Understanding Electronic Cigarette Use

Electronic cigarettes, commonly called vapes or e-cigarettes, are battery-operated devices that create an aerosol for users to inhale. While often viewed as less harmful than traditional cigarettes, these devices carry their own health risks and have become particularly concerning among young people.

Table of contents

• What Are E-Cigarettes
• Different Types of E-Cigarettes
• Substances in E-Cigarettes
• Health Risks and Safety Concerns
• E-Cigarettes and Young People
• Quitting E-Cigarettes
• E-Cigarettes and Smoking Cessation

What Are E-Cigarettes

vapes, vape pens, e-cigs, electronic nicotine delivery systems (ENDS), electronic non-nicotine delivery system (ENNDS)

E-cigarettes are battery-operated devices that heat a liquid and produce an aerosol, which is a mix of small particles released into the air. Some people call this aerosol “vapor,” and using an e-cigarette is commonly referred to as “vaping”^[1]. When a person uses an e-cigarette, they inhale this aerosol into their lungs. People nearby can also breathe in this aerosol when the user exhales^[1].

E-cigarettes work by heating liquid in a small device so users can breathe it into their lungs. The device heats the liquid to create an aerosol, which is not water vapor despite the common name. This mist contains particles of nicotine, flavoring, and other substances suspended in air^[10].

Most e-cigarettes contain nicotine, the addictive substance found in cigarettes and other tobacco products^[1]. Some e-cigarettes can also be used to deliver cannabis and other drugs^[1]. It’s important to know that some products claiming to be nicotine-free have been found to actually contain nicotine^[7].

Different Types of E-Cigarettes

E-cigarettes come in many shapes and sizes. Most have a battery, a heating element, and a place to hold a liquid^[1]. Common parts of e-cigarettes include a cartridge or tank that holds liquid (which can be refillable), a heating element that turns the liquid into breathable particles, a battery to power the heating element, and a mouthpiece to breathe in the aerosol^[10].

There are several main types available. Disposable e-cigarettes come pre-filled and may be rechargeable, but they are not designed to be refilled. Refillable e-cigarettes are rechargeable and have a tank or chamber that is filled with e-liquid. Some refillable devices can be modified to change the amount of aerosol produced or the strength of the delivered substance. E-cigarettes with pre-filled cartridges or pods are rechargeable and intended for reuse^[1].

Some e-cigarettes look like regular cigarettes, cigars, or pipes, while others look like USB flash drives, pens, smartphones, highlighters, toys, or other everyday products^[1]. Some newer devices have features similar to smartphones, including digital display screens, games, and reward systems for vaping such as points and rankings. These features may make the products especially appealing to young people^[1].

Different types include vape pens, vape bars, pod devices, mods, and cigalikes. They can be either rechargeable or disposable^[14].

Substances in E-Cigarettes

The liquids used in e-cigarettes, sometimes called e-juice, e-liquid, vape juice, or vape liquid, typically contain nicotine, flavorings, and a humectant (a substance that helps keep moisture)^[5]. The health effects of nicotine are well documented, although much remains unknown about the specific health effects when nicotine is delivered as an aerosol compared to a component in combusted smoke^[5].

E-liquids usually contain flavoring (each flavoring has its own set of ingredients), nicotine, and propylene glycol and glycerin which are used to create vapor^[10]. Many of the flavoring ingredients have been thoroughly evaluated for safety when included in food, but their effects when they enter the bloodstream through the lungs are less well known. Similarly, much remains unknown about the effects of inhaling aerosolized humectants such as propylene glycol and glycerol^[5].

E-liquids and flavorings sometimes have other ingredients that can be harmful, including chemicals that can cause cancer (called carcinogens), like acetaldehyde and formaldehyde. They may also contain chemicals known to cause lung disease, such as acrolein, diacetyl, and diethylene glycol. Some may include THC (the chemical in marijuana that produces a “high”), vitamin E acetate (which has been linked to lung injury caused by vaping), and heavy metals like nickel, tin, lead, and cadmium. Tiny particles that can get deep into the lungs may also be present^[10].

E-cigarettes often come in bright colors and are available in flavors that appeal to young people, like fruit, candy, menthol, and mint^[1]. There are at least 16,000 attractive flavors available^[7].

Health Risks and Safety Concerns

• lungs
• brain

There are no safe tobacco products, including e-cigarettes^[3]. E-cigarettes contain varying amounts of nicotine and harmful emissions. E-cigarette emissions typically contain nicotine and other toxic substances that are harmful to both users and non-users who are exposed to the aerosols second-hand^[7].

While nicotine is the addictive substance in cigarettes, most of the harm from smoking comes from the thousands of other chemicals in tobacco smoke, many of which are toxic^[14]. Vaping is often thought of as safer than cigarette smoking, but vaping causes health problems too. Both vaping and smoking are addictive and bring potentially dangerous chemicals into the body. The levels of many of these chemicals are higher when tobacco is burned. However, vaping hasn’t been around long enough to know what kind of long-term damage it might cause^[10].

Vaping is not completely risk-free, but it poses a small fraction of the risk of smoking cigarettes. The long-term risks of vaping are not yet clear. E-cigarettes do not produce tar or carbon monoxide, two of the most damaging elements in tobacco smoke. However, the liquid and vapor contain some potentially harmful chemicals also found in cigarette smoke, but at a much lower level^[14].

The particles inhaled while vaping can cause inflammation (swelling) and irritation in the lungs. This can lead to lung damage like scarring and narrowing of the tubes that bring air in and out of the lungs. Researchers don’t yet know all the effects vaping can have on the body^[10].

Nicotine exposure in pregnant women can negatively affect the development of the baby^[7]. Little research has been conducted into the safety of e-cigarettes and e-liquids in pregnancy. It is not known whether the vapor is harmful to a baby during pregnancy. If pregnant, licensed nicotine replacement therapy products such as patches and gum are the recommended option to help stop smoking. However, if using an e-cigarette is helpful for quitting and staying smoke-free, it’s much safer for both the pregnant person and baby than continuing to smoke^[14].

The battery design and type may put the device at risk for a fire or, in rare cases, an explosion. There have been instances of e-cigarettes exploding or catching fire. As with all rechargeable electrical devices, the correct charger should be used and the device should not be left charging unattended or overnight^[14].

There’s no evidence so far that vaping causes harm to other people around the user. This is in contrast to passive smoking (secondhand smoke), which is known to be very harmful to health^[14].

E-Cigarettes and Young People

E-cigarettes should not be used by youth, young adults, or women who are pregnant^[3]. The consumption of nicotine in children and adolescents has negative impacts on brain development, leading to long-term consequences and potentially causing learning and anxiety disorders. Nicotine is highly addictive and harmful to health^[7].

Using nicotine during the years when the brain is still developing (until about age 25) can harm the parts of the brain that control attention, learning, mood, and impulse control^[15]. E-cigarettes are harmful for youth, young adults, and pregnant women. The nicotine in e-cigarettes is harmful for developing babies and can lead to addiction and harm brain development in children and young adults into their early 20s^[19].

E-cigarettes target children through social media and influencers, with appealing flavors and designs. Some products use cartoon characters and have sleek designs that appeal to younger generations. Some look like toys and games^[7]. There is an alarming increase in use of e-cigarettes among children and young people, with rates exceeding adult use in many countries. Even brief exposure to e-cigarette content on social media is associated with greater intention to use these products, as well as more positive attitudes toward e-cigarettes^[7].

Currently, 88 countries have no minimum age at which e-cigarettes can be bought, and 74 countries have no regulations in place for these products^[7]. Although e-cigarette use has been sold in the United States for nearly 20 years, youth use skyrocketed in recent years. An estimated 1.63 million middle and high school students currently use e-cigarettes, which remains a concern^[2].

High-quality studies consistently demonstrate that e-cigarette use increases regular cigarette uptake, particularly among non-smoking youth, by nearly three times^[7]. The most common reason students give for trying an e-cigarette is because a friend used them. The most common reason students give for currently using e-cigarettes is feeling anxious, stressed, or depressed^[15].

Many students who vape report using e-cigarettes because they feel anxious, stressed, or depressed. E-cigarette marketing and advertising, the availability of appealing flavors, social influences, and the effects of nicotine all play a role in why youth start and continue to vape^[15]. Nicotine addiction can harm mental health and be a source of stress. Nicotine addiction or withdrawal can contribute to feelings of stress, anxiety, and depression, or make these feelings worse. Youth might use tobacco products to relieve their symptoms, which can lead to a cycle of nicotine addiction^[15].

Quitting E-Cigarettes

Scientists are studying the best ways to help people quit vaping. Quitting vaping is likely similar to quitting smoking because both involve nicotine addiction, and quitting may lead to withdrawal symptoms^[8].

People who vape can become addicted to nicotine, which can make it hard to quit. However, help is available. Trained quit coaches are available via 1-800-QUIT-NOW to provide confidential help at no cost to callers. There are several free and low-cost resources available, some of which are designed specifically for teens who vape^[8].

Strategies for quitting include making a quit plan, talking to a health care provider about tools and resources that can help, and considering the use of counseling and medication together. Health care providers may suggest medications to help manage nicotine withdrawal symptoms and cravings. Adults who smoke have the best chance of quitting for good when they use medication and counseling together. Learning strategies to manage nicotine withdrawal symptoms is also important^[8].

Expert panels have reached consensus on recommendations for e-cigarette cessation that span several areas including severity and dependence, general approaches, treatment approaches, dual use (using both e-cigarettes and regular cigarettes), medication strategies, behavioral therapy strategies, harm reduction, and relapse prevention^[9].

It’s recommended that health professionals ask and document all tobacco use, including novel nicotine delivery products like e-cigarettes. This includes whether someone currently uses, formerly used, or never used these products, as well as whether they use them exclusively or along with regular tobacco products (called dual use). Information about how often they use the products and the nicotine concentration of the liquid is also valuable^[13].

E-Cigarettes and Smoking Cessation

The U.S. Food and Drug Administration has not approved any e-cigarette products to help people quit smoking. A number of studies suggest that e-cigarettes with nicotine may help adults quit smoking compared to e-cigarettes without nicotine or no treatment. However, the long-term health effects of using e-cigarettes are still uncertain. While e-cigarette aerosol generally contains fewer toxic chemicals than the smoke from cigarettes, it is not harmless^[8].

The U.S. Preventive Services Task Force concluded there was not enough evidence to know if the benefits of using e-cigarettes to quit smoking outweigh the harms^[8]. E-cigarettes may have the potential to benefit adults who smoke and are not pregnant if they are used as a complete substitute for smoked tobacco products. However, no e-cigarette has been approved by the FDA as a smoking cessation aid. More research is needed to better understand the short- and long-term health effects of using e-cigarettes as well as whether e-cigarettes can be effective at helping adults quit smoking^[3].

Evidence shows that people who used e-cigarettes to quit smoking, as well as having expert face-to-face support, can be up to twice as likely to succeed as people who used other nicotine replacement products, such as patches or gum^[14]. Using an e-cigarette can help manage nicotine cravings. To get the best results, it’s important to use it as much as needed and with the right strength of nicotine in the e-liquid. Users will not get the full benefit from vaping unless they stop smoking cigarettes completely^[14].

Dual use, or using both e-cigarettes and regular cigarettes, is not an effective way to safeguard health. Smoking even a few cigarettes a day can be dangerous^[8].

Adults who have never smoked or used other tobacco products, including e-cigarettes, should not start^[3].