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Argumentative Essay on Vaping

Is Vaping Really That Bad?

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Works Cited

Garcia. “Updated: Dallas Has 17 Hospitalizations Linked to Vaping, County Health Official Reports.” Dallas News, Dallas News, 18 Sept. 2019, www.dallasnews.com/news/2019/09/16/updated-Dallas-has-17-hospitalizations-linked-to-vaping-county-health-official-reports/.
Holland, Jeff, and Ashley Mesch. “Your View on Vaping.” 2 Oct. 2019.
Logan, Josh, and Ashley Mesch. “Vaping Effects.” 7 Oct. 2019.

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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

Tobacco control

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Head of School: Engineering, Computer and Mathematical Sciences

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Organizational Behaviour – Assistant / Associate Professor (Tenure-Track)

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Teen Vaping: The New Wave of Nicotine Addiction Essay

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Over the years, the utilization of vaping products has dramatically increased, particularly among youth. With at least 12 deaths and close to 1,000 sickened, vaping, the enormously fashionable alternative for consuming nicotine or perhaps flavorful substances, has unexpectedly been riskier than predicted (Dinardo & Rome, 2019). The Centers for Disease Control (CDC) estimates that more than 2 million young people smoked e-cigarettes in 2021 (Dinardo & Rome, 2019).

It might have a significant effect if state officials asked the region’s health authority to ban all flavored vape goods in reaction to this issue to safeguard the youth’s well-being (Domenico et al., 2021). A state does have other options in addition to that. The best way to overcome this difficulty is for nations to incorporate free science-based application innovations. While enforcing an immediate ban benefits many parents, incorporating an app is preferable since it immediately communicates with the youth by showing them the negative impacts and ultimately nullifies any possibility of teenagers smoking.

Banning commodities, especially which bring some preconceived pleasures increases the demand for those who want them instead of cutting them. It is correct that banning vapes will have a slight effect as parents will majorly appreciate it, but it would only make the youth go to more extraordinary lengths seeking the vapes, hence imposing a threat more. This solution would work in the short term and involve many state officers and laws to force the action.

Alternatively, using scientifically constructed applications that are freely accessible in any state would have a significant positive effect as it directly communicates with youth. Showcasing the adverse effects of vaping and providing statistical facts in the form of notifications on youth’s phones will, by a majority, cut vape users as they are spoken to intellectually and emotionally. On the other hand, this would work over the long term, which is more profitable for the future generation and the nation’s government.

Therefore, incorporating a scientifically created application solution is the best overall solution and should be integrated into states where vaping is prone. A significant drop will be evident as soon as the government spreads awareness of the new freely accessible application. As many people work now not for themselves but the betterment of future generations, this solution would pose the best course of action in entirely eradicating vaping for the youth soon, with no possibility of newly developing again.

Dinardo, P., & Rome, E. S. (2019). Vaping: The new wave of Nicotine Addiction . Cleveland Clinic Journal of Medicine, 86 (12), 789–798. Web.

Domenico, L., DeRemer, C. E., Nichols, K. L., Campbell, C., Moreau, J. R., Childs, G. S., & Merlo, L. J. (2021). Combatting the epidemic of e-cigarette use and vaping among students and transitional-age youth. Current Psychopharmacology, 10 (1), 5–16. Web.

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Chicago (A-D)
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IvyPanda. (2023, November 22). Teen Vaping: The New Wave of Nicotine Addiction. https://ivypanda.com/essays/teen-vaping-the-new-wave-of-nicotine-addiction/

"Teen Vaping: The New Wave of Nicotine Addiction." IvyPanda , 22 Nov. 2023, ivypanda.com/essays/teen-vaping-the-new-wave-of-nicotine-addiction/.

IvyPanda . (2023) 'Teen Vaping: The New Wave of Nicotine Addiction'. 22 November.

IvyPanda . 2023. "Teen Vaping: The New Wave of Nicotine Addiction." November 22, 2023. https://ivypanda.com/essays/teen-vaping-the-new-wave-of-nicotine-addiction/.

1. IvyPanda . "Teen Vaping: The New Wave of Nicotine Addiction." November 22, 2023. https://ivypanda.com/essays/teen-vaping-the-new-wave-of-nicotine-addiction/.

Bibliography

IvyPanda . "Teen Vaping: The New Wave of Nicotine Addiction." November 22, 2023. https://ivypanda.com/essays/teen-vaping-the-new-wave-of-nicotine-addiction/.

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.

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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The Risks of Vaping

A Look at Safety

Illustration of a teenager saying no to friends offering him an electronic cigarette

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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Impact of vaping on...

Impact of vaping on respiratory health

Linked editorial.

Protecting children from harms of vaping

Related content
Peer review
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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Home — Essay Samples — Nursing & Health — Smoking — New Means of Smoking: Pros and Cons of Vaping

New Means of Smoking: Pros and Cons of Vaping

Categories: Smoking Tobacco

About this sample

Words: 396 |

Published: Jun 6, 2019

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Hook Examples for Vaping Essay

Startling Fact: In today’s world, an increasing number of individuals, especially young people, are drawn into the world of vaping, often without a clear understanding of the potential consequences.
Personal Anecdote: Walking through a local park, I couldn’t help but notice a group of teenagers huddled together, each puffing away on their e-cigarettes. Their choice to vape made me reflect on the allure of this controversial habit.
Health Concerns: Vaping promises a smoke-free alternative, but the health risks it poses are far from smoke and mirrors. Understanding the potential impact on our well-being is crucial in addressing this issue.
Historical Perspective: Throughout history, societies have grappled with new trends and substances. Vaping, with its rapid rise and uncertain consequences, echoes past dilemmas about substances and their societal impact.
The Influence of Marketing: Vaping companies employ sophisticated marketing techniques to attract consumers, especially young adults. Analyzing these strategies can shed light on how vaping has become a pervasive trend.

Works Cited

Brown, J., & Lee, C. (2019). Exploring the use of vaping as an alternative to smoking cigarettes. Journal of Health Behavior, 25(2), 45-58.
Centers for Disease Control and Prevention. (2021). Electronic cigarettes (e-cigarettes). Retrieved from https://www.cdc.gov/tobacco/basic_information/e-cigarettes/index.htm
Ghosh, A., & Philen, R. (2020). The pros and cons of vaping: A comprehensive review. Journal of Public Health Research, 19(3), 87-102.
Kalkhoran, S., & Glantz, S. A. (2016). E-cigarettes and smoking cessation in real-world and clinical settings: A systematic review and meta-analysis. The Lancet Respiratory Medicine, 4(2), 116-128.
McRobbie, H., Bullen, C., Hartmann-Boyce, J., & Hajek, P. (2014). Electronic cigarettes for smoking cessation and reduction. Cochrane Database of Systematic Reviews, (12), CD010216.
National Academies of Sciences, Engineering, and Medicine. (2018). Public health consequences of e-cigarettes. National Academies Press.
Ramamurthi, D., & Chau, C. (2018). A systematic review of the health effects of e-cigarettes. American Journal of Public Health, 108(8), e1-e12.
Singh, T., Arrazola, R. A., Corey, C. G., Husten, C. G., Neff, L. J., Homa, D. M., … & King, B. A. (2016). Tobacco use among middle and high school students—United States, 2011-2015. Morbidity and Mortality Weekly Report, 65(14), 361-367.
Stratton, K., Kwan, L. Y., & Eaton, D. L. (Eds.). (2018). Public health consequences of e-cigarettes. National Academies Press.
World Health Organization. (2019). Electronic nicotine delivery systems and electronic non-nicotine delivery systems (ENDS/ENNDS). Retrieved from https://www.who.int/news-room/q-a-detail/electronic-nicotine-delivery-systems-(ends)-electronic-non-nicotine-delivery-systems-(ennds)

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Argumentative Essay on Vaping

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

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

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Impact of vaping on respiratory health

Abbreviations

Introduction

Sources and selection criteria

The origins of vaping

Vaping terminology

Epidemiology of vaping

Vaping as harm reduction

Vaping lung injury—clinical presentations

The 2019 EVALI outbreak

CDC criteria for establishing EVALI diagnosis

Probable case

EVALI—clinical, radiographic, and pathologic features

EVALI—outcomes

Vaping induced lung injury—pathophysiology

Pro-inflammatory vape aerosol effects

THC-containing products

Lipid laden macrophages

Clinical aspects

Health outcomes among vape pen users

Covid-19 and vaping

Clinical impact—collecting and recording a vaping history

Practical considerations—gathering a vaping history

Practical guide to collecting a vaping history

Ask what they are vaping

Ask how they are vaping