Health effects of electronic cigarettes explained

The health effects of e-cigarettes (e-cigarettes) are generally claimed to be less than those of smoking, but worse than not smoking at all. However, health is a function not only of the inhaled materials, but of how and how often the products are used, over what period, manufacturing/distribution quality control, marketing, the regulatory environment, and the actual user population.[1] Reported risks include exposure to toxic chemicals, increased likelihood of respiratory and cardiovascular diseases, and accelerated cancer development.

The public health community is divided over the use of these devices to reduce/prevent smoking.[2] As of 2017 they were not approved by the US Centers for Disease Control and Prevention (CDC) as a smoking cessation product.[3] In the United Kingdom, a 2021 review by Public Health England (PHE) reported vaping to be around 95% less harmful than smoking.[4]

A 2019 review concluded that the risk of early death was similar to that of smokeless tobacco.[5] In addition, e-cigarette marketing has been attacked for not focusing on smoking cessation.

Vaping carries some level of health risks.[6] E-cigarette aerosols can affect drug dependency, as well as psychological, respiratory, cardiovascular, immunologic, and central nervous systems.[7] Studies have reported that e-cigarettes reduce lung function (versus not smoking), reduce cardiac muscle function, and increase inflammation.[8] [9]

THC-containing e-cigarettes were deemed responsible for the 2019–20 vaping lung illness outbreak in North America that led to 68 deaths and was linked to vitamin E acetate in the e-liquid.[10] Misuse and accidents increase risks[11] such as nicotine poisoning,[12] [13] contact with liquid nicotine,[14] and fires caused by product malfunction.[15]

Risk context

When evaluating the health effects of some activity, a reasonable question is "what is the practical alternative?" If the answer is smoking, the answer might be different than if the answer is simply avoiding nicotine. This is because the health impacts of smoking are strongly negative, while the impact of avoiding nicotine without any support is unreservedly positive.

In June 2014, the UK Royal College of Physicians stated, "e-cigarettes could lead to significant falls in the prevalence of smoking in the UK, prevent many deaths and episodes of serious illness, and help to reduce the social inequalities in health that tobacco smoking currently exacerbates."[16] A 2017 National Institute for Health and Care Excellence (NICE) guideline did not recommend e-cigarettes due to concerns regarding safety, efficacy, and product quality.[17]

The American Cancer Society stated, "The makers of e-cigarettes say that the ingredients are 'safe,' but this only means the ingredients have been reported to be safe to eat. Inhaling a substance is not the same as swallowing it. There are questions about how safe it is to inhale some substances in the e-cigarette vapor into the lungs."[18]

Smoking

E-cigarette vapor does not contain tobacco and does not involve combustion, therefore users do not encounter several unquestionably harmful constituents of tobacco smoke, such as ash, tar, and carbon monoxide.[19] A 2014 review concluded that e-cigarette aerosol contains far fewer carcinogens than tobacco smoke, and concluded that e-cigarettes "impart a lower potential disease burden" than traditional cigarettes.[20]

Smokers can use e-cigarettes for various purposes. As an aid to quitting smoking, vaping is a temporary activity that reduces smoking and terminates once the smoker has completed the transition away from nicotine. Alternatively, smokers can substitute or complement smoking with vaping without intending to transition, meaning that any negative effects are not temporary. In the latter context, the relative risks of vaping vs smoking are of great importance.[21] Furthermore, allowing vaping in public places may undermine smoking regulations. Other smoker-transition aids are available and may offer better safety and/or effectiveness profiles then vaping. Given equal effectiveness, relatively safety considerations would become paramount. [22]

Abstinence

Vaping presents safety risks that are definitionally higher than those of simple abstinence, as they have no independent health benefits. This comparison is relevant because some users adopt e-cigarettes for the nicotine (or cannabinoids), even though they have never smoked. Once nicotine dependence is established, users may be more likely to take up smoking.

Individual effects

Health effects for non-smokers must be considered in absolute terms for long-term use as well as the risk of transition into traditiion cigarettes, while for smokers the relative risks are paramount, and if used as a quitting aid, any effects of short-term use are most important.

Non-smokers

E-cigarettes create nicotine dependence in non-smokers.[23] E-cigarettes may act as a gateway drug.[24] This is particularly significant among youth who have no experience with addictive drugs.[25] [26] A 2016 review concluded that nicotine exposure harms youths' growing brains.[27] Pregnant or nursing women and the elderly are more sensitive to nicotine than other individuals.[28]

Smokers

Used as a transition to abstinence, e-cigarettes end the consumption of nicotine and the other harmful substances in tobacco smoke and later any harmful e-liquid ingredient. However, if transition is unsuccessful, e-cigarettes could mean increased nicotine dependence (by combining smoking and vaping) and ongoing harm from other e-liquid ingredients.[29] [30] [31]

Health benefits associated with transitioning from smoking to vaping include decreased post-smoking weight gain and improved exercise tolerance.[32]

Even a partially successful transition may allow smokers to reduce their cigarette consumption and related health effects.[33] A 2022 Cochrane review concluded that vaping increased quit rates compared to e-cigarettes without nicotine and compared to nicotine replacement therapy, although it did not compare vaping to other methods.[34]

A 2018 review concluded that child vapers had a higher likelihood of more and more significant adverse effects than child smokers. Significant harmful effects included cyanosis, nausea, and coma.[35]

The relative safety of electronic versus conventional cigarettes is disputed. 2015[36] and 2018 Public Health England (PHE) reports claimed that vaping is "at least 95% less harmful than smoking".[36] The Royal College of Physicians, the Royal Society for Public Health, and the National Health Service backed these claims.[37] The estimate was limited by "lack of hard evidence for the harms of most products on most of the criteria". The research was funded by EuroSwiss Health and was criticized for its weak methodology,[38] lack of specific evidence, and for financial ties to the tobacco industry. The estimate was disputed in medical journals.[39] [40] Reviews in 2016 and 2018 claimed that the harm from e-cigarettes is much higher than the "95% safer" figure.[41]

A 2025 RCP review[42] reported that e-cigarettes sold in England (which allow nicotine strength[43] of no more than 20 mg/ml[44]) are unlikely to exceed 5% of the harm of cigarettes for non-pregnant adults. This claim is consistent with the 2018 view of the US National Academies of Sciences, Engineering, and Medicine.[45] A 2013 review did not claim that vaping reduced nicotine consumption vs smoking.[46]

General risks

Battery explosions can be caused by thermal runaway and may cause burns or other injuries.[47]

Nicotine poisoning can occur by ingestion, inhalation, or absorption via the skin or eyes.[48] [49]

E-liquid exposure can come by leaks or spills.[50]

A 2018 review concluded that exposure to vapor can reduce lung function.[51]

Adverse effects are mostly associated with short-term use and the reported adverse effects decreased over time.

Airways

Potential adverse effects include airway resistance, irritation of the airways, eyes redness, dry throat,[52] and increase in allergic airway inflammation with elevated infiltration of inflammatory cells including eosinophils into airways. A 2015 study reported that short-term adverse effects reported most often were mouth and throat irritation, dry cough, and nausea.[53] Dryness of the mouth and throat is believed to stem from water absorption by propylene glycol and glycerin.[54]

Throat irritation could be the result of exposure to nicotine, nicotine solvents, or toxicants in the aerosol.

A 2016 study reported nose bleeds, change in bronchial gene expression, release of cytokines and proinflammatory mediators.

Neurological

A 2013 report to the FDA identified minor headache, chest pain, nausea, and cough as side effects. Major adverse events included hospitalizations for pneumonia, congestive heart failure, seizure, rapid heart rate, and burns. However, no causal relationship to vaping was proven. Many effects on the nervous and the sensory systems are possibly related to nicotine overdose or withdrawal.[55]

A 2016 study reported that an e-liquid containing 23% alcohol was linked to reduced performance on the Purdue Pegboard Test.[56]

A 2017 study reported harm to neurons and tremors and spasms.[57]

Injuries

E-cigarettes typically use lithium batteries, which may fail if defective[58] or misused. A 2015 PHE report concluded that fire risks from e-cigarettes "appear to be comparable to similar electrical goods". In 2018 PHE reported six UK case studies involving e-cigarettes with burns. E-liquid ingredients may be flammable.[59] A 2014 review claimed that some users add more or larger batteries to nonadjustable e-cigarettes, which may lead to battery leakage or explosion.[60]

A 2016 study reported that the explosion risk was low.[61] Another 2016 study assembled reports of 92 explosion, fire, or overheating events, with related injuries in 47 individuals.[62] Prominent harms included 2 cervical vertebral fractures, 1 palate fracture, 3 instances of damaged teeth, 33 thermal burns, 4 chemical burns, and 5 lacerations. A 2017 study reported that most e-cigarette fires are triggered by batteries overheating and igniting.[63]

An e-cigarette explosion or fire can induce serious burns and harms that need medical treatment. Explosions have resulted in lost teeth, neck fractures, and burns from combustion and/or battery acid.[64] Reported burns covered from 1% to 8% of body area. They were most commonly reported in the lower extremity, hands, head and neck, and genitalia.[65] Explosions in some cases produced 2nd and 3rd degree burns.[66] A review concluded that some 50% needed surgical management. The most common harms are burns as a result of explosion while carrying an e-cigarette.[67]

A 2017 review concluded, "Several of the reported cases show that 'the battery in pocket' precedes the incident. The damp environment in the pocket may have sufficient moisture to start a chemical reaction within the lithium-ion battery and the presence of metal objects can produce short-circuit which can over heat the battery leading to an explosion."[68] Burn risk extends to bystanders. Property may also be damaged.The United States Fire Administration reported 195 occasions of e-cigarette fires and explosions between January 2009 and December 2016. These incidents resulted in 133 acute injuries, of which 38 (29 percent) were severe. A 2017 review concluded that 80% of e-cigarette explosions occurred during battery charging, many by 3rd-party power adaptors that used inappropriately high charge rates that led to thermal runaway. Some third-party vendors assemble e-cigarettes from incompatible parts that do not meet manufacturers' specifications. Batteries are typically cylindrical, with the least strongest structural points at the ends. Given a battery seal breach, the ends may accelerate away.Burn events while on home oxygen therapy have been reported, leading Health Canada in 2014 to warn of fire risk. The heating element in vaping devices can get hot enough to ignite in the presence of oxygen.[69]

Poisoning

E-cigaratte nicotine poisoning occurs via ingestion, inhalation, or absorption via the skin or eyes.

Such poisoning is apparently rare, suggested by the fact that reviews highlight individual cases. In 2014, an infant died from choking on an e-cigarette component.[70] As of 2016 four adults were reported to have died in the US and Europe after intentionally ingesting e-liquid.[71] Two children, one in the US in 2014 and another in Israel in 2013, died after ingesting liquid nicotine.[72] A two-year-old girl in the UK in 2014 was hospitalized after licking an e-cigarette liquid refill.[73]

A 2022 concluded that toxicity can come from aerosols containing toxic chemicals[74] or excessive concentrations of nicotine as an e-liquid.

A 2014 review concluded that users may alter e-liquid contents, adding substances such as alcohol or nicotine, possibly making them toxic.

As of 2014, calls to US poison control centers involved inhalations, eye exposures, skin exposures, and ingestion, in both adults and children.[75] A 2016 study reported minor, moderate, and serious adverse effects.[76] Minor effects correlated with e-liquid poisoning were tachycardia, tremor, chest pain and hypertension. More serious effects were bradycardia, hypotension, nausea, respiratory paralysis, atrial fibrillation and dyspnea.[77] Initial symptoms included rapid heart rate, sweating, feeling sick, and vomiting. Delayed symptoms included low blood pressure, seizures, and hypoventilation.[78] Rare serious effects included coma, seizure, trouble breathing, and heart attack.[79] After examining poison control centers' reports between 2010 and early 2019, FDA reported that, between the poison control centers and FDA, 35 cases of seizures mentioned use of e-cigarettes.[80]

From 2011-2019, cases of accidental poisoning from nicotine e-liquids grew rapidly in the US.[81] From September 1, 2010, to December 31, 2014, 58% of e-cigarette calls to US poison control centers were related to children under 6. In 2014 Centers for Disease Control and Prevention (CDC) reported that 51.1% of the calls to US poison centers due to e-cigarettes were related to children under age 5, and while 42% of calls were related to people age 20 and older.[82] E-cigarette calls had a greater chance to report an adverse effect and a greater chance to report a moderate or major adverse effect than traditional cigarette calls. Severe outcomes were more than 2.5 times more frequent in children exposed to e-cigarettes and nicotine e-liquid than with traditional cigarettes.[83] US poison control centers reported that 92.5% of children who came in contact with nicotine e-liquid swallowed it during the period from January 2012 to April 2017.

Most frequent adverse effects from ingestion!Effect!Frequency (%)
vomiting40.4
eye irritation or pain20.3
nausea16.8
red eye or conjunctivitis10.5
dizziness7.5
tachycardia7.1
drowsiness7.1
agitation6.3
headache4.8
cough4.5
In 2016 American Association of Poison Control Centers (AAPCC) reported 2,907 exposures regarding e-cigarettes and liquid nicotine.[84] The yearly nicotine exposure rate in the US involving children went up by 1,398% from 2012 to 2015, later dropping by 20% from 2015 to 2016. In 2017 the National Poison Data System stated that exposures to e-cigarettes and liquid nicotine among young children was rising significantly.[85]

Respiratory

As of 2015, the long-term lung function effects of vaping were unknown. A 2014 study reported that limited evidence suggests that e-cigarettes produce less short-term effects on lung function than traditional cigarettes. As of 2015 many e-liquid ingredients had not been examined in the lung.

As of 2017 e-cigarette effects on asthma and other respiratory diseases had not been assessed.

A 2015 review concluded that e-cigarettes may induce acute lung disease.

A 2018 study reported correlations between vaping and pleural effusions. A 2015 study reported that e-cigarette vapors can induce oxidative stress in lung endothelial cells. A 2016 review concluded that e-cigarette vapor that triggered constant lung inflammation could result in lung pathogenesis and induce diseases such as chronic obstructive pulmonary disease and fibrosis. A 2018 review concluded that e-cigarette vapors can result in acute endothelial cell injury, but the long-term effects were uncertain. A 2017 review concluded "Exposure to nicotine that was specifically generated by the use of e-cigarettes, was shown to promote oxidative stress and impairment of autophagy, which in turn serves as a potential mechanism leading to development of chronic obstructive pulmonary disease." A 2014 case report observed the correlation between sub-acute bronchiolitis and vaping. After quitting vaping the symptoms improved. Vaping causes bronchospasm. Adolescents who vaped had a higher frequency of chronic bronchitis symptoms.

A 2015 review reported that the long-term effects regarding respiratory flow resistance were unknown. A 2014 review concluded that e-cigarettes reduced lung function, but much less than traditional cigarettes.[86] A 2015 clinician's guide stated that 5 minutes of vaping considerably increased lung airflow resistance. A 2013 review concluded that a single e-cigarette increased airway resistance.

A 2014 study reported higher levels of exhaled nitric oxide, which was associated with lung inflammation. A 2014 review concluded that harmful effects to cardiovascular and respiratory functions after short-term use of e-cigarettes were appreciably milder than traditional cigarettes. A 2015 review concluded that short-term use increased respiratory resistance comparatively [sic] to traditional cigarettes.

A 2018 study reported that adolescent vapers with asthma or other respiratory ailments could have greater odds of increasing respiratory symptoms and aggravations. In 2018 PHE reported "There have been some studies with adolescents suggesting respiratory symptoms among EC experimenters. However, small scale or uncontrolled switching studies from smoking to vaping have demonstrated some respiratory improvements."

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