What are the respiratory, cardiovascular, oral, and systemic adverse effects of vaping?

Vaping Side Effects

Vaping causes serious harm across multiple organ systems including acute lung injury (EVALI), cardiovascular disease, oral health deterioration, and nicotine addiction—healthcare providers should unequivocally advise complete avoidance of all vaping products. 1, 2

Respiratory Effects

Acute Lung Injury (EVALI)

• E-cigarette or Vaping Product Use-Associated Lung Injury (EVALI) causes severe respiratory compromise requiring hospitalization, with over 2,800 hospitalizations documented during the 2019 outbreak 3, 4, 5
• Patients present with fever, cough, shortness of breath, chest pain, and bilateral ground-glass opacifications on imaging 3, 4
• Vitamin E acetate used as a diluent in THC cartridges is the primary implicated agent, as pulmonary tissue cannot metabolize or absorb it, leading to accumulation 4
• Immediate discontinuation of all vaping products is mandatory for suspected EVALI cases 3

Chronic Respiratory Damage

• Vaping generates pulmonary irritants and carcinogenic carbonyl compounds (formaldehyde, acetaldehyde, acrolein) when propylene glycol and glycerin are heated 4
• Diacetyl, a common buttery flavoring agent, causes bronchiolitis obliterans with inhalational exposure 4
• Passive inhalation of vaporized fine and ultrafine particles, nicotine, and cancer-causing substances poses significant health risks to bystanders 3
• Long-term effects remain largely unknown due to the recent emergence of vaping, but early evidence suggests increased risk of chronic lung disease 6, 7

Cardiovascular Effects

Immediate Hemodynamic Impact

• Nicotine from vapes directly increases myocardial oxygen demand while simultaneously causing arterial narrowing, creating a dangerous supply-demand mismatch 1
• Vaping adversely affects endothelial function, increases vascular stiffness, and elevates blood pressure 1, 2

Long-Term Cardiovascular Disease

• The 10-year fatal cardiovascular risk approximately doubles in all nicotine users with no safe lower threshold identified 1
• Nicotine contributes to progressive atherosclerosis, coronary artery disease, and aortic aneurysms that accumulate over years 3, 1, 2
• The American Heart Association/American College of Cardiology states that nicotine e-cigarettes should not be recommended as first-line therapy for smoking cessation due to lack of long-term safety data and high rates of ongoing dependence 1

Oral Health Effects

• Vaping is associated with increased risk of gingivitis, periodontal disease, and dental caries 8
• Vaping reduces the antioxidant capacity of saliva, compromising oral defense mechanisms 8
• While oral problems in vapers are less severe than traditional smokers, they remain significantly worse than non-users 8

Systemic and Neurological Effects

Nicotine Toxicity

• Nicotine is highly addictive and affects multiple body systems including cardiovascular, gastrointestinal, neurological, and musculoskeletal 3
• Nicotine is associated with peptic ulcer disease, gastrointestinal cancer, and tumor angiogenesis 3
• Nicotine causes deleterious effects on bone health in both animal models and humans 3
• Nicotine has genotoxic effects on fetal cells and adversely affects chromosomes 3

Developmental and Reproductive Harm

• Nicotine has negative impacts on adolescent brain development and increases risk for nicotine addiction leading to tobacco product use 3
• In utero nicotine exposure influences later occurrence of impaired fertility, type 2 diabetes, obesity, hypertension, neurobehavioral defects, and respiratory dysfunction 3
• Nicotine affects neuroregulation and structural brain changes that disturb reflexes and responses, increasing vulnerability to hypoxia 3
• In women, nicotine inhibits estrogen signaling, making the brain more susceptible to ischemia 3

Chemical Exposures and Contaminants

• Metals from heating coils and cartridge casings leach into aerosols, including aluminum, chromium, iron, lead, manganese, nickel, and tin 4
• Flavoring agents lack safety data for inhalational exposures despite being considered safe for ingestion 4
• E-cigarettes contain and emit numerous potentially toxic substances beyond nicotine, with highly variable exposure based on product characteristics 9

Special Population Concerns

Youth and Adolescents

• E-cigarette use among youth poses a clear threat to public health, with usage rates reaching 27.5% among U.S. high school students in 2019 2, 9, 5
• E-cigarette use is associated with increased odds of smoking combustible cigarettes among adolescents who had no previous intention of smoking 2, 9
• An estimated 160,000 students who tried e-cigarettes had never used combustible cigarettes, representing a gateway to nicotine addiction 3

Clinical Management Approach

For Suspected EVALI

• Obtain vital signs, pulse oximetry, focused history ruling out influenza and community-acquired pneumonia 3
• Hospitalize patients with O2 saturation <95% on room air, respiratory distress, or compromising comorbidities 3
• Consider chest X-ray and CT scan even if X-ray is normal; obtain urine toxicology and infectious disease testing 3
• Consider corticosteroids with caution due to risk of worsening respiratory infections 3

Cessation Counseling

• Implement standard smoking cessation therapies including counseling, nicotine replacement therapy, bupropion, or varenicline as alternatives to vaping 1
• Evidence is limited regarding efficacy of e-cigarettes as smoking cessation aids 2, 9
• Warn patients about risks of developing long-term nicotine dependence and encourage prompt cessation 1
• Avoid dual use of both combustible and electronic cigarettes simultaneously 2, 9

Critical Pitfalls to Avoid

• Do not recommend e-cigarettes as a harm reduction strategy or smoking cessation tool—there is no safe level of nicotine exposure 1, 2
• Do not assume vaping is harmless because it lacks combustion—it causes distinct pathology including EVALI and cardiovascular disease 1, 2, 4
• Do not overlook vaping history in patients presenting with respiratory or cardiovascular symptoms 3, 6
• Do not dismiss concerns about secondhand vaping exposure, particularly in indoor environments 3