Updated on March 5, 2024.
Millions of Americans use e-cigarettes regularly and the numbers are rising. In 2021, 4.5 percent of adults in the United States reported they were using e-cigarettes (also known as e-cigs). Among young people, they’re the most popular tobacco product. In fact, in 2023, 4.6 percent of U.S. middle school students and 10 percent of high school students had used e-cigarettes in the previous 30 days, according to the Centers for Disease Control and Prevention (CDC).
To put these numbers into perspective, in 2011, only 1.1 percent of middle and high school students reported using e-cigarettes.
Concerns from health authorities
This worrisome trend was addressed in 2018 by U.S. Surgeon General Vice Admiral Jerome M. Adams, MD, MPH. Dr. Adams issued an advisory on the e-cigarette epidemic among American youth. The statement asked all Americans to help protect children against a lifetime of nicotine addiction.
“Everyone can play an important role in protecting our nation’s young people from the risks of e-cigarettes,” wrote Adams.
E-cigarettes have been controversial ever since they came to the U.S. in 2007, when they were touted as a safe way to quit smoking. Shortly after their arrival, the World Health Organization (WHO) announced that there was no evidence that e-cigs were safe or an effective way to stop using tobacco.
In 2017, the WHO officially began recommending that countries restrict the use of e-cigarettes. The health organization routinely issues calls to action urging nations around the world to control e-cigarettes, including children’s access to them.
In 2020, the U.S. Surgeon General once again put out a report warning against the use of all tobacco-related products, stating that the health of anyone, at any age, would benefit from quitting smoking. Quitting reduces the risk of dozens of serious illnesses, including cancers, stroke, and heart disease, as well as premature death. The report also made it clear that there is no conclusive evidence that e-cigarettes help people quit smoking.
Despite the research, experts’ statements, and the publicity around the dangers of e-cigarettes, confusion remains about e-cigs' general safety and their value as smoking cessation aids. Here’s what you need to know about e-cigs, including persistent myths that need to be dispelled.
What are e-cigarettes, exactly?
Standard “e-cigs” (the “e” stands for “electronic”) run on a battery and have a chamber for storing liquid that usually contains nicotine, the addictive ingredient in many tobacco products. You don’t light them and they don’t burn tobacco. Instead, when you puff on one, your lungs take in a heated mist, or aerosol vapor, which is why smoking e-cigs is also referred to as "vaping."
An e-cig can look like an ordinary cigarette, cigar, or pipe, or like a pen or USB stick. It might be called a “vape,” “vape pen,” “mod,” “e-hookah,” “tank system,” or “electronic nicotine delivery system (ENDS).”
Many teens who vape don’t realize nicotine is likely in their e-cigarette, according to the National Institute on Drug Abuse (NIDA).
Serious health concerns linked to vaping
While experts are still learning about the many ways vaping affects health, it’s become clear that e-cigarettes carry plenty of serious health risks. According to the CDC, the aerosol that a user breathes in from a vaping device contains cancer-causing chemicals, volatile organic compounds (VOCs), ultrafine particles, and even heavy metals like lead.
“There’s no question that e-cigarettes cause inflammation of the airways and chronic bronchitis,” says Norman H. Edelman, MD, professor of pulmonary medicine at Stony Brook University in Stony Brook, New York, and senior scientific advisor to the American Lung Association (ALA). Most e-cigs contain nicotine, which is not only highly addictive, but also toxic to developing fetuses and harmful to adolescent brain development, the CDC reports.
Dr. Edelman adds that vaping nicotine increases blood pressure. It also causes levels of adrenaline to spike. These two effects can raise your risk of having a heart attack.
According to a 2020 review published in Current Emergency and Hospital Medicine Reports, research suggests that electronic cigarettes can also cause tachycardia (a dangerous form of rapid heartbeat) and can cause arteries to stiffen, which may contribute to atherosclerosis. They’ve also been linked to atrial fibrillation (irregular heart rhythm) and heart attacks, though it’s not clear if these are actually caused by the vaping.
E-cigarettes often also include flavorings like diacetyl. These are intended to be enticing to children but have been linked to lung disease. They may also contain benzene, a cancer-causing chemical also found in car exhaust.
According to the ALA, research has shown that e-cigarettes also include acetaldehyde, acrolein, and formaldehyde, substances that can cause lung and heart disease. They even contain an herbicide called acrolein, which can cause a number of serious lung health issues.
For some years, some e-cigarettes containing THC (the psychoactive chemical in cannabis or marijuana) also contained vitamin E acetate, a chemical that in 2019 began to sicken thousands of e-cigarette users. By February 2020, 2,807 e-cigarette users across the U.S. were hospitalized for a condition called e-cigarette, or vaping, product use-associated lung injury (EVALI). Of these reported cases, 68 were fatal. Since then, cases of this illness have dropped, probably in part because of some producers removing vitamin E acetate from their cannabis products.
How is vaping regulated?
Beginning in August 2016, the U.S. Food and Drug Administration (FDA) set a minimum legal sale age of 18 and forbade free e-cig samples, which were being distributed at music and sporting events. As of August 2018, e-cigs containing nicotine were required to bear a warning that the compound is addictive.
According to some experts, though, FDA regulators were moving too slowly. In March 2018, multiple major public health organizations, including the American Heart Association and the American Academy of Pediatrics, sued the agency for delaying its safety review of e-cigarettes and cigars. Because of the lag, products appealing to young people were then still available for purchase. Many of these e-cig products and ingredients carried names such as “Smurf Sauce” and “Unicorn Cakes” and flavors like chocolate.
In January 2020, the FDA passed restrictions on most e-cigarette flavors and required all manufacturers to apply for the right to sell their products. As of January 2024, only three manufacturers in the U.S. are now authorized to sell a total of 23 e-cigarette products. (Importantly, though, the 2020 FDA action applied to reusable pod- or cartridge-based e-cigarette flavors. It did not cover disposable e-cigs, which have seen a tremendous growth among young people.)
Does vaping help smokers quit?
E-cigarettes are not an FDA-approved smoking cessation aid because the evidence on the issue is mixed. According to the CDC, some research has pointed to nicotine-containing e-cigarettes as being more effective at helping people quit smoking than e-cigarettes without nicotine.
But if a person does attempt to quit smoking by using e-cigarettes, it’s important to quit all other tobacco products and aim for the goal of ceasing the use of e-cigarettes entirely.
While the evidence is still unclear about whether vaping helps smokers quit, there is some evidence that it may be a gateway to regular smoking. According to a 2023 review published in Advances in Drug and Alcohol Research, research shows that people who use e-cigarettes are 3 to 4 times more likely to start smoking conventional cigarettes.
It’s also important to understand that e-cigarettes often contain a great deal of nicotine, maybe even more than their packaging may state. Since nicotine is the main source of craving and withdrawal from tobacco products, e-cigarettes may actually make quitting smoking harder rather than easier. While more adverse health effects are coming to light, taking up e-cigarettes is a risk not worth taking.
