What are the health effects of vaping, particularly in young adults with a history of nicotine addiction?

Health Effects of Vaping

Vaping poses serious health risks, particularly for young adults and adolescents, including nicotine addiction, cardiovascular and respiratory damage, and harmful effects on the developing brain—these products should be strongly discouraged in all youth regardless of smoking history. 1

Critical Brain and Neurological Effects

Nicotine is a neuroteratogen that causes lasting structural and functional changes in the developing adolescent brain. 2

• Nicotinic acetylcholine receptors (particularly α4β2 subtype) have higher functional activity in the cortex, hippocampus, striatum, and thalamus during ages 13-18 years compared to adulthood, making adolescents uniquely vulnerable to nicotine's effects 2
• Adolescent nicotine exposure causes acute neurochemical changes including increased dopamine and serotonin in the nucleus accumbens, alterations in dopaminergic and serotonergic transporter densities, and structural changes to the amygdala, prefrontal cortex, ventral tegmental area, and thalamus 2
• Long-term effects include enhanced releasability of dopamine in the prefrontal cortex, upregulation of striatal dopamine transporter density, and altered prefrontal cortex connectivity 2
• These neural changes result in deficits in inhibitory processing, episodic memory, decision making, and processing speed 2
• Nicotine exposure increases risk for psychopathology including ADHD, anxiety, and depression 2

Cardiovascular and Systemic Health Risks

Nicotine causes significant cardiovascular damage that extends beyond the lungs. 2

• Nicotine increases blood pressure, heart rate, causes arterial narrowing and arterial wall hardening that can lead to heart attack 2
• It plays a major role in the development of coronary artery disease, atherosclerosis, and aortic aneurysms 2
• Nicotine is associated with peptic ulcer disease and gastrointestinal cancer, and may promote tumor angiogenesis 2
• It has genotoxic effects on fetal cells and deleterious effects on bone health 2
• Nicotine affects sexual maturation, hormone development, and reproduction 2

Respiratory System Damage

E-cigarettes contain and emit numerous potentially toxic substances beyond nicotine that harm the respiratory system. 1

• Vaping products contain vaporizing solvents, particulate matter, metals, and flavorings that can have deleterious effects on the respiratory system 2, 1
• The American Heart Association reports early molecular and clinical evidence of various acute physiological effects from electronic nicotine delivery systems 3
• Respiratory symptoms have been linked to vaping, though long-term implications remain under investigation 4

Addiction and Gateway Concerns

E-cigarettes deliver high concentrations of nicotine that create significant addiction risk, particularly with newer high-nicotine delivery systems. 2

• Regular use of electronic nicotine delivery systems in adolescents can result in systemic nicotine concentrations similar to those found with regular combustible cigarette use 2
• The introduction of high-nicotine delivery systems such as JUUL transformed the e-cigarette landscape and increased addiction potential for young people 2, 1
• Nicotine is highly addictive and affects many body cells, mediators, and metabolic pathways 2
• E-cigarette use is associated with increased odds of smoking combustible cigarettes among adolescents who had no previous intention of smoking conventional cigarettes 2, 1
• Flavored e-liquids favored by young people often have lower pH than other flavors, resulting in more rapid nicotine absorption 2

Detection Challenges and Clinical Implications

Vaping is particularly difficult to detect compared to traditional smoking, allowing harmful use to escalate unnoticed. 2, 1

• E-cigarette smell dissipates immediately after use and is not detectable by healthcare providers or caregivers 2
• Few behavioral shifts occur after e-cigarette use, and those that do are subtle 2
• Devices are designed to be indiscernible from everyday objects like USB drives or pens 2
• This concealment ability allows adolescents to transition from initial exploration into hazardous use without detection 2, 1

Product Safety and Regulation Concerns

E-cigarettes have not been adequately tested, standardized, or regulated as nicotine delivery systems, making their safety uncertain. 2

• Widespread inaccuracy exists in nicotine concentrations depicted on e-liquid packaging, including nicotine in products labeled as nicotine-free 2
• Idiosyncratic use behaviors (such as puff volume) create variability in nicotine delivery 2
• Individuals using e-cigarettes have difficulty detecting, discerning, and regulating the amount of nicotine entering their system 2
• E-cigarettes do not undergo the premarket animal and human safety studies required of drug products or medical devices 3

Clinical Recommendations

Healthcare providers must actively screen for e-cigarette use during all adolescent visits and strongly discourage use. 1

• Screen for e-cigarette use during all adolescent healthcare visits, recognizing that traditional signs of tobacco use may not be present 1
• Advise adolescents to avoid both smoking and vaping for optimal health outcomes 1
• Use evidence-based behavioral strategies to support complete nicotine cessation rather than transitioning to e-cigarettes 1
• Discuss with adolescents the potential long-term impacts on brain development, addiction risk, and gateway effects to other substances 1

Common Pitfalls to Avoid

The harm-reduction premise that e-cigarettes are "safer than cigarettes" ignores the deleterious effects of nicotine itself and is particularly dangerous messaging for never-smokers 2. While e-cigarettes may pose less risk than combustible cigarettes (a very high-risk comparator), they are not safe, especially for developing brains 2. The perception that vaping lacks negative health effects has contributed to widespread youth adoption 5. Providers must not minimize these risks when counseling young patients.