smokeless tobacco had stalled. That report also found that the tobacco industry’s advertising and promotional activities are causal to the onset of smoking in youth and young adults and the continuation of such use as adults ( USDHHS 2012 ). However, the 2012 report was prepared before e-cigarettes were as widely promoted and used in the United States as they are now. Therefore, this 2016 report documents the scientific literature on these new products and their marketing, within the context of youth and young adults. This report also looks to the future by examining the potential impact of e-cigarette use among youth and young adults, while also summarizing the research on current use, health consequences, and marketing as it applies to youth and young adults.

Evidence for this report was gathered from studies that included one or more of three age groups. We defined these age groups to be young adolescents (11–13 years of age), adolescents (14–17 years of age), and young adults (18–24 years of age). Some studies refer to the younger groups more generally as youth. Despite important issues related to e-cigarette use in adult populations, clinical and otherwise (e. g ., their potential for use in conventional smoking cessation), that literature will generally not be included in this report unless it also discusses youth and young adults ( Farsalinos and Polosa 2014 ; Franck et al. 2014 ; Grana et al. 2014 ).

Given the recency of the research that pertains to e-cigarettes, compared with the decades of research on cigarette smoking, the “precautionary principle” is used to guide actions to address e-cigarette use among youth and young adults. This principle supports intervention to avoid possible health risks when the potential risks remain uncertain and have been as yet partially undefined ( Bialous and Sarma 2014 ; Saitta et al. 2014 ; Hagopian et al. 2015 ). Still, the report underscores and draws its conclusions from the known health risks of e-cigarette use in this age group.

Organization of the Report

This chapter presents a brief introduction to this report and includes its major conclusions followed by the conclusions of the chapters, the historical background of e-cigarettes, descriptions of the products, a review of the marketing and promotional activities of e-cigarette companies, and the current status of regulations from the U.S. Food and Drug Administration ( FDA ). Chapter 2 (“Patterns of E-Cigarette Use Among U.S. Youth and Young Adults”) describes the epidemiology of e-cigarette use, including current use (i.e., past 30 day); ever use; co-occurrence of using e-cigarettes with other tobacco products, like cigarettes; and psychosocial factors associated with using e-cigarettes, relying on data from the most recent nationally representative studies available at the time this report was prepared. Chapter 3 (“Health Effects of E-Cigarette Use Among U.S. Youth and Young Adults”) documents the evidence related to the health effects of e-cigarette use, including those that are associated with direct aerosol inhalation by users, the indirect health effects of e-cigarette use, other non-aerosol health effects of e-cigarette use, and secondhand exposure to constituents of the aerosol. Chapter 4 (“Activities of the E-Cigarette Companies”) describes e-cigarette companies’ influences on e-cigarette use and considers manufacturing and price; the impact of price on sales and use; the rapid changes in the industry, particularly the e-cigarette companies; and the marketing and promotion of e-cigarettes. Chapter 5 (“E-Cigarette Policy and Practice Implications”) discusses the implications for policy and practice at the national, state, and local levels. The report ends with a Call to Action to stakeholders—including policymakers, public health practitioners and clinicians, researchers, and the public—to work to prevent harms from e-cigarette use and secondhand aerosol exposure among youth and young adults.

Preparation of this Report

This Surgeon General’s report was prepared by the Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC , which is part of USDHHS . The initial drafts of the chapters were written by 27 experts who were selected for their knowledge of the topics addressed. These contributions are summarized in five chapters that were evaluated by approximately 30 peer reviewers. After peer review, the entire manuscript was sent to more than 20 scientists and other experts, who examined it for its scientific integrity. After each review cycle, the drafts were revised by the report’s scientific editors on the basis of reviewers’ comments. Subsequently, the report was reviewed by various institutes and agencies within USDHHS.

Scientific Basis of the Report

The statements and conclusions throughout this report are documented by the citation of studies published in the scientific literature. Publication lags have prevented an up-to-the-minute inclusion of all recently published articles and data. This overall report primarily cites peer-reviewed journal articles, including reviews that integrate findings from numerous studies and books that were published through December 2015. However, selected studies from 2016 have been added during the review process that provide further support for the conclusions in this report. When a cited study has been accepted for publication, but the publication has not yet occurred because of the delay between acceptance and final publication, the study is referred to as “in press.” This report also refers, on occasion, to unpublished research, such as presentations at a professional meeting, personal communications from a researcher, or information available in various media. These references are employed when acknowledged by the editors and reviewers as being from reliable sources, which add to the emerging literature on a topic.

• Major Conclusions
• E-cigarettes are a rapidly emerging and diversified product class. These devices typically deliver nicotine, flavorings, and other additives to users via an inhaled aerosol. These devices are referred to by a variety of names, including “e-cigs,” “e-hookahs,” “mods,” “vape pens,” “vapes,” and “tank systems.”
• E-cigarette use among youth and young adults has become a public health concern. In 2014, current use of e-cigarettes by young adults 18–24 years of age surpassed that of adults 25 years of age and older.
• E-cigarettes are now the most commonly used tobacco product among youth, surpassing conventional cigarettes in 2014. E-cigarette use is strongly associated with the use of other tobacco products among youth and young adults, including combustible tobacco products.
• The use of products containing nicotine poses dangers to youth, pregnant women, and fetuses. The use of products containing nicotine in any form among youth, including in e-cigarettes, is unsafe.
• E-cigarette aerosol is not harmless. It can contain harmful and potentially harmful constituents, including nicotine. Nicotine exposure during adolescence can cause addiction and can harm the developing adolescent brain.
• E-cigarettes are marketed by promoting flavors and using a wide variety of media channels and approaches that have been used in the past for marketing conventional tobacco products to youth and young adults.
• Action can be taken at the national, state, local, tribal, and territorial levels to address e-cigarette use among youth and young adults. Actions could include incorporating e-cigarettes into smokefree policies, preventing access to e-cigarettes by youth, price and tax policies, retail licensure, regulation of e-cigarette marketing likely to attract youth, and educational initiatives targeting youth and young adults.
• Chapter Conclusions

Chapter 1. Introduction, Conclusions, and Historical Background Relative to E-Cigarettes

• E-cigarettes are devices that typically deliver nicotine, flavorings, and other additives to users via an inhaled aerosol. These devices are referred to by a variety of names, including “e-cigs,” “e-hookahs,” “mods,” “vape pens,” “vapes,” and “tank systems.”
• E-cigarettes represent an evolution in a long history of tobacco products in the United States, including conventional cigarettes.
• In May 2016, the Food and Drug Administration issued the deeming rule, exercising its regulatory authority over e-cigarettes as a tobacco product.

Chapter 2. Patterns of E-Cigarette Use Among U.S. Youth and Young Adults

• Among middle and high school students, both ever and past-30-day e-cigarette use have more than tripled since 2011. Among young adults 18–24 years of age, ever e-cigarette use more than doubled from 2013 to 2014 following a period of relative stability from 2011 to 2013.
• The most recent data available show that the prevalence of past-30-day use of e-cigarettes is similar among high school students (16% in 2015, 13.4% in 2014) and young adults 18–24 years of age (13.6% in 2013–2014) compared to middle school students (5.3% in 2015, 3.9% in 2014) and adults 25 years of age and older (5.7% in 2013–2014).
• Exclusive, past-30-day use of e-cigarettes among 8th-, 10th-, and 12th-grade students (6.8%, 10.4%, and 10.4%, respectively) exceeded exclusive, past-30-day use of conventional cigarettes in 2015 (1.4%, 2.2%, and 5.3%, respectively). In contrast—in 2013–2014 among young adults 18–24 years of age—exclusive, past-30-day use of conventional cigarettes (9.6%) exceeded exclusive, past-30-day use of e-cigarettes (6.1%). For both age groups, dual use of these products is common.
• E-cigarette use is strongly associated with the use of other tobacco products among youth and young adults, particularly the use of combustible tobacco products. For example, in 2015, 58.8% of high school students who were current users of combustible tobacco products were also current users of e-cigarettes.
• Among youth—older students, Hispanics, and Whites are more likely to use e-cigarettes than younger students and Blacks. Among young adults—males, Hispanics, Whites, and those with lower levels of education are more likely to use e-cigarettes than females, Blacks, and those with higher levels of education.
• The most commonly cited reasons for using e-cigarettes among both youth and young adults are curiosity, flavoring/taste, and low perceived harm compared to other tobacco products. The use of e-cigarettes as an aid to quit conventional cigarettes is not reported as a primary reason for use among youth and young adults.
• Flavored e-cigarette use among young adult current users (18–24 years of age) exceeds that of older adult current users (25 years of age and older). Moreover, among youth who have ever tried an e-cigarette, a majority used a flavored product the first time they tried an e-cigarette.
• E-cigarette products can be used as a delivery system for cannabinoids and potentially for other illicit drugs. More specific surveillance measures are needed to assess the use of drugs other than nicotine in e-cigarettes.

Chapter 3. Health Effects of E-Cigarette Use Among U.S. Youth and Young Adults

• Nicotine exposure during adolescence can cause addiction and can harm the developing adolescent brain.
• Nicotine can cross the placenta and has known effects on fetal and postnatal development. Therefore, nicotine delivered by e-cigarettes during pregnancy can result in multiple adverse consequences, including sudden infant death syndrome, and could result in altered corpus callosum, deficits in auditory processing, and obesity.
• E-cigarettes can expose users to several chemicals, including nicotine, carbonyl compounds, and volatile organic compounds, known to have adverse health effects. The health effects and potentially harmful doses of heated and aerosolized constituents of e-cigarette liquids, including solvents, flavorants, and toxicants, are not completely understood.
• E-cigarette aerosol is not harmless “water vapor,” although it generally contains fewer toxicants than combustible tobacco products.
• Ingestion of e-cigarette liquids containing nicotine can cause acute toxicity and possibly death if the contents of refill cartridges or bottles containing nicotine are consumed.

Chapter 4. Activities of the E-Cigarette Companies

• The e-cigarette market has grown and changed rapidly, with notable increases in total sales of e-cigarette products, types of products, consolidation of companies, marketing expenses, and sales channels.
• Prices of e-cigarette products are inversely related to sales volume: as prices have declined, sales have sharply increased.
• E-cigarette products are marketed in a wide variety of channels that have broad reach among youth and young adults, including television, point-of-sale, magazines, promotional activities, radio, and the Internet.
• Themes in e-cigarette marketing, including sexual content and customer satisfaction, are parallel to themes and techniques that have been found to be appealing to youth and young adults in conventional cigarette advertising and promotion.

Chapter 5. E-Cigarette Policy and Practice Implications

• The dynamic nature of the e-cigarette landscape calls for expansion and enhancement of tobacco-related surveillance to include (a) tracking patterns of use in priority populations; (b) monitoring the characteristics of the retail market; (c) examining policies at the national, state, local, tribal, and territorial levels; (d) examining the channels and messaging for marketing e-cigarettes in order to more fully understand the impact future regulations could have; and (e) searching for sentinel health events in youth and young adult e-cigarette users, while longer-term health consequences are tracked.
• Strategic, comprehensive research is critical to identify and characterize the potential health risks from e-cigarette use, particularly among youth and young adults.
• The adoption of public health strategies that are precautionary to protect youth and young adults from adverse effects related to e-cigarettes is justified.
• A broad program of behavioral, communications, and educational research is crucial to assess how youth perceive e-cigarettes and associated marketing messages, and to determine what kinds of tobacco control communication strategies and channels are most effective.
• Health professionals represent an important channel for education about e-cigarettes, particularly for youth and young adults.
• Diverse actions, modeled after evidence-based tobacco control strategies, can be taken at the state, local, tribal, and territorial levels to address e-cigarette use among youth and young adults, including incorporating e-cigarettes into smoke-free policies; preventing the access of youth to e-cigarettes; price and tax policies; retail licensure; regulation of e-cigarette marketing that is likely to attract youth and young adults, to the extent feasible under the law; and educational initiatives targeting youth and young adults. Among others, research focused on policy, economics, and the e-cigarette industry will aid in the development and implementation of evidence-based strategies and best practices.
• Historical Background

Understanding the role of e-cigarettes requires understanding the long history of tobacco use in the United States, including the role of nicotine delivery, the multiple examples of “reduced-harm” products and associated health claims, and the impact of using tobacco products on the public’s health. Since the late nineteenth century, when the “modern” cigarette came into use, scientists and public health officials have linked cigarette smoking to a remarkable number of adverse effects, and it is now recognized as the primary cause of premature death in the United States ( USDHHS 2014 ). Correspondingly, for a century, manufacturers, scientists, entrepreneurs, and public health leaders have promoted or recommended product changes that might remove some of the harmful elements in cigarette smoke. E-cigarettes are among the latest products.

E-cigarettes are designed for users to inhale nicotine, flavorings, and other additives through an aerosol. The claims and marketing strategies employed by the e-cigarette companies, and the efforts made by others to develop scientific and regulatory tools to deal with these new products, both contribute to the current discourse on e-cigarettes. Many lessons for assessing the potential (and future) consequences of these products can be learned from examining the relevant experiences of the past century, especially the introduction of novel products (including e-cigarettes as well as other tobacco and nicotine products) and the claims of reduced exposure to toxins made by the industry and elsewhere.

Early Efforts to Modify Cigarettes

In the 1880s and 1890s, entrepreneurs promoted novel products that allegedly blocked nicotine and other constituents of conventional cigarettes believed to be poisonous. Dr. Scott’s Electric Cigarettes, advertised in Harper’s Weekly, claimed not only to light without matches but also to contain a cotton filter that “strains and eliminates the injurious qualities from the smoke,” including nicotine ( Harper’s Weekly 1887 ). Nicotine delivery was essential to the development of the modern cigarette in the twentieth century; early on, this substance was thought to be addicting and thus vital to retaining customers. In 1913, the Camel brand was a new kind of cigarette that introduced high-nicotine content by using burley tobacco, which was generally too harsh to inhale into the lungs, but was made more inhalable through the addition of casings (e. g ., sugars, licorice) ( Tindall 1992 ; Proctor 2011 ). In 1916, American Tobacco introduced its Lucky Strike blended cigarette, and in 1918 Liggett & Myers ( L &M) reformulated its Chesterfield brand to make it more palatable to users. As the market grew, advertisements for major brands routinely included health-related statements and testimonials from physicians. During the 1930s and 1940s, prominent advertising campaigns included claims like “Not a cough in a carload” (Old Gold) ( Federal Trade Commission [FTC] 1964 , p. LBA-5); “We removed from the tobacco harmful corrosive ACRIDS (pungent irritants) present in cigarettes manufactured in the old-fashioned way” (Lucky Strike) ( FTC 1964 , p. LBA-2); and “Smoking Camels stimulates the natural flow of digestive fluids … increases alkalinity” (Camel) ( FTC 1964 , p. LBA-1a). Thus, early modifications to the cigarette were made so that it was more palatable, had a higher nicotine delivery and uptake, and could be marketed as “safe” ( FTC 1964 ; Calfee 1985 ).

Filters, Tar Reduction, and Light and Low-Tar Cigarettes

The landmark 1964 Surgeon General’s report on smoking and health concluded that cigarette smoking contributed substantially to mortality from certain specific diseases, including lung cancer ( U.S. Department of Health, Education, and Welfare 1964 ). Although the 1964 report considered the topic, it found the evidence insufficient to assess the potential health benefits of cigarette filters. Cigarettes with filters became the norm by the 1960s, and marketing them with an overt message about harm reduction became the standard ( National Cancer Institute [NCI] 1996 ). However, the Surgeon General convened another group of experts on June 1, 1966, to review the evidence on the role played by the tar and nicotine content in health. The group concluded that “[t]he preponderance of scientific evidence strongly suggests that the lower the ‘tar’ and nicotine content of cigarette smoke, the less harmful are the effects” ( Horn 1966 , p. 16,168). Subsequent studies have repeatedly failed to demonstrate health benefits of smoking light and low-tar cigarettes versus full-flavor cigarettes ( Herning et al. 1981 ; Russell et al. 1982 ; Benowitz et al. 1983 , NCI 2001 ).

Over the years, the tobacco industry used multiple methods to reduce the machine-tested yields of tar and nicotine in cigarettes as a way to claim “healthier” cigarettes. Beginning in the 1970s, tobacco companies advertised the tar and nicotine levels for their cigarettes, which encouraged smokers to believe, without substantiation, they could reduce their risk of exposure to these constituents ( Cummings et al. 2002 ; Pollay and Dewhirst 2002 ). In 1996, the FTC issued a statement that it would allow cigarette companies to include statements about tar and nicotine content in their advertising as long as they used a standardized machine-testing method ( Peeler 1996 ).

The Role of Nicotine and Nicotine Delivery

Although the public health community understood early on that nicotine was the primary psycho-active ingredient in cigarette smoke, before the 1980s, little was known about the importance of nicotine in the addiction process beyond what the cigarette manufacturers had learned from their own research. Some scientists warned that due to nicotine addiction, a reduction in nicotine yields, along with decreases in tar, could lead smokers to change their smoking behavior, such as by smoking a greater number of cigarettes to maintain their nicotine intake or changing their behavior in more subtle ways, such as varying the depth of inhalation or smoking more of the cigarette ( Jarvis et al. 2001 ; National Cancer Institute 2001 ; Thun and Burns 2001 ). Not until the 1970s and 1980s, as researchers studying other forms of drug abuse began to apply their research methods to cigarette smoking, did it become apparent that nicotine was similar in its addictive capability to other drugs of abuse, such as heroin and cocaine ( USDHHS 1981 , 1988 ). As described in the 1988 Surgeon General’s report and in subsequent research, symptoms associated with nicotine addiction include craving, withdrawal, and unconscious behaviors to ensure consistent intake of nicotine ( USDHHS 1988 ; al’Absi et al. 2002 ; Hughes 2007 ).

Although the tobacco industry has long understood the importance of nicotine to maintain long-term cigarette smokers through addiction, public health officials did not fully appreciate this in a broad sense until the 1988 Surgeon General’s report, The Health Consequences of Smoking: Nicotine Addiction ( USDHHS 1988 ).

FDA and Nicotine Regulation

In 1988 (and again in 1994), the Coalition on Smoking OR Health and other public-interest organizations petitioned FDA to classify low-tar and nicotine products as drugs and to classify Premier, the short-lived “smokeless cigarette product” from R.J. Reynolds, as an alternative nicotine-delivery system ( Stratton et al. 2001 ). The Coalition on Smoking OR Health cited indirect claims made through advertising and marketing as evidence of R. J. Reynolds’s intent to have the product used for the mitigation or prevention of disease ( Slade and Ballin 1993 ). Meanwhile, FDA launched an investigation into the practices of the tobacco industry, including the manipulation of nicotine delivery. FDA asserted its jurisdiction over cigarettes and smokeless tobacco and issued certain rules governing access to and promotion of these products ( Federal Register 1996 ). On March 21, 2000, the U.S. Supreme Court ruled 5-4 that Congress had not yet given FDA the necessary statutory authority to issue any rules pertaining to tobacco products ( Gottleib 2000 ; FDA v. Brown & Williamson Tobacco Corp. 2000 ). The subsequent debate over control of nicotine products, including their potential impact on youth, ultimately led to the passage of the 2009 Family Smoking Prevention and Tobacco Control Act, which gave FDA authority to regulate tobacco products. Thus, discussions about the introduction of novel nicotine-containing tobacco products in the market during the 1980s and 1990s helped shape the current regulation of tobacco and nicotine products.

New products introduced in the 1990s or later included modified tobacco cigarettes (e. g ., Advance, Omni); cigarette-like products, also called cigalikes (e.g., Eclipse, Accord); and smokeless tobacco products (e.g., Ariva, Exalt, Revel, snus). Advance, made by Brown and Williamson, was test-marketed with the slogan “All of the taste … Less of the toxins.” Vector launched a national advertising campaign for its Omni cigarette with the slogan “Reduced carcinogens. Premium taste.” In addition to the question of whether the claims were supported by sufficient evidence, scientists and tobacco control leaders raised concerns about the potential for adverse consequences associated with novel nicotine and tobacco products marketed for harm reduction, such as a reduction in cessation rates or increased experimentation by children ( Warner and Martin 2003 ; Joseph et al. 2004 ; Caraballo et al. 2006 ). Studies have shown that smokers are interested in trying novel “reduced-exposure” products and perceive them to have lower health risks, even when advertising messages do not make explicit health claims ( Hamilton et al. 2004 ; O’Connor et al. 2005 ; Caraballo et al. 2006 ; Choi et al. 2012 ; Pearson et al. 2012 ).

At FDA ’s request, the Institute of Medicine ( IOM [now the National Academy of Medicine]) convened a committee of experts to formulate scientific methods and standards by which potentially reduced-exposure products (PREPs), whether the purported reduction was pharmaceutical or tobacco related, could be assessed. The committee concluded that “[f]or many diseases attributable to tobacco use, reducing risk of disease by reducing exposure to tobacco toxicants is feasible” ( Stratton et al. 2001 , p. 232). However, it also cautioned that “PREPs have not yet been evaluated comprehensively enough (including for a sufficient time) to provide a scientific basis for concluding that they are associated with a reduced risk of dis ease compared to conventional tobacco use” ( Stratton et al. 2001 , p. 232). The committee added that “the major concern for public health is that tobacco users who might otherwise quit will use PREPs instead, or others may initiate smoking, feeling that PREPs are safe. That will lead to less harm reduction for a population (as well as less risk reduction for that individual) than would occur without the PREP , and possibly to an adverse effect on the population” ( Stratton et al. 2001 , p. 235). Subsequently, in 2006, Judge Kessler cited these findings in her decision which demanded the removal of light and low-tar labeling due to the misleading nature of these claims ( United States v. Philip Morris 2006 ).

• The E-Cigarette

Invention of the E-Cigarette

An early approximation of the current e-cigarette appeared in a U.S. patent application submitted in 1963 by Herbert A. Gilbert and was patented in August 1965 (U.S. Patent No. 3,200,819) ( Gilbert 1965 ). The application was for a “smokeless nontobacco cigarette,” with the aim of providing “a safe and harmless means for and method of smoking” by replacing burning tobacco and paper with heated, moist, flavored air. A battery-powered heating element would heat the flavor elements without combustion ( Gilbert 1965 ). The Favor cigarette, introduced in 1986, was another early noncombustible product promoted as an alternative nicotine-containing tobacco product ( United Press International 1986 ; Ling and Glantz 2005 ).

The first device in the recent innovation in e-cigarettes was developed in 2003 by the Chinese pharmacist Hon Lik, a former deputy director of the Institute of Chinese Medicine in Liaoning Province. Lik’s patent application described a kind of electronic atomizing cigarette ( Hon 2013 ). With support from Chinese investors, in 2004 the product was introduced on the Chinese market under the company name Ruyan ( Sanford and Goebel 2014 ). The product gained some attention among Chinese smokers early on as a potential cessation device or an alternative cigarette product.

The e-cigarette was part of the U.S. market by the mid-2000s, and by 2010 additional brands started to appear in the nation’s marketplace, including Ruyan and Janty ( Regan et al. 2013 ). Ruyan gained a U.S. patent for its product with the application stating that the product is “an electronic atomization cigarette that functions as substitutes (sic) for quitting smoking and cigarette substitutes.” (U.S. Patent No. 8,490,628 B2, 2013). In August 2013, Imperial Tobacco Group purchased the intellectual property behind the Ruyan e-cigarette for $75 million. As of 2014 an estimated 90% of the world’s production of e-cigarette technology and products came from mainland China, mainly Guangdong Province and Zhejiang Province ( Barboza 2014 ).

Sales of e-cigarettes in the United States have risen rapidly since 2007. Widespread advertising via television commercials and through print advertisements for popular brands, often featuring celebrities, has contributed to a large increase in e-cigarette use by both adults and youth since 2010 ( Felberbaum 2013 ; King et al. 2013 ; Regan et al. 2013 ). Additionally, marketing through social media, as well as other forms of Internet marketing, has been employed to market these devices ( Huang et al. 2014 ; Kim et al. 2014 ).

In 2013, an estimated 13.1 million middle school and high school students were aware of e-cigarettes ( Wang et al. 2014 ). According to data from the National Youth Tobacco Survey, in 2011 the prevalence of current e-cigarette use (defined as use during at least 1 day in the past 30 days) among high school students was 1.5%; prevalence increased dramatically, however, to 16% by 2015, surpassing the rate of conventional-cigarette use among high school students ( CDC 2016b ; see Chapter 2 ). This equates to 2.4 million high school students and 620,000 middle school students having used an e-cigarette at least one time in the past 30 days in 2015 ( CDC 2016b ).

These trends have led to substantial concern and discussion within public health communities, including state and national public health agencies, professional organizations, and school administrators and teachers. A primary concern is the potential for nicotine addiction among nonsmokers, especially youth and young adults, and that this exposure to nicotine among youth and young adults is harmful. The diversity and novelty of e-cigarette products on the market and ongoing product innovations make assessments of the biological effects of current e-cigarettes under actual conditions of use—such as their long-term harmfulness—difficult to measure. Unanswered questions remain about the risk profile of these devices, their potential use by young people as a first step to other nicotine products, and their total impact on public health. There are diverging opinions about the potential public health impact of these new products. Some public health scientists have highlighted the potential for alternative nicotine products to serve as a substitute for conventional cigarettes and thus a harm reduction tool ( Henningfield et al. 2003 ; Abrams 2014 ). Others have cautioned that the use of alternative nicotine products might become a bridge that may lead to greater tobacco product use—including dual- or multiple-product use—or initiate nicotine addiction among nonsmokers, especially youth ( Cobb et al. 2010 ; Wagener et al. 2012 ; Benowitz and Goniewicz 2013 ; Britton 2013 ; Chapman 2013 ; Etter 2013 ; USDHHS 2014 ). Current evidence is insufficient to reject either of these hypotheses.

E-Cigarette Products

Components and devices.

E-cigarette devices are composed of a battery, a reservoir for holding a solution that typically contains nicotine, a heating element or an atomizer, and a mouthpiece through which the user puffs ( Figure 1.2 ). The device heats a liquid solution (often called e-liquid or e-juice) into an aerosol that is inhaled by the user. E-liquid typically uses propylene glycol and/or glycerin as a solvent for the nicotine and flavoring chemicals

Parts of an e-cigarette device. Source: Photo by Mandie Mills, CDC.

Flavors and E-Cigarettes

The e-liquids in e-cigarettes are most often flavored; a study estimated that 7,700 unique flavors exist ( Zhu et al. 2014 ) and that most of them are fruit or candy flavors ( Figure 1.3 ). A content analysis of the products available via online retail websites documented that tobacco, mint, coffee, and fruit flavors were most common, followed by candy (e. g ., bubble gum), unique flavors (e.g., Belgian waffle), and alcoholic drink flavors (e.g., strawberry daiquiri) ( Grana and Ling 2014 ). Some retail stores are also manufacturers that create custom flavors, which increases the variety of flavors available.

Examples of e-liquid flavors. Source: Photo by Mandie Mills, CDC.

The widespread availability and popularity of flavored e-cigarettes is a key concern regarding the potential public health implications of the products. The concern, among youth, is that the availability of e-cigarettes with sweet flavors will facilitate nicotine addiction and simulated smoking behavior—which will lead to the use of conventional tobacco products ( Kong et al. 2015 ; Krishnan-Sarin et al. 2015 ). Flavors have been used for decades to attract youth to tobacco products and to mask the flavor and harshness of tobacco ( USDHHS 2012 ). Industry documents show that tobacco companies marketed flavored little cigars and cigarillos to youth and to African Americans to facilitate their uptake of cigarettes ( Kostygina et al. 2014 ). Companies also intended flavored smokeless tobacco products to facilitate “graduation” to unflavored products that more easily deliver more nicotine to the user ( USDHHS 2012 ). Various studies have shown that youth are more likely than adults to choose flavored cigarettes and cigars ( CDC 2015b ). Concern over these findings led Congress to include a ban on characterizing flavors for cigarettes, other than tobacco or menthol, in the Tobacco Control Act. A similar concern exists about e-cigarettes, and this concern is supported by studies indicating that youth and young adults who have ever used e-cigarettes begin their use with sweet flavors rather than tobacco flavors ( Kong et al. 2015 ; Krishnan-Sarin et al. 2015 ). Notably, 81.5% of current youth e-cigarette users said they used e-cigarettes “because they come in flavors I like” ( Ambrose et al. 2015 ).

E-Cigarette Devices

First-generation e-cigarettes were often similar in size and shape to conventional cigarettes, with a design that also simulated a traditional cigarette in terms of the colors used (e. g ., a white body with tan mouthpiece). These devices were often called cigalikes, but there were other products designed to simulate a cigar or pipe. Other cigalikes were slightly longer or narrower than a cigarette; they may combine white with tan or may be black or colored brightly. These newer models use a cartridge design for the part of the device that holds the e-liquid, which is either prefilled with the liquid or empty and ready to be filled. The user then squeezes drops of the e-liquid onto a wick (or bit of cotton or polyfil) connected to the heating element and atomizer ( Figure 1.4 ). As e-cigarettes have become more popular, their designs have become more diverse, as have the types of venues where they are sold ( Noel et al. 2011 ; Zhu et al. 2014 ).

E-liquids being poured into an e-cigarette device. Source: Photo by Mandie Mills, CDC.

Second-generation devices include products that are shaped like pens, are comparatively larger and cylindrical, and are often referred to as “tank systems” in a nod to the transparent reservoir that holds larger amounts of e-liquid than previous cartridge-containing models. Third- and fourth-generation devices represent a diverse set of products and, aesthetically, constitute the greatest departure from the traditional cigarette shape, as many are square or rectangular and feature customizable and rebuildable atomizers and batteries. In addition, since the beginning of the availability of e-cigarettes and their component parts, users have been modifying the devices or building their own devices, which are often referred to as “mods.” The differences in design and engineering of the products are key factors in the size, distribution, and amount of aerosol particles and the variability in levels of chemicals and nicotine present in the e-liquid/aerosol and delivered to the user ( Brown and Cheng 2014 ).

E-Cigarette Product Components and Risks

One of the primary features of the more recent generation of devices is that they contain larger batteries and are capable of heating the liquid to a higher temperature, potentially releasing more nicotine, forming additional toxicants, and creating larger clouds of particulate matter ( Bhatnagar et al. 2014 ; Kosmider et al. 2014 ). For instance, one study demonstrated that, at high temperatures (150°C), exceedingly high levels of formaldehyde—a carcinogen (found to be 10 times higher than at ambient temperatures)—are present that are formed through the heating of the e-liquid solvents (propylene glycol and glycerin), although the level of tolerance of actual users to the taste of the aerosol heated to this temperature is debated ( Kosmider et al. 2014 ; CDC 2015a ; Flavor and Extract Manufacturers Association of the United States 2015 ; Pankow et al. 2015 ). There is also concern regarding the safety of inhaling e-cigarette flavorings. Although some manufacturers have claimed their flavorants are generally recognized as safe for food additives (i.e., to be used in preparing foods for eating), little is known about the long-term health effects of inhaling these substances into the lungs ( CDC 2015a ).

Many devices can be readily customized by their users, which is also leading to the concern that these devices are often being used to deliver drugs other than nicotine ( Brown and Cheng 2014 ). Most commonly reported in the news media, on blogs, and by user anecdote is the use of certain types of e-cigarette-related products for delivering different forms of marijuana ( Morean et al. 2015 ; Schauer et al. 2016 ). The tank systems, for example, have been used with liquid tetrahydrocannabinol ( THC ) or hash oil. Some personal vaporizer devices can be used with marijuana plant material or a concentrated resin form of marijuana called “wax.” One study describes the use, in Europe, of e-cigarette devices to smoke marijuana ( Etter 2015 ).

The various e-cigarette products, viewed as a group, lack standardization in terms of design, capacity for safely holding e-liquid, packaging of the e-liquid, and features designed to minimize hazards with use ( Yang et al. 2014 ). All of these design features may have implications for the health impact of e-cigarette use. Notably, from 2010 to 2014, calls to poison control centers in the United States about exposures related to e-cigarettes increased dramatically. According to the American Association of Poison Control Centers (2015) , 271 cases were reported in 2011, but 3,783 calls were reported in 2014. Among all calls, 51% involved exposure among children younger than 5 years of age ( CDC 2014 ). Most poisonings appear to have been caused by exposure to nicotine-containing liquid ( CDC 2014 ). The lack of a requirement for child-resistant packaging for e-liquid containers may have contributed to these poisonings. Since these data were released, one death in the United States has been confirmed in a child who drank e-liquid containing nicotine ( Mohney 2014 ). Additionally, serious adverse reactions, including at least two deaths, have been reported to FDA in cases that could be attributed to the use of e-cigarettes ( FDA 2013 ). This increase in poisonings prompted the Child Nicotine Poisoning Prevention Act of 2015 (2016) , which was enacted in January 2016. This law requires any container of liquid nicotine that is sold, manufactured, distributed, or imported into the United States to be placed in packaging that is difficult to open by children under 5 years of age.

Secondary risks are also of concern regarding e-cigarettes, including passive exposure to nicotine and other chemicals, and adverse events due to device malfunction. Nicotine is a neuroteratogen, and its use by pregnant women exposes a developing fetus to risks that are well documented in the 50th-anniversary Surgeon General’s report on smoking ( USDHHS 2014 ) and include impaired brain development ( England et al. 2015 ) and other serious consequences. Finally, another consequence of the lack of device regulation is the occurrence of battery failures and subsequent explosions. Explosions have typically occurred during charging, resulting in house and car fires, and sometimes causing injuries to those involved. From 2009 to late 2014, 25 incidents of explosions and fires involving e-cigarettes occurred in the United States ( Chen 2013 ; U.S. Fire Administration 2014 ; FDA 2013 ).

• E-Cigarette Companies

E-cigarette companies include manufacturers, wholesalers, importers, retailers, distributors, and some other groups that overlap with these entities ( Barboza 2014 ; Whelan 2015 ). Currently, most of the products are manufactured in Shenzhen, Guangdong Province, China ( Cobb et al. 2010 ; Grana et al. 2014 ; Zhu et al. 2014 ). One study placed the number of brands at 466 in January 2014 and found a net increase of 10.5 brands per month ( Zhu et al. 2014 ). All the major tobacco companies (e. g ., Reynolds American, Altria; Table 1.1 ) and many smaller, independent companies are now in the business. When e-cigarettes first entered the U.S. market, they were sold primarily by independent companies via the Internet and in shopping malls at kiosks where those interested could sample the products. A unique feature of the e-cigarette industry, compared to other tobacco and nicotine products, is the recruitment of visitors to their websites as “affiliates” or distributors to help market the products and, in turn, receive commissions on sales ( Grana and Ling 2014 ; Cobb et al. 2015 ). For example, some companies offer a way for users to earn a commission by advertising the products (e.g., a banner ad is placed on one’s website, and when someone clicks on the link and subsequently purchases a product, the website owner gets a percentage commission). Some companies also offer rewards programs for recruiting new customers or for brand loyalty, with web-site users earning points for free or reduced-price products ( Richardson et al. 2015 ).

Multinational tobacco companies with e-cigarette brands.

E-cigarettes are now in widespread national distribution through convenience stores, tobacco stores, pharmacies, “big box” retail chains such as Costco, online retailers, and shops devoted to e-cigarette products (often called “vape shops”) ( Giovenco et al. 2015 ; Public Health Law Center 2015 ). The “vape shops” offer a place to buy customizable devices and e-liquid solutions in many flavors and sometimes include a café or other elements that promote socializing, essentially making such places like a lounge. With the rapid increase in distribution and marketing in the industry, sales have increased rapidly and were projected to reach $2.5 billion in 2014 and $3.5 billion in 2015, including projections for retail and online channels, as well as “vape shops” ( Wells Fargo Securities 2015 ).

The advertising and marketing of e-cigarette products has engendered skepticism among public health professionals and legislators, who have noted many similarities to the advertising claims and promotional tactics used for decades by the tobacco industry to sell conventional tobacco products ( Campaign for Tobacco-Free Kids 2013 ; CDC 2016a ). Indeed, several of the e-cigarette marketing themes have been reprised from the most memorable cigarette advertising, including those focused on freedom, rebellion, and glamor ( Grana and Ling 2014 ). E-cigarette products are marketed with a variety of unsubstantiated health and cessation messages, with some websites featuring videos of endorsements by physicians (another reprisal of old tobacco industry advertising) ( Grana and Ling 2014 ; Zhu et al. 2014 ). Unlike conventional cigarettes, for which advertising has been prohibited from radio and television since 1971, e-cigarette products are advertised on both radio and television, with many ads featuring celebrities. E-cigarettes also are promoted through sports and music festival sponsorships, in contrast to conventional cigarettes and smokeless tobacco products, which have been prohibited from such sponsorships since the Master Settlement Agreement in 1998. E-cigarettes also appear as product placements in television shows and movies ( Grana et al. 2011 ; Grana and Ling 2014 ).

Another key avenue for e-cigarette promotion is social media, such as Twitter, Facebook, YouTube, and Instagram. As is true in the tobacco industry, the e-cigarette industry organizes users through advocacy groups ( Noel et al. 2011 ; Harris et al. 2014 ; Saitta et al. 2014 ; Caponnetto et al. 2015 ). The extensive marketing and advocacy through various channels broadens exposure to e-cigarette marketing messages and products; such activity may encourage nonsmokers, particularly youth and young adults, to perceive e-cigarette use as socially normative. The plethora of unregulated advertising is of particular concern, as exposure to advertising for tobacco products among youth is associated with cigarette smoking in a dose-response fashion ( USDHHS 2012 ).

• Federal Regulation of E-Cigarettes

A “Two-Pronged” Approach to Comprehensive Tobacco Control

Since the passage of the Tobacco Control Act in 2009, FDA has had the authority to regulate the manufacturing, distribution, and marketing of tobacco products sold in the United States. FDA had immediate jurisdiction over cigarettes, roll-your-own cigarette tobacco, and smokeless tobacco. In May 2016, FDA asserted jurisdiction over products that meet the statutory definition of a tobacco product, including e-cigarettes, except accessories of these products ( Federal Register 2016 ). That regulation is currently under litigation.

The IOM ’s 2007 report, Ending the Tobacco Problem: A Blueprint for the Nation, established a “two-pronged” strategy for comprehensive tobacco control: (1) full implementation of proven, traditional tobacco control measures such as clean indoor air laws, taxation, and countermarketing campaigns; and (2) “strong federal regulation of tobacco products and their marketing and distribution” ( Bonnie et al. 2007 , p. 1).

Included in FDA ’s broad authority are the restriction of marketing and sales to youth, requiring disclosure of ingredients and harmful and potentially harmful constituents, setting product standards (e. g ., requiring the reduction or elimination of ingredients or constituents), requiring premarket approval of new tobacco products and review of modified-risk tobacco products, and requiring health warnings. The standard for FDA to use many of its regulatory authorities is whether such an action is appropriate for the protection of public health ( Federal Food, Drug, and Cosmetic Act , § 907(a)(3)(A)). The public health standard in the Tobacco Control Act also requires FDA to consider the health impact of certain regulatory actions at both the individual and population levels, including their impact on nonusers, and on initiation and cessation ( Federal Food, Drug, and Cosmetic Act , § 907(a)(3)(B)).

Importantly, the Tobacco Control Act preserves the authority of state, local, tribal, and territorial governments to enact any policy “in addition to, or more stringent than” requirements established under the Tobacco Control Act “relating to or prohibiting the sale, distribution, possession, exposure to, access to, advertising and promotion of, or use of tobacco products by individuals of any age” ( Federal Food, Drug, and Cosmetic Act , § 916(a)(1)). This preservation of state and local authority ensures the continuation of more local-level, comprehensive tobacco control. However, the statute expressly preempts states and localities from establishing or continuing requirements that are different from or in addition to FDA requirements regarding standards for tobacco products, premarket review, adulteration, misbranding, labeling, registration, good manufacturing practices, or modified-risk tobacco products ( Federal Food, Drug, and Cosmetic Act , § 916(a)(2)(A)). But this express preemption provision does not apply to state and local authority to impose requirements relating to the “sale, distribution, possession, information reporting to the State, exposure to, access to, the advertising and promotion of, or use of, tobacco products by individuals of any age …” ( Federal Food, Drug, and Cosmetic Act , § 916(a)(2)(b)). The interaction of these complex provisions related to federal preemption of state law has been the subject of challenges by the tobacco industry to state and local laws. Thus far, courts have upheld certain local ordinances restricting the sale of flavored tobacco products ( National Association of Tobacco Outlets, Inc. v. City of Providence 2013 ; U.S. Smokeless Tobacco Manufacturing Co. v. City of New York 2013 ).

Legal Basis for Regulating E-Cigarettes as Tobacco Products

In the United States, e-cigarettes can be regulated either as products marketed for therapeutic purposes or as tobacco products. Since the advent of e-cigarettes in the United States around 2007, manufacturers have had the option to apply to FDA ’s Center for Drug Evaluation and Research ( CDER ) or Center for Devices and Radiological Health (CDRH) for approval to market e-cigarettes for therapeutic purposes; as of August 2016, no e-cigarette manufacturers have received approval through this avenue.

In 2008 and early 2009, FDA detained multiple shipments of e-cigarettes from overseas manufacturers and denied them entry into the United States on the grounds that e-cigarettes were unapproved drug-device combination products ( FDA 2011 ). Sottera, Inc., which now does business as NJOY, challenged that determination ( Smoking Everywhere, Inc. and Sottera, Inc., d/b/a NJOY v. U.S. Food and Drug Administration, et al. 2010 ; Bloomberg Business 2015 ). Between the filing of the lawsuit and a decision on the motion for preliminary injunction, Congress passed the Tobacco Control Act and the President signed it into law. The Tobacco Control Act defines the term “tobacco product,” in part, as any product, including component parts or accessories, “made or derived from tobacco” that is not a “drug,” “device,” or “combination product” as defined by the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 321(rr)) ( Family Smoking Prevention and Tobacco Control Act 2009 , § 101(a)). The District Court subsequently granted a preliminary injunction relying on the Supreme Court’s decision in Brown and Williamson (1996) and the recently enacted Tobacco Control Act. FDA appealed the decision and the U.S. Court of Appeals for the D.C. Circuit held that e-cigarettes and, therefore, other products “made or derived from tobacco” are not drug/device combinations unless they are marketed for therapeutic purposes, but can be regulated by FDA as tobacco products under the Tobacco Control Act ( Sottera, Inc. v. Food & Drug Administration 2010 ).

On September 25, 2015, FDA proposed regulations to describe the circumstances in which a product made or derived from tobacco that is intended for human consumption will be subject to regulation as a drug, device, or a combination product. The comment period for this proposed regulation closed on November 24, 2015.

Most e-cigarettes marketed and sold in the United States today contain nicotine made or derived from tobacco. Although some e-cigarettes claim that they contain nicotine not derived from tobacco, or that they contain no nicotine at all ( Lempert et al. 2016 ), there may be reason to doubt some of these claims. Currently, synthetic nicotine and nicotine derived from genetically modified, nontobacco plants are cost-prohibitive for e-cigarette manufacturers, although technological advances could eventually increase the cost-effectiveness of using nicotine that was not derived from tobacco ( Lempert et al. 2016 ). The health effects of passive exposure to e-cigarettes with no nicotine, as well as their actual use and the extent of exposure to these products, have just begun to be studied ( Hall et al. 2014 ; Marini et al. 2014 ; Schweitzer et al. 2015 ) and some states and localities are taking steps to regulate e-cigarettes that do not contain nicotine or tobacco ( Lempert et al. 2016 ).

Deeming Rule

The Tobacco Control Act added a new chapter to the Federal Food, Drug, and Cosmetic Act , which provides FDA with authority over tobacco products. The new chapter applied immediately to all cigarettes, cigarette tobacco, roll-your-own tobacco, and smokeless tobacco; and the law included “any other tobacco products that the Secretary of Health and Human Services by regulation deems to be subject to this chapter” ( Federal Food, Drug, and Cosmetic Act , §901 (b)). Therefore, to regulate e-cigarettes as tobacco products, FDA was required to undertake a rulemaking process to extend its regulatory authority to include e-cigarettes.

• Prohibitions on adulterated and misbranded products;
• Required disclosure of existing health information, including lists of ingredients and documents on health effects;
• Required registration of manufacturers;
• Required disclosure of a list of all tobacco products, including information related to labeling and advertising;
• Premarket review of new tobacco products (i.e., those not on the market on February 15, 2007);
• Restrictions on products marketed with claims about modified risk.
• Minimum age restrictions to prevent sales to minors;
• Requirements to include a nicotine warning; and
• Prohibitions on vending machine sales, unless in a facility that never admits youth.

Future Regulatory Options

• Product standards, including restrictions on flavors;
• Restrictions on promotion, marketing, and advertising, and prohibitions on brand-name sponsorship of events;
• Minimum package sizes;
• Prohibitions on self-service displays;
• Child-resistant packaging and the inclusion of health warnings; and
• Regulation of nicotine levels in products.

Despite this broad authority, FDA is prohibited from certain regulatory actions, even if those actions may be appropriate for the protection of public health. Specifically, FDA generally cannot restrict tobacco use in public places, levy taxes on tobacco products, prohibit sales by a specific category of retail outlet (e. g ., pharmacies), completely eliminate nicotine in tobacco products, require prescriptions for tobacco products unless it is marketed for therapeutic purposes, or establish a federal minimum age of sale for tobacco products above 18 years of age. Thus, even if FDA fully exercises all of its existing authority over e-cigarettes, regulation will still need to be complemented at the state and local levels, including efforts previously shown to be effective for conventional tobacco products, such as comprehensive smokefree laws at the state and local levels, pricing strategies, raising the minimum age of sales to minors to 21, and high-impact countermarketing campaigns. In the current context of rising rates of use by youth, localities and states can also implement policies and programs that minimize the individual- and population-level harms of e-cigarettes (see Chapter 5 ).

This chapter presents the major conclusions of this Surgeon General’s report and the conclusions of each chapter. E-cigarettes are presented within their historical context, with an overview of the components of these devices and the types of products. In 2016, FDA announced its final rule to regulate e-cigarettes under the Family Smoking Prevention and Tobacco Control Act. The chapter outlines options for the regulation of e-cigarettes, particularly as they relate to youth and young adults, based on successful smoking policies. The need to protect youth and young adults from initiating or continuing the use of nicotine-containing products forms a strong basis for the need to regulate e-cigarettes at the local, state, and national levels in the future.

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Vaping and Its Negative Aspects Essay

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Introduction

Works cited, attention-arousing and orienting material.

Vaping has become a curse of the recent decade. Vapes are better than nicotine-containing cigarettes. Vapes do not harm the health of a smoker. Vapes are about vaping, not smoking. As one popular vape-producing company puts it, “live long and vape strong”. It seems that vapes create a new reality in which smoking could be safe. Well, what if I say that, in the US, in one week 12 people died because of vaping and 805 people were diagnosed with the breathing illness related to vaping (Pesce par. 1). If these statistics are not enough to give up vaping, the goal of the current speaker is to persuade that vapes are not as warm and fuzzy as companies want us to believe.

Credibility

Vaping is regarded as an escape for smokers who try to give up their addiction since the latter could substitute the former. Still, there are numerous sources that vaping is a decent and safe habit. The argument against vaping is backed by the results of the researches, the viewpoints of medical experts, and the experience of vapers. The importance of this topic is undeniable since even underaged people become addicted to vapes.

Thesis Statement

Vaping has numerous devastating effects and did not worth doing.

Preview of main points

There are two major reasons to give up a habitude of vape. Firstly, vaping is addictive and undermines the ability to self-control. Secondly, usage of a vape, even if it is nicotine-free, poses a health hazard and leads to diseases of the respiratory system.

Vaping is addictive

It is a well-known fact that there are numerous kinds of vaping liquids. They have various chemical compositions, tastes, and smells. Some of them might contain nicotine, while others are free of it. The problem is that vaping causes addiction in any case.

One of the reasons for this is that vapes are regarded as tools to socialize and make new acquaintances (Levin par. 21).

In essence, new friends and a higher circle of socialization is positive outcome of vaping.

However, the issue lies in the fact that young people that are shy to make friends, for instance, during classes, start vaping to fit in with the team.

• Vice versa, if an individual intends to give up vaping, he or she might postpone this idea because of the fear to distance herself from the friends who use vapes.
• In the interview with the 21-years old man, Levin illustrates how strong the addiction might be (par. 16). Josh Evans avows that he inhales the vapors even though sometimes it makes him feel physically bad and fail to fight against vaping (Levin par.16).
• The final point worth being mentioned is that addiction to vaping leads to more serious addictions in the long-term perspective.

In two years, the number of young adults using vaping cartridges with the flavor of cannabis or nicotine increased more than twice (Pesce para.2).

According to the President of the Campaign for Tobacco-Free Kids, Matthew Myers, people that become addicted to vapes or e-cigarettes at a young age, grow into heavily smoking adults (Lemons 17).

(Transition: The fact that vapes triggers addiction would not be that important if it were not for the health hazard.)

Vaping is dangerous for health

Blaha informs that all lung fluid samples of people ill with “e-cigarette, or vaping, product use associated lung injury (EVALI)” show the presence of vitamin E acetate (par 6.).

From this, it could be inferred that vaping liquids contain chemicals that cause diseases of the respiratory system. Thus, even nicotine-free vapes could have a devastating effect on health.

Another point of concern about vaping is that hitherto remains a lot of doubts about how certain chemicals in liquids affect health (Blaha par. 9). Nevertheless, some studies confirm that vaping leads not only to asthma but also to cardiovascular disease (Blaha par.9).

Therefore, it could be argued that vaping remains an insufficiently studied phenomenon. The absence of a clear understanding of the consequences of vaping, as well as PR campaigns of brands that produce vapes and liquids, give a reason to think that vaping does not affect health. At the same time, the growing number of young people with breathing diseases makes them think that vaping is not as good as it might seem at the first sight.

(Transition: As you can notice, vaping has a significant number of disadvantages that should motivate people either not to try it or give up the habit.)

Summary statement

Vaping is not only addictive but also challenges the well-being of a vaper. In the scientific community, there is no common opinion on the effect of the chemicals that are included in the composition of vaping liquids. Notwithstanding this fact, the example of people diagnosed with EVALI proves that vaping represents a threat and that life would be better without this addiction.

Concluding remarks

Still, it is important to remember that our health and quality of life depend on our own choices. Vapes were not created by nature and human beings survived for centuries without smoking and vaping. I will leave you with the question: if the necessity to vape was not put in our bodies and minds by nature, do we need it?

Blaha, Michael Joseph. “5 Vaping Facts You Need to Know.” Health Conditions and Diseases , 2020. Web.

Lemons, Jane Fullerton. E-Cigarette Dilemma . CQ Press, 2019. Web.

Levin, Dan. “Vaping on Campus: No Parents, No Principals, a Big Problem.” The New York Times , 2019. Web.

Pesce, Nicole Lyn. “These Charts Show the Shocking Number of High School and College Students Who Vape.” Market Watch , 2019. Web.

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The Risks of Vaping

A Look at Safety

You’ve probably heard a lot about vaping lately. You might also know about the recent outbreak of lung injuries and deaths linked to vaping in the U.S. But those aren’t the only risks that come with vaping. Here’s what you need to know.

Vaping devices, also known as e-cigarettes, vape pens, and e-hookahs among other terms, come in many shapes and sizes. Some look like traditional cigarettes, cigars, or pipes. Others are shaped like every-day objects, such as pens or USB memory sticks.

While they may look different, most vaping devices work in a similar way. Puffing activates a battery-powered heating device. This heats the liquid in a cartridge, turning it into vapors that are inhaled.

Vaping exposes the lungs to a variety of chemicals. These may include the main active chemicals in tobacco (nicotine) or marijuana (THC), flavorants, and other ingredients that are added to vaping liquids. Plus, other chemicals can be produced during the vaporizing process.

“If the liquid has nicotine in it, then the user is inhaling nicotine along with the other ingredients in the liquid,” explains Dr. Thomas Eissenberg, an expert on tobacco research at Virginia Commonwealth University.

While vaping devices work similarly, some are more powerful than others. They create more vapor and deliver more chemicals.

So how safe is vaping? Studies suggest nicotine vaping may be less harmful than traditional cigarettes when people who regularly smoke switch to them as a complete replacement. But nicotine vaping could still damage your health.

“Your lungs aren’t meant to deal with the constant challenge of non-air that people are putting into them—sometimes as many as 200 puffs a day—day after day, week after week, year after year,” Eissenberg says.

“You’re inhaling propylene glycol, vegetable glycerin, flavorants that were meant to be eaten but not inhaled, and nicotine,” he explains. “And all of those are heated up in this little reactor, which is an e-cigarette. When they get heated up, those components can turn into other potentially dangerous chemicals.”

One harmful chemical may be a thickening agent called Vitamin E acetate, which is sometimes used as an additive in THC-containing vape products. The CDC identified it as a “chemical of concern” among people with vaping-associated lung injuries. They recommend avoiding any vaping product containing Vitamin E acetate or THC, particularly those from informal sources like friends, family, or in-person or online dealers.

Vaping is now more popular among teens than smoking traditional cigarettes. One in four high school seniors say they vaped nicotine in the past month. And studies have found that teens who vape nicotine may be more likely to go on to smoke traditional cigarettes.

Marijuana vaping has also increased dramatically among teens. About 20% of high school seniors vaped marijuana in the past year. The rates have more than doubled in the past two years.

New laws are aimed at curbing vaping among teens. People must now be 21 to buy any tobacco product, including vaping products. And companies can no longer produce and sell flavors that appeal to children like fruit and mint.

If you’ve already started vaping or smoking cigarettes, it’s never too late to quit. See the Wise Choices box for tips on stopping.

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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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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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The contentious history of cigarette warning labels—and the hazy future of vaping

By Clare Watson / Knowable Magazine

Posted on Aug 27, 2024 8:00 AM EDT

14 minute read

This article was originally featured on  Knowable Magazine .

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.

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.

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.

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.

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.

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.

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.

This article originally appeared in  Knowable Magazine , an independent journalistic endeavor from Annual Reviews. Sign up for the  newsletter .

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Essay on Smoking

500 words essay on  smoking.

One of the most common problems we are facing in today’s world which is killing people is smoking. A lot of people pick up this habit because of stress , personal issues and more. In fact, some even begin showing it off. When someone smokes a cigarette, they not only hurt themselves but everyone around them. It has many ill-effects on the human body which we will go through in the essay on smoking.

Ill-Effects of Smoking

Tobacco can have a disastrous impact on our health. Nonetheless, people consume it daily for a long period of time till it’s too late. Nearly one billion people in the whole world smoke. It is a shocking figure as that 1 billion puts millions of people at risk along with themselves.

Cigarettes have a major impact on the lungs. Around a third of all cancer cases happen due to smoking. For instance, it can affect breathing and causes shortness of breath and coughing. Further, it also increases the risk of respiratory tract infection which ultimately reduces the quality of life.

In addition to these serious health consequences, smoking impacts the well-being of a person as well. It alters the sense of smell and taste. Further, it also reduces the ability to perform physical exercises.

It also hampers your physical appearances like giving yellow teeth and aged skin. You also get a greater risk of depression or anxiety . Smoking also affects our relationship with our family, friends and colleagues.

Most importantly, it is also an expensive habit. In other words, it entails heavy financial costs. Even though some people don’t have money to get by, they waste it on cigarettes because of their addiction.

How to Quit Smoking?

There are many ways through which one can quit smoking. The first one is preparing for the day when you will quit. It is not easy to quit a habit abruptly, so set a date to give yourself time to prepare mentally.

Further, you can also use NRTs for your nicotine dependence. They can reduce your craving and withdrawal symptoms. NRTs like skin patches, chewing gums, lozenges, nasal spray and inhalers can help greatly.

Moreover, you can also consider non-nicotine medications. They require a prescription so it is essential to talk to your doctor to get access to it. Most importantly, seek behavioural support. To tackle your dependence on nicotine, it is essential to get counselling services, self-materials or more to get through this phase.

One can also try alternative therapies if they want to try them. There is no harm in trying as long as you are determined to quit smoking. For instance, filters, smoking deterrents, e-cigarettes, acupuncture, cold laser therapy, yoga and more can work for some people.

Always remember that you cannot quit smoking instantly as it will be bad for you as well. Try cutting down on it and then slowly and steadily give it up altogether.

Get the huge list of more than 500 Essay Topics and Ideas

Conclusion of the Essay on Smoking

Thus, if anyone is a slave to cigarettes, it is essential for them to understand that it is never too late to stop smoking. With the help and a good action plan, anyone can quit it for good. Moreover, the benefits will be evident within a few days of quitting.

FAQ of Essay on Smoking

Question 1: What are the effects of smoking?

Answer 1: Smoking has major effects like cancer, heart disease, stroke, lung diseases, diabetes, and more. It also increases the risk for tuberculosis, certain eye diseases, and problems with the immune system .

Question 2: Why should we avoid smoking?

Answer 2: We must avoid smoking as it can lengthen your life expectancy. Moreover, by not smoking, you decrease your risk of disease which includes lung cancer, throat cancer, heart disease, high blood pressure, and more.

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Use these two tactics to help reduce smoking and vaping temptation

• Health Matters

Tuesday, 27 Aug 2024

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Highly visible displays of cigarettes and vaping products promote impulse buys and make it difficult for those attempting to quit their habits. Removing them from consumer sight in shops would help reduce these problems. — Filepic

The Control of Smoking Products for Public Health Bill 2023 was passed in 2023, with the regulations due to be announced in the third quarter of this year (2024).

It is hoped that some of these regulations will focus on undermining the sophisticated marketing efforts of the tobacco and vaping industry.

Despite stringent regulations in many countries, they continue to employ a wide array of tactics to promote their products, particularly among young and vulnerable populations.

Remove the displays

Point-of-sale (POS) displays in retail environments are a potent marketing tool for tobacco and vape products.

These displays often position products in prominent locations, making them highly visible to consumers.

These include those who had not intended to purchase the products, but might be tempted to make an impulse buy due to their easy availability.

Banning these displays is an effective strategy to reduce smoking and vaping by removing the visibility of products in everyday retail settings.

When products are stored out of sight – typically behind curtains or in closed cabinets – shoppers are less likely to make impulse purchases.

This is particularly important for current smokers who might be trying to quit, as seeing tobacco products can trigger cravings and weaken their resolve.

According to the World Health Organization (WHO), POS display bans, first introduced in Iceland in 2001, have seen reductions in tobacco sales as the products become less of a focal point in stores, leading to fewer spontaneous purchases.

POS displays not only target current users, but more importantly, also influence non-smokers and non-vapers.

This is especially true for youth, who are targeted via marketing gimmicks such as the use of vibrant colours, flavours and cartoon characters.

The visibility of tobacco and vaping products in stores normalises smoking and vaping, and can make it appear more acceptable or desirable.

By banning POS displays, retailers reduce the likelihood that young people will be exposed, thereby decreasing the chances of initiation.

Research from countries such as Ireland and Indonesia have demonstrated that POS displays do not affect retail sales in the short term, giving time for retailers to adjust and prepare.

This makes sense as existing consumers will continue to seek their preferred product, but non-smoking and non-vaping youth will be deterred from starting in the first place.

Protecting the digital space

As traditional advertising channels become increasingly restricted, the tobacco and vaping industry have turned to online and social media platforms to promote their products.

These digital spaces offer unique opportunities for targeted marketing, particularly to younger audiences who are more active online.

Online and social media platforms allow these companies to reach specific demographics through targeted ads, influencer partnerships and viral content.

These tactics often glamourise smoking and vaping, making them appear trendy or desirable, particularly to teenagers and young adults.

Young people are particularly susceptible to tobacco and vaping marketing, and the digital environment offers these industries a direct line to this demographic.

Influencers, hashtags and interactive content are often used to subtly promote tobacco and vape products, making them more appealing to youth.

Restricting these practices helps prevent young people from being exposed to content that encourages smoking and vaping, thereby reducing the likelihood of initiation.

A report released by the Campaign for Tobacco-Free Kids described how tobacco companies Philip Morris International and British American Tobacco are advertising nicotine products to youth on social media.

Some highlights include:

• The companies use a network of influencers and content creators to market their brands online.
• To maximise reach, impressions and a perception of authenticity, a mix of influencers are used: from those with 1,000 followers to celebrities with millions.
• The companies seek out influencers with a variety of interests and reach an expansive audience of young people who would otherwise not see nicotine content on social media.

As the government contemplates stricter policies for social media platforms in order to protect youth from cyberbullying and the greater public from misinformation, it should acknowledge the importance of protecting youth from a prolonged suicide by nicotine addiction.

Online marketing restrictions also help protect other vulnerable populations, including those with lower socioeconomic status or lower levels of education, who may be disproportionately targeted by marketing.

By limiting the ability of tobacco and vaping companies to reach these groups through digital channels, the government can reduce disparities in tobacco use and protect public health.

Keeping up the fight

The use of POS display bans and online marketing restrictions are powerful tools in the fight against tobacco use.

By undermining the marketing and product placement efforts of the tobacco industry, these measures help reduce the appeal and accessibility of tobacco products, particularly to young and vulnerable populations.

Together, they create an environment where smoking is less visible, less socially acceptable and less desirable, leading to lower smoking rates and improved public health outcomes.

Dr Helmy Haja Mydin is a consultant respiratory physician and Social & Economic Research Initiative senior policy advisor. For further information, email [email protected]. The information provided is for educational and communication purposes only. The Star does not give any warranty on accuracy, completeness, functionality, usefulness or other assurances as to the content appearing in this column. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.

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Tags / Keywords: Vaping , smoking , social media , child health

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Smoking Cessation and Risk of Hidradenitis Suppurativa Development

• 1 Department of Dermatology, Seoul National University College of Medicine, Seoul, Republic of Korea
• 2 Department of Dermatology, Seoul National University Hospital, Seoul, Republic of Korea
• 3 Department of Mathematics Education, Sungkyunkwan University, Seoul, Republic of Korea
• Editorial Smoking Cessation and Hidradenitis Suppurativa Alexandra Charrow, MD, MBE; Leandra A. Barnes, MD JAMA Dermatology

Question   Does smoking cessation reduce the risk of hidradenitis suppurativa (HS) development?

Findings   In this nationwide cohort study of 6 230 189 Korean participants, quitting smoking was associated with a statistically significant lowered risk of HS onset compared to continuous smoking; conversely, those who initially quit smoking but resumed and those who had no previous smoking history but started had similar risks of HS onset as sustained smokers. Time-smoking interaction analyses revealed a rapid reduction in HS risk after approximately 3 years of smoking cessation, resembling levels of those with a history of smoking but who maintained cessation and those who reported never smoking.

Meaning   Quitting smoking and maintaining a smoking-free status may reduce the risk of HS onset, suggesting the importance of smoking cessation and refraining from initiating or resuming smoking for HS prevention.

Importance   Although tobacco smoking is established as a risk factor for hidradenitis suppurativa (HS), studies on the effects of smoking cessation on HS are limited, and evidence is lacking.

Objective   To examine the association between changes in smoking status and the development of HS.

Design, Setting, and Participants   This population-based cohort study enrolled participants from the Korean National Health Insurance Service database who had undergone 2 consecutive biennial health examinations (2004-2005 and 2006-2007) as the primary cohort. Within the primary cohort, the secondary cohort comprised individuals who underwent all biennial health examinations throughout the follow-up period and maintained the same smoking status from 2006 to 2007 to the end of the follow-up period. Data were analyzed from July to December 2023.

Exposures   Changes in smoking habit status.

Main Outcomes and Measures   Risk of HS development. The HS risk according to change in smoking status between the 2 consecutive health examinations was estimated using a Cox proportional hazards model.

Results   Of the 6 230 189 participants enrolled, the mean (SD) age was 47.2 (13.5) years, and 55.6% were male. During 84 457 025 person-years of follow-up, 3761 HS events occurred. In the primary cohort, compared to those who consistently reported active smoking at both checkups (ie, sustained smokers), lower HS risk was seen among those who were confirmed to smoke initially but quit by the second checkup (ie, smoking quitters) (adjusted hazard ratio [AHR], 0.68; 95% CI, 0.56-0.83), those who maintained cessation status throughout (AHR, 0.67; 95% CI, 0.57-0.77), and those who reported never smoking at either checkup (ie, never smokers) (AHR, 0.57; 95% CI, 0.52-0.63). Those who initially quit smoking but resumed by the second checkup and those who had no previous smoking history but started at the second checkup (ie, new smokers) exhibited similar HS risk as sustained smokers. The secondary cohort results aligned with those of the primary cohort, showing a more pronounced risk reduction with smoking cessation (AHR, 0.57; 95% CI, 0.39-0.83). Considering time-smoking interaction, the cumulative incidence and the risk of HS in smoking quitters were similar to those in sustained smokers in the early stages of observation. However, 3 to 4 years after smoking cessation, the rate decelerated, resembling that of never smokers, and there was a statistically significant decrease in the risk that persisted (between 3 and 6 years from the index date: AHR, 0.58; 95% CI, 0.36-0.92; and ≥12 years from the index date: AHR, 0.70; 95% CI, 0.50-0.97). New smokers initially paralleled never smokers but accelerated after 2 to 3 years, reaching sustained smokers’ levels.

Conclusions and Relevance   In this cohort study, quitting smoking and sustaining a smoke-free status were associated with a reduced risk of HS development compared to continuous smoking. In contrast, resuming or initiating smoking may have as detrimental an effect on HS development as continual smoking.

• Editorial Smoking Cessation and Hidradenitis Suppurativa JAMA Dermatology

Read More About

Kim SR , Choi Y , Jo SJ. Smoking Cessation and Risk of Hidradenitis Suppurativa Development. JAMA Dermatol. Published online August 21, 2024. doi:10.1001/jamadermatol.2024.2613

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