Health Risks of Vaping
No tobacco product use is risk-free, including vaping—e-cigarettes contain and emit numerous potentially toxic substances beyond nicotine that pose serious cardiovascular, respiratory, and neurological risks, particularly to adolescents, pregnant individuals, and those with pre-existing conditions. 1, 2
Cardiovascular Dangers
Nicotine itself causes significant cardiovascular harm by increasing blood pressure, heart rate, and blood flow to the heart while narrowing and hardening arterial walls, which can directly lead to heart attacks. 1, 2 E-cigarettes adversely affect cholesterol metabolism and cardiovascular health through multiple mechanisms including effects on lipid profiles and promotion of atherosclerosis—they are definitively not harmless alternatives to traditional cigarettes. 2, 3
The cardiovascular risks extend beyond nicotine alone, as most e-cigarette products contain and emit numerous potentially toxic substances that contribute to cardiovascular disease development. 1
Respiratory Health Impacts
Acute Effects
The most commonly reported adverse effects from e-cigarette use include:
Chronic and Severe Respiratory Consequences
E-cigarette solutions and aerosols contain toxicants, carcinogens, and metal particles that pose serious respiratory health risks. 2, 3 More than 80 compounds have been identified in e-liquids and aerosols, including known toxics such as formaldehyde, acetaldehyde, metallic nanoparticles, and acrolein. 4
Airway irritation, mucus hypersecretion, and inflammatory responses (including systemic changes) occur after e-cigarette exposure, leading to increased respiratory symptoms, changes in respiratory function, and impaired host defense mechanisms. 4
EVALI Outbreak
The 2019 outbreak of E-cigarette or Vaping product Use-Associated Lung Injury (EVALI) resulted in over 2,800 hospitalizations in the United States, with the vast majority of cases associated with tetrahydrocannabinol (THC)-containing e-cigarettes. 1 This outbreak definitively demonstrated that vaping can cause serious lung injuries including pneumonia and bronchiolitis. 5
E-cigarette use has been linked with increased symptoms in individuals with asthma, cystic fibrosis, and chronic obstructive pulmonary disease. 4
Extreme Dangers for Adolescents and Youth
The developing brains of children and adolescents are particularly vulnerable to nicotine dependence, with addiction occurring far earlier than previously believed. 2 Nicotine is a neuroteratogen that acts on nicotinic acetylcholine receptors throughout the central and peripheral nervous system, with the α4β2 receptor showing higher functional activity in the cortex, hippocampus, striatum, and thalamus during adolescence (ages 13-18) compared to adulthood. 3
Nicotine exposure during adolescence causes addiction and harms the developing brain. 1
Epidemic Among Youth
Between 2011-2014, e-cigarette use increased by 650% among middle school students and 890% among high school students. 2 By 2019, prevalence reached 27.5% in high school students. 6 In 2014, more youth reported using e-cigarettes than any other tobacco product. 2
E-cigarettes threaten to renormalize and glamorize nicotine use, reversing more than 50 years of progress in tobacco control. 2
Pregnancy-Specific Risks
Nicotine crosses the placenta during pregnancy, resulting in multiple adverse consequences including sudden infant death syndrome. 1, 2 No trials have evaluated e-cigarettes for tobacco smoking cessation in pregnant persons. 1
The evidence on vaping during pregnancy is of poor quality, with no studies adequately assessing exposure to both smoking and vaping. 7 However, given nicotine's known harms to fetal development and the presence of additional toxic substances in e-cigarettes, pregnant individuals should avoid all vaping products. 1
Secondhand and Thirdhand Exposure Risks
Nonusers are involuntarily exposed to e-cigarette emissions through secondhand and thirdhand aerosol containing nicotine, carcinogens, and metal particles. 2 Thirdhand aerosol remains on surfaces and in dust after e-cigarette use, can be reemitted into the gas phase, or react with oxidants to yield secondary pollutants. 2
There is no safe level of tobacco smoke or aerosol exposure for children. 2
Patients with Pre-existing Conditions
Individuals with diabetes and other chronic conditions should avoid vaping due to substantially increased cardiovascular disease risk. 3, 8 Those with pre-existing pulmonary disease experience worsening of symptoms with e-cigarette use. 4
Critical Common Pitfalls
Many people incorrectly perceive e-cigarettes as harmless or significantly less harmful than traditional cigarettes—this is categorically false. 2, 8 While e-cigarettes likely pose less risk compared to combustible tobacco cigarettes, they should never be characterized as harmless. 2
There is no safe tobacco product—e-cigarette products contribute to nicotine dependence and continued use after cessation attempts remains high. 1, 2
Clinical Screening Recommendations
Screen for tobacco, nicotine, and electronic cigarette use at diagnosis and regularly thereafter, starting at puberty for all adolescents and young adults. 2, 3 Use open communication and consistent, validated screening tools to detect vaping use. 3
Electronic cigarette use or vaping should be discouraged in all patients, particularly youth with chronic conditions who face increased cardiovascular disease risk. 2, 3
Evidence on Cessation Use
The USPSTF concludes that evidence on e-cigarettes for tobacco smoking cessation is insufficient, and the balance of benefits and harms cannot be determined. 1 Results from trials were mixed on whether smoking cessation increased with e-cigarettes, but continued e-cigarette use after intervention remained high, indicating persistent nicotine dependence. 1
Clinicians should direct patients to other tobacco cessation interventions with proven effectiveness and established safety rather than recommending e-cigarettes. 1