Millions of Americans use e-cigarettes regularly, and the number of vapers in the United States is on the rise, particularly among young people.
In fact, e-cigarettes were the most commonly used tobacco product among the roughly 6.2 million middle school and high school students who used one in 2019, according to a December 2019 report from the Centers for Disease Control and Prevention (CDC).
The agency noted that 27.5 percent of high school students reported vaping—a 6.7 percent jump from the year before. Meanwhile, 10.5 percent of middle schoolers used e-cigarettes in 2019, up from nearly 5 percent in 2018.
To put this into perspective, back in 2011, only 1.5 percent of high school students and just 0.6 percent of middle school students reported using e-cigarettes.
This worrisome trend was already in play in December 2018, when U.S. Surgeon General Vice Admiral Jerome M. Adams, MD, MPH, issued an advisory on the e-cigarette epidemic among American youth. The statement asked all Americans to help protect children against a lifetime of nicotine addiction.
“We need to protect our kids from all tobacco products, including all shapes and sizes of e-cigarettes,” Dr. Adams says. “Everyone can play an important role in protecting our nation’s young people from the risks of e-cigarettes.”
But e-cigarettes have been controversial ever since they came to the U.S. in 2007, touted as a safe way to quit smoking. Shortly after their arrival, the World Health Organization (WHO) announced that there was no evidence that e-cigs were safe or an effective way or stop using tobacco. In 2016, the WHO officially recommended countries restrict their use.
Still, there's confusion about e-cigs' general safety, as well as their efficacy as smoking cessation aids.
What are e-cigarettes, exactly?
Standard “e-cigs” (the “e” stands for “electronic”) run on a battery and have a chamber for storing liquid that usually contains nicotine. You don’t light them, and they don’t produce smoke, the most dangerous aspect of ordinary smoking. Instead, when you puff on one, your lungs take in a heated mist, or vapor, which is why smoking e-cigs is also referred to as "vaping."
An e-cig can look like an ordinary cigarette, cigar or pipe, or like a pen or USB stick. It might be called a "JUUL," “e-hookah,” “mod,” “vape pen,” “vape,” “tank system” or “electronic nicotine delivery system (ENDS).”
About 14 percent of teens who vape admit they don’t know what’s in their e-cigarette, according to the National Institute on Drug Abuse (NIDA). This isn’t surprising as e-cig manufacturers aren’t required to list ingredients. Nearly 6 percent of teens think they are vaping marijuana, the agency notes. Meanwhile, 13 percent of teen users know that their e-cigarette has nicotine in it, but a staggering 66 percent think it only contains flavoring.
How safe is vaping?
Although vaping initially appeared safer than smoking tobacco, new and increasingly alarming developments are coming to light. Most worrisome: As of January 21, 2020, 2,711 e-cigarette users across the U.S. were hospitalized for severe vaping-related lung injury. Of these reported cases, 60 were fatal.
While experts are still learning about how vaping affects health, they do know of some specific dangers.
“There’s no question that e-cigarettes cause inflammation of the airways and chronic bronchitis,” says Norman H. Edelman, MD, Senior Scientific Advisor to the American Lung Association. Most e-cigs contain nicotine, which is highly addictive, toxic to developing fetuses and can harm adolescent brain development, the CDC reports. Dr. Edelman adds that vaping nicotine increases blood pressure and “there’s data that nicotine promotes lung disease and lung cancer,” he says.
In addition to nicotine, e-cigs contain other chemicals—like kid-friendly flavoring and benzene—that may be dangerous. One 2018 study found higher levels of five cancer-causing toxins in the urine of 16-year-old e-cig users. Another 2018 study, presented at a conference hosted by the Society for Research on Nicotine & Tobacco, found that people who vaped daily had almost double the risk of heart attack compared to those who didn’t vape. Other research suggests that vaping makes germs like staph more resistant to drugs.
How is vaping regulated?
Beginning in August 2016, the U.S. Food and Drug Administration (FDA) set a minimum legal sale age of 18 and forbade free e-cig samples, which were being distributed at music and sporting events. As of August 2018, e-cigs containing nicotine were required to bear a warning that the compound is addictive.
According to some, however, FDA regulators are moving too slowly. In March 2018, multiple major public health organizations, including the American Heart Association and American Academy of Pediatrics, sued the agency for delaying its safety review of e-cigarettes and cigars. Because of the lull, products appealing to young people—with names such as “Smurf Sauce” and “Unicorn Cakes” and flavors like chocolate—are still available for purchase.
Some experts believe those products may lead those minors to regular smoking, and in 2018, two studies did find that teens move on from e-cigs to ordinary cigarettes—but Edelman believes the question remains unresolved.
Does vaping help smokers quit?
E-cigarettes are not an FDA-approved smoking cessation aid since the evidence on the issue is mixed. On one hand, a 2019 study in the New England Journal of Medicine found that when used as part of a structured quit program, e-cigarettes may be more effective than nicotine replacement therapy. On the other hand, a 2017 CDC briefing concluded that smokers were more likely to swap in e-cigarettes rather than use a patch or gum, but most didn’t quit smoking entirely. Instead, they end up as “dual users.” In 2015, among U.S. adult e-cigarette users, nearly 59 percent also regularly smoked. Only about 30 percent were former smokers.
Teens are more likely to use e-cigarettes than adults, and boys vape more often than girls. But once they try e-cigarettes, all teen users are actually more likely to start smoking within six months, NIDA reports.
Bottom line: It’s best to quit smoking entirely and e-cigs could make that harder. “Vaping actually makes it less likely that smokers will quit by about 27 percent,” says Stanton Glantz, Director of the University of California, San Francisco Center for Tobacco Control Research and Education. And while more adverse health effects are coming to light, taking up e-cigarettes is a risk not worth taking.
