Brainstorming for Topics: Vape Nation
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Issues with Vapeing things other than e-juice?
Vilify the entire e-cigarettes idea
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What is Vapeing?
Nicotine without the Tar?
- Is Vaping Better Than Smoking? American Heart Association information. Is this bias?
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- Electronic cigarettes: harm reduction tool or new substance use behavior?
Advertised to Teens
Profiling for Advertising
- Ever notice that Commercials on certain channels seem bias?
Branding vs Marketing vs Advertising
- Exploiting the “video game craze”: A case study of the tobacco industry’s use of video games as a marketing tool.
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- Last Updated: Oct 3, 2023 8:44 AM
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- Open access
- Published: 18 May 2021
An updated overview of e-cigarette impact on human health
- Patrice Marques ORCID: orcid.org/0000-0003-0465-1727 1 , 2 ,
- Laura Piqueras ORCID: orcid.org/0000-0001-8010-5168 1 , 2 , 3 &
- Maria-Jesus Sanz ORCID: orcid.org/0000-0002-8885-294X 1 , 2 , 3
Respiratory Research volume 22 , Article number: 151 ( 2021 ) Cite this article
The electronic cigarette ( e-cigarette ), for many considered as a safe alternative to conventional cigarettes, has revolutionised the tobacco industry in the last decades. In e-cigarettes , tobacco combustion is replaced by e-liquid heating, leading some manufacturers to propose that e-cigarettes have less harmful respiratory effects than tobacco consumption. Other innovative features such as the adjustment of nicotine content and the choice of pleasant flavours have won over many users. Nevertheless, the safety of e-cigarette consumption and its potential as a smoking cessation method remain controversial due to limited evidence. Moreover, it has been reported that the heating process itself can lead to the formation of new decomposition compounds of questionable toxicity. Numerous in vivo and in vitro studies have been performed to better understand the impact of these new inhalable compounds on human health. Results of toxicological analyses suggest that e-cigarettes can be safer than conventional cigarettes, although harmful effects from short-term e-cigarette use have been described. Worryingly, the potential long-term effects of e-cigarette consumption have been scarcely investigated. In this review, we take stock of the main findings in this field and their consequences for human health including coronavirus disease 2019 (COVID-19).
Electronic nicotine dispensing systems (ENDS), commonly known as electronic cigarettes or e-cigarettes , have been popularly considered a less harmful alternative to conventional cigarette smoking since they first appeared on the market more than a decade ago. E-cigarettes are electronic devices, essentially consisting of a cartridge, filled with an e-liquid, a heating element/atomiser necessary to heat the e-liquid to create a vapour that can be inhaled through a mouthpiece, and a rechargeable battery (Fig. 1 ) [ 1 , 2 ]. Both the electronic devices and the different e-liquids are easily available in shops or online stores.
Effect of the heating process on aerosol composition. Main harmful effects documented. Several compounds detected in e-cigarette aerosols are not present in e-liquid s and the device material also seems to contribute to the presence of metal and silicate particles in the aerosols. The heating conditions especially on humectants, flavourings and the low-quality material used have been identified as the generator of the new compounds in aerosols. Some compounds generated from humectants (propylene glycol and glycerol) and flavourings, have been associated with clear airways impact, inflammation, impairment of cardiovascular function and toxicity. In addition, some of them are carcinogens or potential carcinogens
The e-liquid typically contains humectants and flavourings, with or without nicotine; once vapourised by the atomiser, the aerosol (vapour) provides a sensation similar to tobacco smoking, but purportedly without harmful effects [ 3 ]. However, it has been reported that the heating process can lead to the generation of new decomposition compounds that may be hazardous [ 4 , 5 ]. The levels of nicotine, which is the key addictive component of tobacco, can also vary between the commercially available e-liquids, and even nicotine-free options are available. For this particular reason, e-cigarettes are often viewed as a smoking cessation tool, given that those with nicotine can prevent smoking craving, yet this idea has not been fully demonstrated [ 2 , 6 , 7 ].
Because e-cigarettes are combustion-free, and because most of the damaging and well-known effects of tobacco are derived from this reaction, there is a common and widely spread assumption that e-cigarette consumption or “vaping” is safer than conventional cigarette smoking. However, are they risk-free? Is there sufficient toxicological data on all the components employed in e-liquids ? Do we really know the composition of the inhaled vapour during the heating process and its impact on health? Can e-cigarettes be used to curb tobacco use? Do their consumption impact on coronavirus disease 2019 (COVID-19)? In the present review, we have attempted to clarify these questions based on the existing scientific literature, and we have compiled new insights related with the toxicity derived from the use of these devices.
Effect of e-cigarette vapour versus conventional cigarette exposure: in vivo and in vitro effects
Numerous studies have been performed to evaluate the safety/toxicity of e-cigarette use both in vivo and in in vitro cell culture.
One of the first studies in humans involved the analysis of 9 volunteers that consumed e-cigarettes , with or without nicotine, in a ventilated room for 2 h [ 8 ]. Pollutants in indoor air, exhaled nitric oxide (NO) and urinary metabolite profiles were analysed. The results of this acute experiment revealed that e-cigarettes are not emission-free, and ultrafine particles formed from propylene glycol (PG) could be detected in the lungs. The study also suggested that the presence of nicotine in e-cigarettes increased the levels of NO exhaled from consumers and provoked marked airway inflammation; however, no differences were found in the levels of exhaled carbon monoxide (CO), an oxidative stress marker, before and after e-cigarette consumption [ 8 ]. A more recent human study detected significantly higher levels of metabolites of hazardous compounds including benzene, ethylene oxide, acrylonitrile, acrolein and acrylamide in the urine of adolescent dual users ( e-cigarettes and conventional tobacco consumers) than in adolescent e-cigarette -only users (Table 1 ) [ 9 ]. Moreover, the urine levels of metabolites of acrylonitrile, acrolein, propylene oxide, acrylamide and crotonaldehyde, all of which are detrimental for human health, were significantly higher in e-cigarette -only users than in non-smoker controls, reaching up to twice the registered values of those from non-smoker subjects (Table 1 ) [ 9 ]. In line with these observations, dysregulation of lung homeostasis has been documented in non-smokers subjected to acute inhalation of e-cigarette aerosols [ 10 ].
Little is known about the effect of vaping on the immune system. Interestingly, both traditional and e-cigarette consumption by non-smokers was found to provoke short-term effects on platelet function, increasing platelet activation (levels of soluble CD40 ligand and the adhesion molecule P-selectin) and platelet aggregation, although to a lesser extent with e-cigarettes [ 11 ]. As found with platelets, the exposure of neutrophils to e-cigarette aerosol resulted in increased CD11b and CD66b expression being both markers of neutrophil activation [ 12 ]. Additionally, increased oxidative stress, vascular endothelial damage, impaired endothelial function, and changes in vascular tone have all been reported in different human studies on vaping [ 13 , 14 , 15 , 16 , 17 ]. In this context, it is widely accepted that platelet and leukocyte activation as well as endothelial dysfunction are associated with atherogenesis and cardiovascular morbidity [ 18 , 19 ]. In line with these observations the potential association of daily e-cigarettes consumption and the increased risk of myocardial infarction remains controversial but benefits may occur when switching from tobacco to chronic e-cigarette use in blood pressure regulation, endothelial function and vascular stiffness (reviewed in [ 20 ]). Nevertheless, whether or not e-cigarette vaping has cardiovascular consequences requires further investigation.
More recently, in August 2019, the US Centers for Disease Control and Prevention (CDC) declared an outbreak of the e-cigarette or vaping product use-associated lung injury (EVALI) which caused several deaths in young population (reviewed in [ 20 ]). Indeed, computed tomography (CT scan) revealed local inflammation that impaired gas exchange caused by aerosolised oils from e-cigarettes [ 21 ]. However, most of the reported cases of lung injury were associated with use of e-cigarettes for tetrahydrocannabinol (THC) consumption as well as vitamin E additives [ 20 ] and not necessarily attributable to other e-cigarette components.
On the other hand, in a comparative study of mice subjected to either lab air, e-cigarette aerosol or cigarette smoke (CS) for 3 days (6 h-exposure per day), those exposed to e-cigarette aerosols showed significant increases in interleukin (IL)-6 but normal lung parenchyma with no evidence of apoptotic activity or elevations in IL-1β or tumour necrosis factor-α (TNFα) [ 22 ]. By contrast, animals exposed to CS showed lung inflammatory cell infiltration and elevations in inflammatory marker expression such as IL-6, IL-1β and TNFα [ 22 ]. Beyond airway disease, exposure to aerosols from e-liquids with or without nicotine has also been also associated with neurotoxicity in an early-life murine model [ 23 ].
Results from in vitro studies are in general agreement with the limited number of in vivo studies. For example, in an analysis using primary human umbilical vein endothelial cells (HUVEC) exposed to 11 commercially-available vapours, 5 were found to be acutely cytotoxic, and only 3 of those contained nicotine [ 24 ]. In addition, 5 of the 11 vapours tested (including 4 that were cytotoxic) reduced HUVEC proliferation and one of them increased the production of intracellular reactive oxygen species (ROS) [ 24 ]. Three of the most cytotoxic vapours—with effects similar to those of conventional high-nicotine CS extracts—also caused comparable morphological changes [ 24 ]. Endothelial cell migration is an important mechanism of vascular repair than can be disrupted in smokers due to endothelial dysfunction [ 25 , 26 ]. In a comparative study of CS and e-cigarette aerosols, Taylor et al . found that exposure of HUVEC to e-cigarette aqueous extracts for 20 h did not affect migration in a scratch wound assay [ 27 ], whereas equivalent cells exposed to CS extract showed a significant inhibition in migration that was concentration dependent [ 27 ].
In cultured human airway epithelial cells, both e-cigarette aerosol and CS extract induced IL-8/CXCL8 (neutrophil chemoattractant) release [ 28 ]. In contrast, while CS extract reduced epithelial barrier integrity (determined by the translocation of dextran from the apical to the basolateral side of the cell layer), e-cigarette aerosol did not, suggesting that only CS extract negatively affected host defence [ 28 ]. Moreover, Higham et al . also found that e-cigarette aerosol caused IL-8/CXCL8 and matrix metallopeptidase 9 (MMP-9) release together with enhanced activity of elastase from neutrophils [ 12 ] which might facilitate neutrophil migration to the site of inflammation [ 12 ].
In a comparative study, repeated exposure of human gingival fibroblasts to CS condensate or to nicotine-rich or nicotine-free e-vapour condensates led to alterations in morphology, suppression of proliferation and induction of apoptosis, with changes in all three parameters greater in cells exposed to CS condensate [ 29 ]. Likewise, both e-cigarette aerosol and CS extract increased cell death in adenocarcinomic human alveolar basal epithelial cells (A549 cells), and again the effect was more damaging with CS extract than with e-cigarette aerosol (detrimental effects found at 2 mg/mL of CS extract vs. 64 mg/mL of e-cigarette extract) [ 22 ], which is in agreement with another study examining battery output voltage and cytotoxicity [ 30 ].
All this evidence would suggest that e-cigarettes are potentially less harmful than conventional cigarettes (Fig. 2 ) [ 11 , 14 , 22 , 24 , 27 , 28 , 29 ]. Importantly, however, most of these studies have investigated only short-term effects [ 10 , 14 , 15 , 22 , 27 , 28 , 29 , 31 , 32 ], and the long-term effects of e-cigarette consumption on human health are still unclear and require further study.
Comparison of the degree of harmful effects documented from e-cigarette and conventional cigarette consumption. Human studies, in vivo mice exposure and in vitro studies. All of these effects from e-cigarettes were documented to be lower than those exerted by conventional cigarettes, which may suggest that e-cigarette consumption could be a safer option than conventional tobacco smoking but not a clear safe choice
Consequences of nicotine content
Beyond flavour, one of the major issues in the e-liquid market is the range of nicotine content available. Depending on the manufacturer, the concentration of this alkaloid can be presented as low , medium or high , or expressed as mg/mL or as a percentage (% v/v). The concentrations range from 0 (0%, nicotine-free option) to 20 mg/mL (2.0%)—the maximum nicotine threshold according to directive 2014/40/EU of the European Parliament and the European Union Council [ 33 , 34 ]. Despite this normative, however, some commercial e-liquids have nicotine concentrations close to 54 mg/mL [ 35 ], much higher than the limits established by the European Union.
The mislabelling of nicotine content in e-liquids has been previously addressed [ 8 , 34 ]. For instance, gas chromatography with a flame ionisation detector (GC-FID) revealed inconsistencies in the nicotine content with respect to the manufacturer´s declaration (average of 22 ± 0.8 mg/mL vs. 18 mg/mL) [ 8 ], which equates to a content ~ 22% higher than that indicated in the product label. Of note, several studies have detected nicotine in those e-liquids labelled as nicotine-free [ 5 , 35 , 36 ]. One study detected the presence of nicotine (0.11–6.90 mg/mL) in 5 of 23 nicotine-free labelled e-liquids by nuclear magnetic resonance spectroscopy [ 35 ], and another study found nicotine (average 8.9 mg/mL) in 13.6% (17/125) of the nicotine-free e-liquids as analysed by high performance liquid chromatography (HPLC) [ 36 ]. Among the 17 samples tested in this latter study 14 were identified to be counterfeit or suspected counterfeit. A third study detected nicotine in 7 of 10 nicotine-free refills, although the concentrations were lower than those identified in the previous analyses (0.1–15 µg/mL) [ 5 ]. Not only is there evidence of mislabelling of nicotine content among refills labelled as nicotine-free, but there also seems to be a history of poor labelling accuracy in nicotine-containing e-liquids [ 37 , 38 ].
A comparison of the serum levels of nicotine from e-cigarette or conventional cigarette consumption has been recently reported [ 39 ]. Participants took one vape from an e-cigarette , with at least 12 mg/mL of nicotine, or inhaled a conventional cigarette, every 20 s for 10 min. Blood samples were collected 1, 2, 4, 6, 8, 10, 12 and 15 min after the first puff, and nicotine serum levels were measured by liquid chromatography-mass spectrometry (LC–MS). The results revealed higher serum levels of nicotine in the conventional CS group than in the e-cigarette group (25.9 ± 16.7 ng/mL vs. 11.5 ± 9.8 ng/mL). However, e-cigarettes containing 20 mg/mL of nicotine are more equivalent to normal cigarettes, based on the delivery of approximately 1 mg of nicotine every 5 min [ 40 ].
In this line, a study compared the acute impact of CS vs. e-cigarette vaping with equivalent nicotine content in healthy smokers and non-smokers. Both increased markers of oxidative stress and decreased NO bioavailability, flow-mediated dilation, and vitamin E levels showing no significant differences between tobacco and e-cigarette exposure (reviewed in [ 20 ]). Inasmuch, short-term e-cigarette use in healthy smokers resulted in marked impairment of endothelial function and an increase in arterial stiffness (reviewed in [ 20 ]). Similar effects on endothelial dysfunction and arterial stiffness were found in animals when they were exposed to e-cigarette vapor either for several days or chronically (reviewed in [ 20 ]). In contrast, other studies found acute microvascular endothelial dysfunction, increased oxidative stress and arterial stiffness in smokers after exposure to e-cigarettes with nicotine, but not after e-cigarettes without nicotine (reviewed in [ 20 ]). In women smokers, a study found a significant difference in stiffness after smoking just one tobacco cigarette, but not after use of e-cigarettes (reviewed in [ 20 ]).
It is well known that nicotine is extremely addictive and has a multitude of harmful effects. Nicotine has significant biologic activity and adversely affects several physiological systems including the cardiovascular, respiratory, immunological and reproductive systems, and can also compromise lung and kidney function [ 41 ]. Recently, a sub-chronic whole-body exposure of e-liquid (2 h/day, 5 days/week, 30 days) containing PG alone or PG with nicotine (25 mg/mL) to wild type (WT) animals or knockout (KO) mice in α7 nicotinic acetylcholine receptor (nAChRα7-KO) revealed a partly nAChRα7-dependent lung inflammation [ 42 ]. While sub-chronic exposure to PG/nicotine promote nAChRα7-dependent increased levels of different cytokines and chemokines in the bronchoalveolar lavage fluid (BALF) such as IL-1α, IL-2, IL-9, interferon γ (IFNγ), granulocyte-macrophage colony-stimulating factor (GM-CSF), monocyte chemoattractant protein-1 (MCP-1/CCL2) and regulated on activation, normal T cell expressed and secreted (RANTES/CCL5), the enhanced levels of IL-1β, IL-5 and TNFα were nAChRα7 independent. In general, most of the cytokines detected in BALF were significantly increased in WT mice exposed to PG with nicotine compared to PG alone or air control [ 42 ]. Some of these effects were found to be through nicotine activation of NF-κB signalling albeit in females but not in males. In addition, PG with nicotine caused increased macrophage and CD4 + /CD8 + T-lymphocytes cell counts in BALF compared to air control, but these effects were ameliorated when animals were sub-chronically exposed to PG alone [ 42 ].
Of note, another study indicated that although RANTES/CCL5 and CCR1 mRNA were upregulated in flavour/nicotine-containing e-cigarette users, vaping flavour and nicotine-less e-cigarettes did not significantly dysregulate cytokine and inflammasome activation [ 43 ].
In addition to its toxicological effects on foetus development, nicotine can disrupt brain development in adolescents and young adults [ 44 , 45 , 46 ]. Several studies have also suggested that nicotine is potentially carcinogenic (reviewed in [ 41 ]), but more work is needed to prove its carcinogenicity independently of the combustion products of tobacco [ 47 ]. In this latter regard, no differences were encountered in the frequency of tumour appearance in rats subjected to long-term (2 years) inhalation of nicotine when compared with control rats [ 48 ]. Despite the lack of carcinogenicity evidence, it has been reported that nicotine promotes tumour cell survival by decreasing apoptosis and increasing proliferation [ 49 ], indicating that it may work as a “tumour enhancer”. In a very recent study, chronic administration of nicotine to mice (1 mg/kg every 3 days for a 60-day period) enhanced brain metastasis by skewing the polarity of M2 microglia, which increases metastatic tumour growth [ 50 ]. Assuming that a conventional cigarette contains 0.172–1.702 mg of nicotine [ 51 ], the daily nicotine dose administered to these animals corresponds to 40–400 cigarettes for a 70 kg-adult, which is a dose of an extremely heavy smoker. We would argue that further studies with chronic administration of low doses of nicotine are required to clearly evaluate its impact on carcinogenicity.
In the aforementioned study exposing human gingival fibroblasts to CS condensate or to nicotine-rich or nicotine-free e-vapour condensates [ 29 ], the detrimental effects were greater in cells exposed to nicotine-rich condensate than to nicotine-free condensate, suggesting that the possible injurious effects of nicotine should be considered when purchasing e-refills . It is also noteworthy that among the 3 most cytotoxic vapours for HUVEC evaluated in the Putzhammer et al . study, 2 were nicotine-free, which suggests that nicotine is not the only hazardous component in e-cigarettes [ 24 ] .
The lethal dose of nicotine for an adult is estimated at 30–60 mg [ 52 ]. Given that nicotine easily diffuses from the dermis to the bloodstream, acute nicotine exposure by e-liquid spilling (5 mL of a 20 mg/mL nicotine-containing refill is equivalent to 100 mg of nicotine) can easily be toxic or even deadly [ 8 ]. Thus, devices with rechargeable refills are another issue of concern with e-cigarettes , especially when e-liquids are not sold in child-safe containers, increasing the risk of spilling, swallowing or breathing.
These data overall indicate that the harmful effects of nicotine should not be underestimated. Despite the established regulations, some inaccuracies in nicotine content labelling remain in different brands of e-liquids . Consequently, stricter regulation and a higher quality control in the e-liquid industry are required.
Effect of humectants and their heating-related products
In this particular aspect, again the composition of the e-liquid varies significantly among different commercial brands [ 4 , 35 ]. The most common and major components of e-liquids are PG or 1,2-propanediol, and glycerol or glycerine (propane-1,2,3-triol). Both types of compounds are used as humectants to prevent the e-liquid from drying out [ 2 , 53 ] and are classified by the Food and Drug Administration (FDA) as “Generally Recognised as Safe” [ 54 ]. In fact, they are widely used as alimentary and pharmaceutical products [ 2 ]. In an analysis of 54 commercially available e-liquids , PG and glycerol were detected in almost all samples at concentrations ranging from 0.4% to 98% (average 57%) and from 0.3% to 95% (average 37%), respectively [ 35 ].
With regards to toxicity, little is known about the effects of humectants when they are heated and chronically inhaled. Studies have indicated that PG can induce respiratory irritation and increase the probability of asthma development [ 55 , 56 ], and both PG and glycerol from e-cigarettes might reach concentrations sufficiently high to potentially cause irritation of the airways [ 57 ]. Indeed, the latter study established that one e-cigarette puff results in a PG exposure of 430–603 mg/m 3 , which is higher than the levels reported to cause airway irritation (average 309 mg/m 3 ) based on a human study [ 55 ]. The same study established that one e-cigarette puff results in a glycerol exposure of 348–495 mg/m 3 [ 57 ], which is close to the levels reported to cause airway irritation in rats (662 mg/m 3 ) [ 58 ].
Airway epithelial injury induced by acute vaping of PG and glycerol aerosols (50:50 vol/vol), with or without nicotine, has been reported in two randomised clinical trials in young tobacco smokers [ 32 ]. In vitro, aerosols from glycerol only-containing refills showed cytotoxicity in A549 and human embryonic stem cells, even at a low battery output voltage [ 59 ]. PG was also found to affect early neurodevelopment in a zebrafish model [ 60 ]. Another important issue is that, under heating conditions PG can produce acetaldehyde or formaldehyde (119.2 or 143.7 ng/puff at 20 W, respectively, on average), while glycerol can also generate acrolein (53.0, 1000.0 or 5.9 ng/puff at 20 W, respectively, on average), all carbonyls with a well-documented toxicity [ 61 ]. Although, assuming 15 puffs per e-cigarette unit, carbonyls produced by PG or glycerol heating would be below the maximum levels found in a conventional cigarette combustion (Table 2 ) [ 51 , 62 ]. Nevertheless, further studies are required to properly test the deleterious effects of all these compounds at physiological doses resembling those to which individuals are chronically exposed.
Although PG and glycerol are the major components of e-liquids other components have been detected. When the aerosols of 4 commercially available e-liquids chosen from a top 10 list of “ Best E-Cigarettes of 2014” , were analysed by gas chromatography-mass spectrometry (GC–MS) after heating, numerous compounds were detected, with nearly half of them not previously identified [ 4 ], thus suggesting that the heating process per se generates new compounds of unknown consequence. Of note, the analysis identified formaldehyde, acetaldehyde and acrolein [ 4 ], 3 carbonyl compounds with known high toxicity [ 63 , 64 , 65 , 66 , 67 ]. While no information was given regarding formaldehyde and acetaldehyde concentrations, the authors calculated that one puff could result in an acrolein exposure of 0.003–0.015 μg/mL [ 4 ]. Assuming 40 mL per puff and 15 puffs per e-cigarette unit (according to several manufacturers) [ 4 ], each e-cigarette unit would generate approximately 1.8–9 μg of acrolein, which is less than the levels of acrolein emitted by a conventional tobacco cigarette (18.3–98.2 μg) [ 51 ]. However, given that e-cigarette units of vaping are not well established, users may puff intermittently throughout the whole day. Thus, assuming 400 to 500 puffs per cartridge, users could be exposed to up to 300 μg of acrolein.
In a similar study, acrolein was found in 11 of 12 aerosols tested, with a similar content range (approximately 0.07–4.19 μg per e-cigarette unit) [ 68 ]. In the same study, both formaldehyde and acetaldehyde were detected in all of the aerosols tested, with contents of 0.2–5.61 μg and 0.11–1.36 μg, respectively, per e-cigarette unit [ 68 ]. It is important to point out that the levels of these toxic products in e-cigarette aerosols are significantly lower than those found in CS: 9 times lower for formaldehyde, 450 times lower for acetaldehyde and 15 times lower for acrolein (Table 2 ) [ 62 , 68 ].
Other compounds that have been detected in aerosols include acetamide, a potential human carcinogen [ 5 ], and some aldehydes [ 69 ], although their levels were minimal. Interestingly, the existence of harmful concentrations of diethylene glycol, a known cytotoxic agent, in e-liquid aerosols is contentious with some studies detecting its presence [ 4 , 68 , 70 , 71 , 72 ], and others finding low subtoxic concentrations [ 73 , 74 ]. Similar observations were reported for the content ethylene glycol. In this regard, either it was detected at concentrations that did not exceed the authorised limit [ 73 ], or it was absent from the aerosols produced [ 4 , 71 , 72 ]. Only one study revealed its presence at high concentration in a very low number of samples [ 5 ]. Nevertheless, its presence above 1 mg/g is not allowed by the FDA [ 73 ]. Figure 1 lists the main compounds detected in aerosols derived from humectant heating and their potential damaging effects. It would seem that future studies should analyse the possible toxic effects of humectants and related products at concentrations similar to those that e-cigarette vapers are exposed to reach conclusive results.
Impact of flavouring compounds
The range of e-liquid flavours available to consumers is extensive and is used to attract both current smokers and new e-cigarette users, which is a growing public health concern [ 6 ]. In fact, over 5 million middle- and high-school students were current users of e-cigarettes in 2019 [ 75 ], and appealing flavours have been identified as the primary reason for e-cigarette consumption in 81% of young users [ 76 ]. Since 2016, the FDA regulates the flavours used in the e-cigarette market and has recently published an enforcement policy on unauthorised flavours, including fruit and mint flavours, which are more appealing to young users [ 77 ]. However, the long-term effects of all flavour chemicals used by this industry (which are more than 15,000) remain unknown and they are not usually included in the product label [ 78 ]. Furthermore, there is no safety guarantee since they may harbour potential toxic or irritating properties [ 5 ].
With regards to the multitude of available flavours, some have demonstrated cytotoxicity [ 59 , 79 ]. Bahl et al. evaluated the toxicity of 36 different e-liquids and 29 different flavours on human embryonic stem cells, mouse neural stem cells and human pulmonary fibroblasts using a metabolic activity assay. In general, those e-liquids that were bubblegum-, butterscotch- and caramel-flavoured did not show any overt cytotoxicity even at the highest dose tested. By contrast, those e-liquids with Freedom Smoke Menthol Arctic and Global Smoke Caramel flavours had marked cytotoxic effects on pulmonary fibroblasts and those with Cinnamon Ceylon flavour were the most cytotoxic in all cell lines [ 79 ]. A further study from the same group [ 80 ] revealed that high cytotoxicity is a recurrent feature of cinnamon-flavoured e-liquids. In this line, results from GC–MS and HPLC analyses indicated that cinnamaldehyde (CAD) and 2-methoxycinnamaldehyde, but not dipropylene glycol or vanillin, were mainly responsible for the high cytotoxicity of cinnamon-flavoured e-liquids [ 80 ]. Other flavouring-related compounds that are associated with respiratory complications [ 81 , 82 , 83 ], such as diacetyl, 2,3-pentanedione or acetoin, were found in 47 out of 51 aerosols of flavoured e-liquids tested [ 84 ] . Allen et al . calculated an average of 239 μg of diacetyl per cartridge [ 84 ]. Assuming again 400 puffs per cartridge and 40 mL per puff, is it is possible to estimate an average of 0.015 ppm of diacetyl per puff, which could compromise normal lung function in the long-term [ 85 ].
The cytotoxic and pro-inflammatory effects of different e-cigarette flavouring chemicals were also tested on two human monocytic cell lines—mono mac 6 (MM6) and U937 [ 86 ]. Among the flavouring chemicals tested, CAD was found to be the most toxic and O-vanillin and pentanedione also showed significant cytotoxicity; by contrast, acetoin, diacetyl, maltol, and coumarin did not show any toxicity at the concentrations assayed (10–1000 µM). Of interest, a higher toxicity was evident when combinations of different flavours or mixed equal proportions of e-liquids from 10 differently flavoured e-liquids were tested, suggesting that vaping a single flavour is less toxic than inhaling mixed flavours [ 86 ]. Also, all the tested flavours produced significant levels of ROS in a cell-free ROS production assay. Finally, diacetyl, pentanedione, O-vanillin, maltol, coumarin, and CAD induced significant IL-8 secretion from MM6 and U937 monocytes [ 86 ]. It should be borne in mind, however, that the concentrations assayed were in the supra-physiological range and it is likely that, once inhaled, these concentrations are not reached in the airway space. Indeed, one of the limitations of the study was that human cells are not exposed to e-liquids per se, but rather to the aerosols where the concentrations are lower [ 86 ]. In this line, the maximum concentration tested (1000 µM) would correspond to approximately 80 to 150 ppm, which is far higher than the levels found in aerosols of some of these compounds [ 84 ]. Moreover, on a day-to-day basis, lungs of e-cigarette users are not constantly exposed to these chemicals for 24 h at these concentrations. Similar limitations were found when five of seven flavourings were found to cause cytotoxicity in human bronchial epithelial cells [ 87 ].
Recently, a commonly commercialized crème brûlée -flavoured aerosol was found to contain high concentrations of benzoic acid (86.9 μg/puff), a well-established respiratory irritant [ 88 ]. When human lung epithelial cells (BEAS-2B and H292) were exposed to this aerosol for 1 h, a marked cytotoxicity was observed in BEAS-2B but not in H292 cells, 24 h later. However, increased ROS production was registered in H292 cells [ 88 ].
Therefore, to fully understand the effects of these compounds, it is relevant the cell cultures selected for performing these assays, as well as the use of in vivo models that mimic the real-life situation of chronic e-cigarette vapers to clarify their impact on human health.
The e-cigarette device
While the bulk of studies related to the impact of e-cigarette use on human health has focused on the e-liquid components and the resulting aerosols produced after heating, a few studies have addressed the material of the electronic device and its potential consequences—specifically, the potential presence of metals such as copper, nickel or silver particles in e-liquids and aerosols originating from the filaments and wires and the atomiser [ 89 , 90 , 91 ].
Other important components in the aerosols include silicate particles from the fiberglass wicks or silicone [ 89 , 90 , 91 ]. Many of these products are known to cause abnormalities in respiratory function and respiratory diseases [ 89 , 90 , 91 ], but more in-depth studies are required. Interestingly, the battery output voltage also seems to have an impact on the cytotoxicity of the aerosol vapours, with e-liquids from a higher battery output voltage showing more toxicity to A549 cells [ 30 ].
A recent study compared the acute effects of e-cigarette vapor (with PG/vegetable glycerine plus tobacco flavouring but without nicotine) generated from stainless‐steel atomizer (SS) heating element or from a nickel‐chromium alloy (NC) [ 92 ]. Some rats received a single e-cigarette exposure for 2 h from a NC heating element (60 or 70 W); other rats received a similar exposure of e-cigarette vapor using a SS heating element for the same period of time (60 or 70 W) and, a final group of animals were exposed for 2 h to air. Neither the air‐exposed rats nor those exposed to e-cigarette vapor using SS heating elements developed respiratory distress. In contrast, 80% of the rats exposed to e-cigarette vapor using NC heating units developed clinical acute respiratory distress when a 70‐W power setting was employed. Thus, suggesting that operating units at higher than recommended settings can cause adverse effects. Nevertheless, there is no doubt that the deleterious effects of battery output voltage are not comparable to those exerted by CS extracts [ 30 ] (Figs. 1 and 2 ).
E-cigarettes as a smoking cessation tool
CS contains a large number of substances—about 7000 different constituents in total, with sizes ranging from atoms to particulate matter, and with many hundreds likely responsible for the harmful effects of this habit [ 93 ]. Given that tobacco is being substituted in great part by e-cigarettes with different chemical compositions, manufacturers claim that e -cigarette will not cause lung diseases such as lung cancer, chronic obstructive pulmonary disease, or cardiovascular disorders often associated with conventional cigarette consumption [ 3 , 94 ]. However, the World Health Organisation suggests that e-cigarettes cannot be considered as a viable method to quit smoking, due to a lack of evidence [ 7 , 95 ]. Indeed, the results of studies addressing the use of e-cigarettes as a smoking cessation tool remain controversial [ 96 , 97 , 98 , 99 , 100 ]. Moreover, both FDA and CDC are actively investigating the incidence of severe respiratory symptoms associated with the use of vaping products [ 77 ]. Because many e-liquids contain nicotine, which is well known for its powerful addictive properties [ 41 ], e-cigarette users can easily switch to conventional cigarette smoking, avoiding smoking cessation. Nevertheless, the possibility of vaping nicotine-free e-cigarettes has led to the branding of these devices as smoking cessation tools [ 2 , 6 , 7 ].
In a recently published randomised trial of 886 subjects who were willing to quit smoking [ 100 ], the abstinence rate was found to be twice as high in the e-cigarette group than in the nicotine-replacement group (18.0% vs. 9.9%) after 1 year. Of note, the abstinence rate found in the nicotine-replacement group was lower than what is usually expected with this therapy. Nevertheless, the incidence of throat and mouth irritation was higher in the e-cigarette group than in the nicotine-replacement group (65.3% vs. 51.2%, respectively). Also, the participant adherence to the treatment after 1-year abstinence was significantly higher in the e-cigarette group (80%) than in nicotine-replacement products group (9%) [ 100 ].
On the other hand, it is estimated that COPD could become the third leading cause of death in 2030 [ 101 ]. Given that COPD is generally associated with smoking habits (approximately 15 to 20% of smokers develop COPD) [ 101 ], smoking cessation is imperative among COPD smokers. Published data revealed a clear reduction of conventional cigarette consumption in COPD smokers that switched to e-cigarettes [ 101 ]. Indeed, a significant reduction in exacerbations was observed and, consequently, the ability to perform physical activities was improved when data was compared with those non-vapers COPD smokers. Nevertheless, a longer follow-up of these COPD patients is required to find out whether they have quitted conventional smoking or even vaping, since the final goal under these circumstances is to quit both habits.
Based on the current literature, it seems that several factors have led to the success of e-cigarette use as a smoking cessation tool. First, some e-cigarette flavours positively affect smoking cessation outcomes among smokers [ 102 ]. Second, e-cigarettes have been described to improve smoking cessation rate only among highly-dependent smokers and not among conventional smokers, suggesting that the individual degree of nicotine dependence plays an important role in this process [ 97 ]. Third, the general belief of their relative harmfulness to consumers' health compared with conventional combustible tobacco [ 103 ]. And finally, the exposure to point-of-sale marketing of e-cigarette has also been identified to affect the smoking cessation success [ 96 ].
Implication of e-cigarette consumption in COVID-19 time
Different reports have pointed out that smokers and vapers are more vulnerable to SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus 2) infections or more prone to adverse outcomes if they suffer COVID-19 [ 104 ]. However, while a systematic review indicated that cigarette smoking is probably associated with enhanced damage from COVID-19, a meta-analysis did not, yet the latter had several limitations due to the small sample sizes [ 105 ].
Interestingly, most of these reports linking COVID-19 harmful effects with smoking or vaping, are based on their capability of increasing the expression of angiotensin-converting enzyme 2 (ACE2) in the lung. It is well known that ACE2 is the gate for SARS-CoV-2 entrance to the airways [ 106 ] and it is mainly expressed in type 2 alveolar epithelial cells and alveolar macrophages [ 107 ]. To date, most of the studies in this field indicate that current smokers have higher expression of ACE2 in the airways (reviewed by [ 108 ]) than healthy non-smokers [ 109 , 110 ]. However, while a recent report indicated that e-cigarette vaping also caused nicotine-dependent ACE2 up-regulation [ 42 ], others have revealed that neither acute inhalation of e-cigarette vapour nor e-cigarette users had increased lung ACE2 expression regardless nicotine presence in the e-liquid [ 43 , 110 ].
In regard to these contentions, current knowledge suggests that increased ACE2 expression is not necessarily linked to enhanced susceptibility to SARS-CoV-2 infection and adverse outcome. Indeed, elderly population express lower levels of ACE2 than young people and SARS-CoV-2/ACE2 interaction further decreases ACE2 expression. In fact, most of the deaths provoked by COVID-19 took place in people over 60 years old of age [ 111 ]. Therefore, it is plausible that the increased susceptibility to disease progression and the subsequent fatal outcome in this population is related to poor angiotensin 1-7 (Ang-1-7) generation, the main peptide generated by ACE2, and probably to their inaccessibility to its anti-inflammatory effects. Furthermore, it seems that all the efforts towards increasing ACE2 expression may result in a better resolution of the pneumonic process associated to this pandemic disease.
Nevertheless, additional complications associated to COVID-19 are increased thrombotic events and cytokine storm. In the lungs, e-cigarette consumption has been correlated to toxicity, oxidative stress, and inflammatory response [ 32 , 112 ]. More recently, a study revealed that while the use of nicotine/flavour-containing e-cigarettes led to significant cytokine dysregulation and potential inflammasome activation, none of these effects were detected in non-flavoured and non-nicotine-containing e-cigarettes [ 43 ]. Therefore, taken together these observations, e-cigarette use may still be a potent risk factor for severe COVID-19 development depending on the flavour and nicotine content.
In summary, it seems that either smoking or nicotine vaping may adversely impact on COVID-19 outcome. However, additional follow up studies are required in COVID-19 pandemic to clarify the effect of e-cigarette use on lung and cardiovascular complications derived from SARS-CoV-2 infection.
The harmful effects of CS and their deleterious consequences are both well recognised and widely investigated. However, and based on the studies carried out so far, it seems that e-cigarette consumption is less toxic than tobacco smoking. This does not necessarily mean, however, that e-cigarettes are free from hazardous effects. Indeed, studies investigating their long-term effects on human health are urgently required. In this regard, the main additional studies needed in this field are summarized in Table 3 .
The composition of e-liquids requires stricter regulation, as they can be easily bought online and many incidences of mislabelling have been detected, which can seriously affect consumers’ health. Beyond their unknown long-term effects on human health, the extended list of appealing flavours available seems to attract new “never-smokers”, which is especially worrying among young users. Additionally, there is still a lack of evidence of e-cigarette consumption as a smoking cessation method. Indeed, e-cigarettes containing nicotine may relieve the craving for smoking, but not the conventional cigarette smoking habit.
Interestingly, there is a strong difference of opinion on e-cigarettes between countries. Whereas countries such as Brazil, Uruguay and India have banned the sale of e-cigarettes , others such as the United Kingdom support this device to quit smoking. The increasing number of adolescent users and reported deaths in the United States prompted the government to ban the sale of flavoured e-cigarettes in 2020. The difference in opinion worldwide may be due to different restrictions imposed. For example, while no more than 20 ng/mL of nicotine is allowed in the EU, e-liquids with 59 mg/dL are currently available in the United States. Nevertheless, despite the national restrictions, users can easily access foreign or even counterfeit products online.
In regard to COVID-19 pandemic, the actual literature suggests that nicotine vaping may display adverse outcomes. Therefore, follow up studies are necessary to clarify the impact of e-cigarette consumption on human health in SARS-CoV-2 infection.
In conclusion, e-cigarettes could be a good alternative to conventional tobacco cigarettes, with less side effects; however, a stricter sale control, a proper regulation of the industry including flavour restriction, as well as further toxicological studies, including their chronic effects, are warranted.
Availability of data and materials
Angiotensin-converting enzyme 2
Bronchoalveolar lavage fluid
US Centers for Disease Control and Prevention
Chronic obstructive pulmonary disease
Coronavirus disease 2019
Electronic nicotine dispensing systems
e-cigarette or vaping product use-associated lung injury
Food and Drug Administration
Gas chromatography with a flame ionisation detector
Gas chromatography-mass spectrometry
Granulocyte–macrophage colony-stimulating factor
High performance liquid chromatography
Human umbilical vein endothelial cells
Liquid chromatography-mass spectrometry
Monocyte chemoattractant protein-1
Matrix metallopeptidase 9
α7 Nicotinic acetylcholine receptor
Regulated on activation, normal T cell expressed and secreted
Reactive oxygen species
Severe acute respiratory syndrome coronavirus 2
Tumour necrosis factor-α
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The authors gratefully acknowledge Dr. Cruz González, Pulmonologist at University Clinic Hospital of Valencia (Valencia, Spain) for her thoughtful suggestions and support.
This work was supported by the Spanish Ministry of Science and Innovation [Grant Number SAF2017-89714-R]; Carlos III Health Institute [Grant Numbers PIE15/00013, PI18/00209]; Generalitat Valenciana [Grant Number PROMETEO/2019/032, Gent T CDEI-04/20-A and AICO/2019/250], and the European Regional Development Fund.
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Department of Pharmacology, Faculty of Medicine, University of Valencia, Avda. Blasco Ibañez 15, 46010, Valencia, Spain
Patrice Marques, Laura Piqueras & Maria-Jesus Sanz
Institute of Health Research INCLIVA, University Clinic Hospital of Valencia, Valencia, Spain
CIBERDEM-Spanish Biomedical Research Centre in Diabetes and Associated Metabolic Disorders, ISCIII, Av. Monforte de Lemos 3-5, 28029, Madrid, Spain
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Marques, P., Piqueras, L. & Sanz, MJ. An updated overview of e-cigarette impact on human health. Respir Res 22 , 151 (2021). https://doi.org/10.1186/s12931-021-01737-5
Received : 22 October 2020
Accepted : 03 May 2021
Published : 18 May 2021
DOI : https://doi.org/10.1186/s12931-021-01737-5
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Vaping epidemic: challenges and opportunities
1 Department of Preventive Medicine, USC Keck School of Medicine, University of Southern California, M/C 9603, Los Angeles, CA 90033, USA
This article is a timely, concise, and unbiased analysis of the national and international responses to the spate of vaping-related lung illnesses and deaths and the epidemic of teen vaping. In view of the recent outbreak of vaping-related lung injuries and deaths in the U.S. and the epidemic of teen vaping, the viewpoints and recommendations presented in this article have immediate policy implications in the U.S. and around the world. The perspectives and recommendations are expected to assist medical communities, public health professionals, and regulatory authorities in addressing complex issues related to vaping regulation, which is intertwined with public health, economy, and politics of nations, worldwide.
Electronic cigarettes (e-cigs) use, otherwise known as ‘vaping’, is promoted as a safe or less-harmful alternative to smoking or as an aide to smoking cessation [ 1 ]. Since the introduction of e-cigs into the U.S. market over a decade ago, the appeal and popularity of vaping have significantly increased [ 2 ]. Accordingly, there has been a massive and steady rise in vaping prevalence, especially among adolescent never smokers and adult smokers seeking a putatively less-harmful tobacco substitute [ 3 ]. Meanwhile, the number and type of e-cig products have increased exponentially, albeit little or no systematic regulation of sales has been in place [ 4 ].
E-cigs are handheld battery-powered vaporizing devices that simulate tobacco smoking by heating a liquid to produce an inhalable aerosol (vapor) [ 5 ]. The liquid, also referred to as ‘e-liquid/e-juice’, contains a mixture of propylene glycol, glycerin, flavors, nicotine at variable concentrations (incl. zero), and other substances and additives, e.g. , cannabinoids (optional), such as tetrahydrocannabinol (THC) and cannabinoid (CBD) oils [ 1 ]. Of note, THS is the main psychoactive mind-altering compound in marijuana that produces the infamous “high”. In recent years, significant increases in marijuana vaping have been reported, especially among U.S. adolescents [ 6 , 7 ]. Vaping replicates some of the behavioral aspects of cigarette smoking, including the hand-to-mouth action, but without burning tobacco, which is responsible for production of a myriad of toxicants and carcinogens. Because vapor in e-cigs is not produced as a result of tobacco pyrolysis, vaping is claimed to be, at best, a safe, and at worst, a less unhealthy alternative to smoking [ 1 ]. However, chemical analyses of e-cig liquid and vapor have shown the presence of many of the same toxicants and carcinogens as those found in tobacco smoke, albeit in generally lower concentrations [ 2 , 4 ]. Currently, investigating the biological consequences of exposure to e-cig derived toxicants and carcinogens is a high priority research area [ 8 ].
2. Epidemic of teen vaping
Recent data from National Institutes of Health’s (NIH) Monitoring the Future Survey show a significant rise in American teens’ use of e-cigs in just a single year, with 37.3% of 12 th graders reporting use in the past 12 months, compared to 27.8% in 2017 [ 9 , 10 ]. The data from the NIH survey confirm the 2018 National Youth Tobacco Survey, which demonstrates a surge in e-cig use among youth, reaching epidemic proportions [ 11 ]. The number of high school students who use e-cigs has increased by 78% last year to approximately 3.6 millions, which correspond to about 21% of all U.S. high school students. Similarly, use among middle school students has risen by 48% [ 11 ]. Due to these alarming trends, many experts in public health and tobacco control have voiced concerns that we might be on the verge of addicting a new generation to the harmful effects of nicotine use.
3. Vaping-related severe lung injury and death
In the past several months, the health concerns about vaping have escalated to an unprecedented level both in the United States and around the world. Since August 2019, the Centers for Disease Control and Prevention (CDC), the U.S. Food and Drug Administration (FDA), state and local health departments, and other clinical and public health partners have been dealing with a nation-wide outbreak of vaping-related severe lung illnesses, also referred to as “ e -cig, or v aping, product use- a ssociated l ung i njury (EVALI)”. National and state data have shown a sharp increase in symptoms or cases of EVALI in August 2019, a peak in September 2019, and a gradual, but persistent decrease since then. As of February 18, 2020, a total of 2,807 hospitalized EVALI cases or deaths have been reported to CDC from all 50 states, the District of Columbia, and two U.S. territories, including Puerto Rico and U.S. Virgin Islands. Sixty-eight deaths have been confirmed in 29 states and the District of Columbia. Analysis of data from patient reports and product sample testing have revealed that THC-emulsified with vitamin E acetate-containing e-cigs or vaping products, especially those obtained from informal sources like friends, family, or in-person or online dealers, are strongly linked to EVALI. As such, Vitamin E acetate has been detected in product samples tested by FDA and state laboratories and in EVALI patients’ lung fluid samples (bronchoalveolar lavage (BAL)) tested by CDC from geographically diverse states. In contrast, no vitamin E acetate has been found in the lung fluid of people who did not have EVALI. As it stands, there is not sufficient evidence to rule out the contribution of other chemical constituents of THC- or non-THC-containing vaping products to some of the reported EVALI cases. In light of the above findings, the continued decline in EVALI cases reported since September 2019 have been ascribed to (I) increased public awareness of the risk associated with THC-containing e-cigs or vaping products; (II) removal of vitamin E acetate from some vaping products; and (III) law enforcement actions taken against the sale and distribution of illicit e-cigs and vaping products [ 12 ].
4. National and international reactions to the call for e-cig regulation
Worldwide, backlash against e-cig use is gaining more momentum. On Wednesday September 18, 2019, India joined the list of countries to effectively ban the sale, import, advertising, and production of e-cigs [ 13 ]. An emergency ordinance, to be converted into law by the parliament, was approved by the Prime Minister, Narendra Modi. According to this executive order, first-time offenders will face up to one year in prison and a fine of 100,000 rupees (~$1,400), while repeat offenders will be sentenced to 3 years in prison and 500,000 rupees (~$7,000) fine. Simply possessing e-cigs or similar devices will also be an offense, punishable by up to 6 months imprisonment and a fine of up to 50,000 rupees (~$700) [ 13 ].
Thus far, 42 other countries have banned e-cig sale, 55 countries allow sale but have put restrictions on where and how e-cig products can be sold, while 30 countries regulate the amount of nicotine used in e-cig devices [ 14 ]. For example, Singapore has an outright ban on e-cigs, whereas Japan allows sale and distribution of non-nicotine e-cigs and “heat-not-burn” tobacco products. Because liquid nicotine is highly regulated in Japan, vaping devices with nicotine-containing e-juices are banned; however, non-nicotine e-cigs and heated smoking devices, e.g. , “I Quit Original Smoking” (IQOS), are widely marketed and sold. Legislation on e-cigs is also being tightened in other countries; in July 2019, China, home to nearly one-third of the world’s smokers (300 million Chinese smoke tobacco), announced a need for “severely strengthening the supervision of e-cig”. Just days prior to the India’s ban on e-cigs, vaping products from Juul, the San Francisco based world’s largest maker of e-cigs with 72% of the market share, were mysteriously vanished from online Chinese marketplaces [ 14 ]. India’s ban also came on the heels of New York becoming the first U.S. state to ban flavored vape products on September 17, 2019. A similar emergency directive has earlier been approved in Michigan, and is expected to go into effects in a few weeks’ time. However, the New York state’s emergency ban on flavored vaping products was later challenged in court by the Vapor Technology Association, an industry group, and two of its member businesses. The request for injunction against enforcing the ban argued that it would force vaping businesses across the state to close. In January 2020, Acting State Supreme Court Justice, Catherine Cholakis, blocked the ban by ruling that the state Public Health and Health Planning Council overstepped its authority last September when it issued the emergency ban. In her ruling, Judge Cholakis stated that regulating the vaping industry is a job for the state Legislature, not the executive branch, whose function is to implement policy set by lawmakers. Kyle Kotary, a spokesman for Governor Andrew Cuomo (D), called Cholakis’ decision “unfortunate ” but added that the judge had acknowledged the seriousness of the vaping issue in her ruling. “That said, we’re reviewing the decision, evaluating our procedural options and moving forward with comprehensive legislation to address the public health concerns related to vaping,” the Governor’s spokesman, also stated.
On Wednesday September 11, 2019, Donald Trump announced his administration’s plan for a ban on most flavored e-cig products believed to be responsible for teen vaping, and the issuance of the FDA’s guidance on how to take these products off the market [ 15 ]. In response, industry and political allies warned that such a ban would cost thousands of jobs and alienate voters. Two days later, Trump quickly dialed back and softened his rhetoric by tweeting that “While I like the Vaping alternative to Cigarettes, we need to make sure this alternative is SAFE for ALL! Let’s get counterfeits off the market, and keep young children from Vaping!”. In November 2019, he further backtracked after a White House meeting with tobacco industry giants, vaping advocates, and public health groups. On January 2, 2020, the Trump Administration finally announced a ban on some—but not all—flavored e-cig products, in a compromise that sparked criticism from both vaping advocates and adversaries. The limited ban applies to the cartridge-based e-cig devices manufactured by companies like Juul Labs, which are highly popular among teenagers. Under this ban, companies are prohibited from selling sweet and fruity flavored vape pods and e-liquid cartridges, whilst menthol and tobacco flavored products as well as larger, open-tank vaping systems, which users can manually fill with e-liquids of their choice, remain exempt.
In countries where e-cig use is encouraged as a way to quit smoking, the news of spate of U.S. deaths and pulmonary illnesses associated with vaping drew a different reaction. On September 12, 2019, Public Health England (PHE), the country’s leading health body, shared its advice by stating that: “Our advice on e-cigarettes remains unchanged - vaping isn’t completely risk free but is far less harmful than smoking tobacco. There is no situation where it would be better for your health to continue smoking rather than switching completely to vaping. All UK e-cigarette products are tightly regulated for quality and safety by @MHRAgovuk. It’s important to use UK-regulated e-liquids and never risk vaping home-made or illicit e-liquids or adding substances, any of which could be harmful. Smoking kills thousands eveiy year and creating a smoke free generation is one of oar top priorities. Vaping is a fraction of the risk of smoking and makes it much more likely you’ll quit successfully than relying on willpower alone. The sooner you stop smoking completely the better.” The PHE’s advice echoed remarks from its head of Tobacco Control, Martin Dockrell, who had earlier told the Guardian: “Unlike the US, all e-cigarette products in the UK are tightly regulated for quality and safety by the Medicines and Healthcare Products Regulatory Agency and they operate the yellow card scheme, encouraging vapers to report any bad experiences” [ 16 ].
5. Challenges and opportunities of e-cig regulation
The epidemic of teen vaping and the outbreak of vaping-related lung injuries and deaths in the U.S. underscore the urgent need to systematically regulate e-cig manufacturing, marketing, and distribution. However, development of plausible and effective vaping regulations and most importantly, their enforcement are likely to present unique challenges to different countries across the globe. The challenges may vary depending on the legal, regulatory, economic, and sociopolitical contexts of each nation. For example, India’s ban on e-cigs raises the importance of transparency when authorities decide to address a highly ‘complex’ problem. According to various officials, the government’s decision to ban vaping has been in the making for the past two years, and is based, at least, in part, on a white paper by the Indian Council of Medical Research (hardly an ally of the tobacco companies), which warns against the net negative impact e-cigs have on public health and the threat they pose to future generations. Notwithstanding those statements, accusations and suspicions have been floating around the government’s motive in imposing a ban on vaping. India has one of the highest rates of tobacco use in the world, with 106 million adult smokers (second only to China) and another 200 million users of chewing tobacco and other such products [ 17 ]. The government owns 28% of I.T.C. Limited (ITC, Ltd), a leading manufacturer of cigarettes, which means it directly profits from cigarette sales and high taxes, while also earning immense revenues from exporting $1 billion-worth of tobacco, annually [ 13 , 14 ]. Conversely, India’s vaping market, which is relatively small and valued at $15.6 millions, relies exclusively on imported vaping products [ 14 ]. As a source of revenue for the government, the latter clearly pales into insignificance compared to the locally grown tobacco and the associated industry. Skepticism has also been high as to why the government is bent on banning e-cigs whilst tobacco cigarettes and bidis (traditional small, thin, hand-rolled cigarettes wrapped in a tendu or temburni leaf), which are proven to kill one million Indians per year [ 17 ], remain exempt. Not only that, the government continues to encourage and subsidize tobacco farming. With 45.7 million people whose livelihoods depend on the tobacco sector [ 14 ], the Indian government should embrace this ‘opportunity’ to make a compelling case that the push for e-cig ban was solely to protect the health and wellbeing of the population, and not economically driven nor to appease a large voting bloc.
Globally, 35 million people are estimated to use e-cigs or “heat-not-burn” tobacco products [ 17 , 14 ]. Although the global market for e-cigs is still small compared to tobacco cigarettes, it is growing very swiftly. Last year, worldwide sales of tobacco cigarettes reached more than $713 billions, compared to $15.7 billions for e-cigs. By 2023, the sales of vaping products are projected to more than double to $40 billions, while cigarette sales are expected to decline slightly [ 17 , 14 ]. Governments around the world are facing the predicament of how to best deal with the epidemic of vaping. An ideal solution would entail improving the public’s health, as the first and foremost priority, while avoiding compromising the nations’ economy, causing social backlash or political fallout, and getting engulfed by a tsunami of litigations, most certainly, to be brought by vaping industry, tobacco companies, and other stakeholders. Presumably, commercial interests in both marketing of e-cig products and delaying/blocking vaping regulations will be a driving factor in most, if not, all countries involved.
6. Concluding remarks and future directions
The Latin phrase “scientia potentia est” (translation: “knowledge is power”) is a reminder that gaining knowledge on various aspects of vaping can empower us to solve the ‘complex’ problem of “to vape or not to vape”. Philosopher, essayist, poet, and novelist, George Santayana, famously said: “Those who cannot remember the past are condemned to repeat it.” Let’s remind ourselves of Santayana’s phrase and learn from the history of tobacco regulation and smoking prevention. Throughout the years, development of effective regulations on tobacco products leading to successful declines in smoking rates has always been interwoven with scientific breakthroughs providing ‘compelling’ evidence on the adverse health consequences of smoking [ 17 ]. Thus, evidence-based regulations and scientifically driven recommendations on vaping will not only be more effective, sensible, and enforceable, but they will also minimize/eliminate the risk of unintended outcomes, such as inadvertently turning e-cigs into a “prohibitos autem fructum” (translation: forbidden fruit). While research data are accumulating on the adverse biological effects of e-cig use [ 18 – 20 ]. evidence is also emerging on the efficacy of vaping combined with behavioral therapy in helping smokers quit [ 21 ] (although initial studies have produced mixed results [ 22 ]). The existing data clearly demonstrate that vaping is not risk free. This together with the growing concern that vaping may lead to nicotine addiction and smoking, especially among youth, underlines the importance of investigating the health risks associated with vaping. The health-risk profile of vaping should be determined both in absolute terms (to inform never-smokers of potential risks posed by vaping) and relative to smoking (to inform smokers about the relative risk of vaping to smoking). Let’s keep a fair and open mind while continuing our important research on the health risks or potential benefits of vaping vs. smoking. An unbiased and balanced interpretation of the findings will ensure the scientific integrity of our work and the effectiveness of their implications for regulatory purposes. Towards that goal, our hope is that the present article has offered readers with a concise and unbiased presentation of the stances taken by ‘both’ sides of the debate on vaping regulation, which is all but certain to impact public health, economy, and politics of nations, worldwide.
This work was supported by grants from the National Institute of Dental and Craniofacial Research of the National Institutes of Health (1R01DE026043 to AB) and the University of California Tobacco-Related Disease Research Program (TRDRP-28IR-0058 to AB and TRDRP-26IP-0051 to ST). The sponsors of the study had no role in study design, data collection, data analysis, data interpretation, writing of the report, or in the decision to submit for publication.
Financial disclosure: No financial disclosures are reported by the authors of this paper.
Publisher's Disclaimer: This Author Accepted Manuscript is a PDF file of an unedited peer-reviewed manuscript that has been accepted for publication but has not been copyedited or corrected. The official version of record that is published in the journal is kept up to date and so may therefore differ from this version.
Conflict of interest statement: Both authors (AB and ST) declare that there are no financial or non-financial conflicts of interest.
Conflicts of Interest Statement
Both authors (A.B. and S.T.) declare no conflict of interest.
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VAPING PREVENTION & EDUCATION
Project: “vaping's not our thing”, project planner.
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Visit Vaping 101 in the student section to gather facts about addiction and the dangers of vaping. Find more information in The Risks of Vaping Magazine and explore the Must-Know Facts About E⁠-⁠Cigarettes videos for more data.
Have your students summarize what they have learned by answering the questions below:
- How can vaping lead to addiction?
- Why are teens more at risk for addiction than adults?
- What are the signs of a vaping addiction?
- What other health risks do e⁠-⁠cigarettes pose?
- What advice would you give teens about vaping?
- What can someone do if they become addicted to vaping?
Use the project rubric to help your students create their poster or infographic. Ask your students the questions below throughout their creative process. As they plan, have your students write and/or draw, and edit their work.
- How well does the entry focus on the dangers of vaping to teens?
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- Is the information scientifically accurate?
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- How persuasive are the imagery, language, and facts?
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Encourage your students to share their poster or infographic with friends or family. Use their feedback to edit and improve their entry. Then, hang it up around the school or in your classroom to spread the word to other teens on the dangers of vaping.
PROJECT RUBRIC: "Vaping's Not Our Thing"
The rubric below can help your students determine how successful their poster or infographic will be. Ask your students the questions below throughout their creative process. As they plan, have your students write and/or draw, and edit their work.
1. SCIENTIFIC CONTENT - 10PTS
2. impact & persuasiveness - 10pts, 3. creativity - 5pts, 4. presentation - 5pts.
RESOURCES INFORMATION LIBRARY
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This resource is collection of the best and latest research on vaping and other reduced-harm products, medical journal articles, as well as journalistic pieces organized by topic that contain valuable data, information, and perspectives on tobacco harm reduction, vaping, and safer nicotine products.
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These resources are some of the highest rated, latest research on vaping.
Balancing Consideration of the Risks and Benefits of E-Cigarettes
Nicotine without smoke: tobacco harm reduction, electronic cigarettes for smoking cessation, a randomized trial of e-cigarettes versus nicotine-replacement therapy, educational videos, recommended videos, what vaping did.
Vaping: what people are getting wrong | The Economist
Vaping: a more balanced message | Michigan Public Health
Why bans of low-risk nicotine alternatives to smoking in lmic's will do more harm than good, vaping demystified.
The E-Cigarette Summit 2019, London | Ethan Nadelman Presentation
Why Health Groups Lie About Vaping
Vaporized: U.K. Government Promotes Vaping As Smoking Cessation Tool | CNBC Prime
Marc Slis, Vape Shop Owner - Michigan Testimony
Stop Smoking Start Vaping
Dr. Colin Mendelsohn
Velvet Glove, Iron Fist
The Rediscovery of Tobacco
The Cigarette Century
Allan M. Brandt
Sander L. Gilman & Zhou Xun
Cigarettes Are Sublime
For Smokers Only
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Say Why To Drugs
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Vaping vs smoking, other vaping side effects, how to quit vaping, quitting vaping tip 1: identify and manage triggers, tip 2: prepare for cravings and withdrawal, tip 3: find support, tips for parents of children who vape, how to talk to your teen about vaping, how to help your child quit vaping, vaping: the health risks and how to quit.
Using e-cigarettes and other vape devices can lead to nicotine addiction and expose you to dangerous toxins. Learn more about how it compares to smoking, the unique risks young people face, and how to quit the habit.
Vaping involves inhaling the vapor from an e-cigarette, e-pipe, vape pod, vape pen, or similar device. Many kids and teens look at vaping and see a harmless activity. You might think that it’s essentially just flavored steam that helps you relax. Or you might believe that vaping is so common among people your own age that the dangers must be overblown.
It’s true that vaping is an increasingly common habit among young people. In a 2021 U.S. survey, more than two million middle and high school students said they had used electronic or e-cigarettes within the past month. E-cigarettes were far more popular among those students than regular cigarettes, cigars, and other tobacco products.
Those numbers are alarming to health professionals because the dangers of vaping are very real. The aerosol from vape devices often contains nicotine, an addictive drug that can affect the developing brain of a teenager. On top of that, when you inhale the vapor from your e-cigarette, you also breathe in a variety of chemicals, some of which may be toxic. So, that seemingly harmless vapor has the potential to adversely affect your physical and mental health.
If you just vape on occasion, learning more about the risks may be enough to convince you to avoid e-cigarettes in the future.
If you’re already a habitual vape user, you might find that cutting nicotine out is a difficult process. Even if you’re fearful of the health risks and want to quit, withdrawal symptoms can trigger you to keep returning to your vape. But there are ways to cope without the nicotine and kick the vaping habit. With the right information, support, and strategies, you can drop the habit for good and protect your health.
E-cigarettes have been touted as a safer alternative to traditional cigarettes. Some people even switch to vaping to minimize the risks associated with smoking .
While it’s true that vaped aerosols can contain fewer toxic chemicals than the smoke from cigarettes, that doesn’t mean vaping is a risk-free activity. According to a CDC study, roughly 99 percent of e-cigarettes sold in the U.S. have some level of nicotine, and the content isn’t always disclosed.
Nicotine is a stimulant that raises your heart rate and gives you a temporary high. But whether it comes from vaping or smoking, nicotine is also highly addictive and greatly increases your risk for serious disease.
The effects of nicotine
Although many people initially use nicotine to find relief from anxiety or depression , they quickly discover that addiction can develop. And that addiction can take a damaging toll on your mood and health.
[Read: Self-Medicating Depression, Anxiety, and Stress]
If you have a nicotine dependency and go too long without the drug, you may begin to experience symptoms of withdrawal. This can include feeling depressed, anxious, unfocused, or irritable. So, you vape again to reduce those symptoms, and the cycle repeats. Nicotine addiction has a powerful hold over you.
Nicotine can also affect your brain, which continues to develop until you reach your mid-20s. Nicotine impairs regions of the brain responsible for learning, focus, mood, and impulse control. This can have consequences for everything from your schoolwork to your social life.
Difficulty retaining information in class or staying focused on your homework can lead to academic challenges. Mood swings and impulsive behavior may cause you to lash out at your closest friends, causing rifts in your social circle.
In addition to nicotine, the aerosol from your vape may expose you to other unhealthy chemicals. Formaldehyde, an irritant and probable carcinogen, can form when the liquid is heated. Chemicals like acrolein, diacetyl, and diethylene glycol can damage your lungs. Vaping can also expose your body to metals, such as tin, lead, nickel, and cadmium.
Vaping may pose dangers that researchers have yet to uncover. As recently as 2019, a synthetic form of vitamin E was identified as a possible culprit behind an outbreak of lung injuries among vape users. In addition, one 2021 study of vaping aerosols and liquids identified the presence of nearly 2,000 unknown chemicals.
Risk of diseases
More and more studies indicate that vaping can affect oral health. Nicotine interferes with blood flow in the gums, and e-cigarette aerosol alters the state of oral bacteria. This raises the risk of periodontal disease, which comes with symptoms such as bad breath, swollen and bleeding gums, difficulty chewing, and loose teeth.
New research also shows that e-cigarette users may have an increased risk of prediabetes and lung diseases, such as asthma and chronic obstructive pulmonary disease (COPD). If you use both e-cigarettes and traditional cigarettes, you further increase your health risks. One study found that people who use both types of nicotine sources significantly raise their odds of cardiovascular disease.
There are many reasons to stop vaping, but breaking the habit can be a frustrating process. You may manage to avoid e-cigarettes for a day, before giving in to the desire to vape. Then, a sense of shame and regret accompanies the nicotine high. After repeatedly failing to quit, you might feel helpless, discouraged, and begin to wonder if there’s something wrong with you.
Know that you’re not alone. Nicotine addiction is an issue that many people struggle with. However, a thoughtful and strategic approach to tackling the addiction and related habits can make all the difference.
Start by reflecting on your own motivations for quitting . For most people, quitting e-cigarettes comes with multiple benefits. Write down all of your motivations. Perhaps you want to save money for something important instead of spending money on vape accessories. Or maybe you want to quit vaping to avoid the physical and mental consequences of addiction . If your relationships with friends, partners, or parents have suffered due to your habit, quitting might improve your social life. Having a list of reasons to quit vaping will help keep you on track whenever you’re tempted to resume the habit.
Next, set a quit date . When do you plan to be completely free of the vaping habit? Pick a day that falls within the next two weeks, so the drive to quit remains strong. However, don’t pick a day that you know will be extremely stressful, such as the day of an important test. Once you have your target goal set, you can begin to adjust your behavior and break the addiction.
Triggers are specific situations that increase your urge to vape. For example, smelling vapor in the air or seeing friends vape might increase your craving. Maybe online or television ads tempt you to pick up an e-cigarette.
Certain emotional states can also act as triggers. The stress of prepping for a job interview, for example, could increase your desire to vape. You might also turn to nicotine to cope with loneliness or boredom.
If you have a hard time identifying your triggers, keep a craving journal. Record information such as when the craving started, what you were doing, and who you were with. You can also note the intensity of the craving.
Once you know your triggers, you can develop strategies to avoid or minimize them.
First, get rid of any vape accessories in your backpack, locker, car, or room.
If social pressure is a trigger, take a break from friends who vape or let them know you’re trying to quit. If someone tries to coerce you into vaping again, simply give a firm but polite “no thank you.” A good friend will respect that boundary.
When it comes to emotion-based triggers, you’ll need to learn new ways to cope with those emotions.
If you’re experiencing loneliness and boredom:
- Use self-compassion and positive self-talk to challenge shyness and anxiety.
- Join clubs and attend events that match your interests.
- Look for opportunities to do volunteer work.
[Read: Loneliness and Social Isolation]
If you’re stressed or anxious:
- Incorporate a mindfulness meditation or breathing exercises into your day.
- Avoid overcommitting and taking on too much responsibility.
- Take care of your body by getting enough sleep and eating a healthy diet.
[Read: Stress Management]
If you’re feeling depressed:
- Use regular physical activity to improve your mood.
- Surround yourself with friends and family members who make you feel safe and cared for.
- Reach out to a helpline if you feel overwhelmed by negative thoughts.
[Read: Coping with Depression]
Nicotine withdrawal symptoms are uncomfortable sensations that set in shortly after you quit vaping. They might last days or weeks, but know that they're a normal part of the process.
Common nicotine withdrawal symptoms can include:
- Grogginess and difficulty concentrating
Cravings can be intense, but they usually only last for a few minutes. There are plenty of ways to cope until they pass. Experiment with these strategies to see what works best for you:
Have go-to distractions . Try listening to music, playing with a pet, or playing a video game whenever the craving to vape hits.
Get physically active . Take a short jog, ride your bike, or do some push-ups or jumping jacks instead of vaping. These activities can serve as distractions, but they can also boost your mood and energize you .
Review your reasons for quitting . Remember that list of your motivations to quit? Revisit it. Reflect on how much better you'll feel when you drop the habit. Envision yourself being free of nicotine.
Use an oral substitute for vaping . For example, chewing gum or crunching on a carrot can help distract you.
Practice deep breathing to calm your nervous system . Slowly inhale through your nose for several seconds. Follow this with a longer exhale. Repeat until you feel your anxiety decrease. Or try our Deep Breathing Meditation .
Drink more water . If the cravings come with other withdrawal symptoms, such as headaches and hunger, staying hydrated can help.
Although cravings are common in the first few days of quitting, you'll likely find that they eventually decrease in both frequency and intensity.
Dropping the vaping habit is ultimately your own responsibility, but leaning on others for support can help. Tell your loved ones that you're trying to quit vaping and would like their backing. Talking to them about your goal will also help them understand any changes in your mood over the next few days or weeks.
Let people know what specific actions they can take to help you . You may want friends to avoid vaping around you, for example. Or you could ask a sibling to bluntly remind you of the health consequences, or to join you in a new exercise routine or hobby to reduce your stress and boredom. Remember to take the time to show your appreciation for supportive friends and family members.
[Read: Social Support for Stress Relief]
You can also look for professional support . Reach out to ad addiction counselor for advice on quitting. You can contact a counselor by phone or online. Your doctor may also be able to prescribe medication that eases withdrawal symptoms. However, you can also find over-the-counter solutions, such as gum and patches.
Be patient with yourself . It might seem difficult at first, but with effort you can kick the habit. Of course, quitting is no small task. So, as you reach each milestone, take time to celebrate your accomplishments. And if you slip up and vape, don’t be too hard on yourself. Turn it into a learning experience. What triggered you to vape again? What can you do to address that trigger in the future?
If your child or teen vapes, it’s natural to feel worried. You may fear that vaping will have serious health consequences or lead your child to adopt other risky habits.
Despite your fears, you also know that talking to teens about these kinds of subjects can be tricky. You may not want to run the risk of an argument or make them feel defensive. But there are many ways to tactfully broach the subject.
First, it’s helpful to understand why your child is vaping to start with.
Why kids and teens vape
The more you understand the reasons why young people vape, the easier it will be to talk to your child about the dangers. Common reasons include:
Peer pressure . Many kids and teens say they initially tried e-cigarettes because their friends were using them. Friends might pressure one another to vape by downplaying the risks. Even when there’s no overt pressure from friends, non-vaping teens might feel the need to try it out to fit in with the group.
Attractive flavors . Although vape manufacturers avoid directly advertising to younger users, kids and teens often find flavored products appealing. Products that mimic the taste of fruit, candy, and desserts can be particularly enticing.
Negative emotions . Adolescence can be a turbulent time that’s filled with self-discovery, social stressors, and school demands. Young e-cigarette users often rely on their vape devices to manage the stress, anxiety, and depression that come with this stage of life.
[Read: Help for Parents of Troubled Teens]
Perception of safety . For years, e-cigarettes have successfully been pitched as safer alternatives to traditional cigarettes. Unfortunately, kids and teens have also picked up on this messaging and often underestimate the risks of vaping. The sweet flavors can also play into the harmless appearance of vape products.
Accessibility . It’s often easier for young people to obtain e-cigarettes, especially if the products are popular among their friend groups. Vaping is also often cheaper than other tobacco products.
Aesthetics . Many vape devices are easy to conceal from adults but have a sleek design that teens can show off to one another. Some young people may also think that vaping makes them look older and more mature.
Setting the right tone can make a big difference in how well the conversation goes. You don’t need to make the conversation seem like a big deal by pulling your child into the dining room for a formal chat. In fact, this might make them feel interrogated.
Take a casual approach and let the topic come up naturally . If you're together when you see an ad or someone vaping in public, for example, you can raise the subject naturally. Avoid starting the conversation when you or your child are already stressed or in a rush, though.
Use open-ended questions to invite discussion . Try asking for your child's opinion on vaping, or the risks of e-cigarettes versus cigarettes. The goal is to have a conversation rather than a lecture. Don’t criticize them. Listen to their answers in a nonjudgmental way and ask follow-up questions.
Share what you know about the risks of vaping . You might want to mention how vaping affects the teeth and gums, as well as the potential for nicotine addiction. You can also mention the illegality of underage vaping, but avoid making threats. Make it clear that your concerns come from a place of love rather than the desire to control their every action.
The conversation doesn’t need to be one, long chat. You can have many short talks with your child over the span of days, weeks, or months. If your child is initially hesitant to open up about their experiences, return to the topic later. Thinking of it as an ongoing conversation also gives you both time to research and learn more between discussions.
Your support can make all the difference in helping your child kick their vaping habit. Start by educating yourself on addiction and withdrawal symptoms . The more you know about these subjects, the better prepared you’ll be to help your child quit.
Help them cope with triggers and temptations . Sit down with your child and make a list of potential triggers. Then, you can work together to brainstorm coping strategies, such as:
- Getting rid of vape devices.
- Practicing saying “no” to peer pressure.
- Keeping gum or other smoking substitutes on hand.
Regularly talk with your child about their stressors . Do they feel depressed about a breakup or anxious about school? You don’t always need to have solutions to their problems. Sometimes just listening and making your child feel heard is enough to improve their well-being.
Encourage your child to embrace hobbies and social activities . Suggest that they try out team sports, learn an instrument, or join a local club that matches their interests. If they have existing hobbies, do what you can to support them. As your child focuses more on their hobbies and interests, they may feel less tempted to use vaping to manage negative emotions. Volunteer opportunities can also alleviate boredom, boost self-esteem, and help foster a sense of direction.
Make them feel empowered . Compliment your teen on their ability to think critically and independently. Let them know you trust them to make smart decisions, even in the face of peer pressure. Remind them of other hurdles they’ve overcome and things they’ve accomplished when they put their mind to it. By doing this, you help your child tap into the self-confidence and emotional resilience they need to overcome addiction and quit vaping.
Hotlines and support
Visit Quit Vaping at Smokefree Teen, call the quitline at 1-800-784-8669, or use the text messaging program at This is Quitting .
Visit Health Canada or call the helpline at 1-866-366-3667.
QuitNow or call 137 848.
Nicotine Anonymous offers a 12-Step program modeled after Alcoholics Anonymous with meetings in many different countries.
- Deal With Vape Cravings - Tips for managing urges to vape. (Smokefree.gov)
- Handling Nicotine Withdrawal and Triggers - Withdrawal symptoms and how to deal with them. (National Cancer Institute)
- Vaping Addiction and Nicotine Withdrawal - Dealing with both the mental and physical addiction. (Smokefree.gov)
- Know the Risks: E-cigarettes & Young People - Tips for young people and their parents. (U.S. Surgeon General’s Report)
- Vaping Reality Check - Tool to assess the impact vaping is having on you. (Smokefree.gov)
- Pharmacologic Product Guide: FDA-Approved Medications for Smoking Cessation - List of products for smoking cessation. (American Academy of Family Physicians)
- Substance-Related and Addictive Disorders. (2013). In Diagnostic and Statistical Manual of Mental Disorders . American Psychiatric Association. Link
- Need another reason not to vape? Your oral health is at risk | American Heart Association . (n.d.). Retrieved April 18, 2022, from Link
- Osei, A. D., Mirbolouk, M., Orimoloye, O. A., Dzaye, O., Uddin, S. M. I., Benjamin, E. J., Hall, M. E., DeFilippis, A. P., Bhatnagar, A., Biswal, S. S., & Blaha, M. J. (2020). Association Between E-Cigarette Use and Chronic Obstructive Pulmonary Disease by Smoking Status: Behavioral Risk Factor Surveillance System 2016 and 2017. American Journal of Preventive Medicine , 58(3), 336–342. Link
- Osei, A. D., Mirbolouk, M., Orimoloye, O. A., Dzaye, O., Uddin, S. M. I., Benjamin, E. J., Hall, M. E., DeFilippis, A. P., Stokes, A., Bhatnagar, A., Nasir, K., & Blaha, M. J. (2019). Association Between E-Cigarette Use and Cardiovascular Disease Among Never and Current Combustible-Cigarette Smokers. The American Journal of Medicine , 132(8), 949-954.e2. Link
- Osei, A. D., Mirbolouk, M., Orimoloye, O. A., Dzaye, O., Uddin, S. M. I., Dardari, Z. A., DeFilippis, A. P., Bhatnagar, A., & Blaha, M. J. (2019). The association between e-cigarette use and asthma among never combustible cigarette smokers: Behavioral risk factor surveillance system (BRFSS) 2016 & 2017. BMC Pulmonary Medicine , 19(1), 180. Link
- Outbreak of Lung Injury Associated with the Use of E-Cigarette, or Vaping, Products | Electronic Cigarettes | Smoking & Tobacco Use | CDC . (n.d.). Retrieved April 18, 2022, from Link
- Pushalkar, S., Paul, B., Li, Q., Yang, J., Vasconcelos, R., Makwana, S., González, J. M., Shah, S., Xie, C., Janal, M. N., Queiroz, E., Bederoff, M., Leinwand, J., Solarewicz, J., Xu, F., Aboseria, E., Guo, Y., Aguallo, D., Gomez, C., … Saxena, D. (2020). Electronic Cigarette Aerosol Modulates the Oral Microbiome and Increases Risk of Infection. IScience , 23(3), 100884. Link
- Quick Facts on the Risks of E-cigarettes for Kids, Teens, and Young Adults | CDC . (n.d.). Retrieved April 18, 2022, from Link
- Results from the Annual National Youth Tobacco Survey | FDA . (n.d.). Retrieved April 18, 2022, from Link
- Salloum, R. G., Tan, A. S. L., & Thompson, L. (2021). What Parents Need to Know About Teen Vaping and What They Can Do About It. JAMA Pediatrics , 175(4), 440. Link
- Tehrani, M. W., Newmeyer, M. N., Rule, A. M., & Prasse, C. (2021). Characterizing the Chemical Landscape in Commercial E-Cigarette Liquids and Aerosols by Liquid Chromatography–High-Resolution Mass Spectrometry. Chemical Research in Toxicology , 34(10), 2216–2226. Link
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Home — Essay Samples — Nursing & Health — Smoking — Vaping: All You Need to Know about this Trend
Vaping: All You Need to Know About This Trend
- Categories: Smoking
About this sample
Table of contents
Hook examples for vaping essay, vaping essay example.
- The Rise of Vapor: Step into the world of vaping and explore how this modern trend has taken the world by storm, reshaping the way people consume nicotine.
- Invisible Dangers: Uncover the hidden health risks lurking behind the enticing flavors and billowing clouds of vapor, as we delve into the alarming consequences of vaping.
- The Marketing Maze: Discover the strategies employed by vaping companies to target a new generation of users, and how the industry's advertising tactics have raised ethical concerns.
- Teen Epidemic: Examine the startling rise in teenage vaping and the impact it has on adolescent health, education, and society as a whole.
- A Path to Quit: Explore the potential vaping holds as both a smoking cessation tool and a harm reduction method, considering the debates and challenges surrounding this approach.
It’s All about Vaping
Vapers” community, vaping a fashion, vaping business.
- House of Vapes
- Prohibition Vapes
- Vape & Juice
- The Wheatsheaf
- Prospect of Whitby
What’s the Final Point?
- Cooper, R. (2018). Skipping a Beat: Assessing the state of gender equality in the Australian music industry. University of Sydney.
- Hibberd, J. (2020, March 8). How Women Are Changing the Indie Rock Scene. Rolling Stone.
- LISTEN. (n.d.). About. Retrieved from https://www.listenlistenlisten.org/about
- McMahon, K. (2019, April 29). The Triple J Gender Imbalance Is Being Highlighted Again By Industry Experts. Junkee.
- Merritt, S. (2019, October 3). Where are all the women in music production? Sydney Morning Herald.
- Music Industry Observer. (2021, January 25). How COVID-19 Has Impacted Women in the Music Industry. Music Industry Observer.
- O'Connor, R. (2018, March 8). International Women's Day: Meet the women trying to change the face of the Australian music industry. ABC News.
- Rogers, K. (2018, November 21). An In-Depth Look at the State of Women in the Music Industry. Mixmag.
- Triscari, C. (2020, December 1). The music industry is finally waking up to its diversity problem. NME.
- UN Women. (2015). Gender Equality and the Music Industry. UN Women.
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190 Smoking Essay Topics
🏆 best essay topics on smoking, 👍 good smoking research topics & essay examples, 🌶️ hot smoking ideas to write about, 🎓 most interesting smoking research titles, 💡 simple smoking essay ideas, 📌 easy smoking essay topics, ❓ research questions about smoking.
- Should Smoking Be Illegal? The ban on smoking is a very hard step to be undertaken especially when the number of worldwide users is in billions. Attempts by some nations to do this have often been met with failures.
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- Cigarette Smoking Role in Public Health Cigarette smoking produces little marginal social benefits. This paper provides an insight into the debate surrounding cigarette smoking and public health.
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- Banning Public Smoking The essentiality of the essentiality of this paper is to explore the effects of public smoking and provide arguments that will lead to the prohibition of public smoking.
- Anti-Smoking Poster Visual Analysis in Advertising This discussion presents a visual analysis of an anti-smoking poster that explores usage of words, images, colors, settings, and layout to deliver message to the audience.
- Smoking Cessation and Depression It was estimated that nicotine affects the human’s reward system. As a result, smoking cessation might lead to depression and other mental disorder.
- Relationship between Asthma and Smoking The relationship between asthma and smoking explains why many adults who develop asthma past their 50th birthdays often have a history of smoking tobacco.
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- Smoking Hazards and Cessation Benefits in the US In the article on smoking-related hazards, the reference to the measurements made by national healthcare representatives to define the benefits of smoking-cessation.
- E-Cigarettes Smoking: Threat or Solution? Nowadays, the new challenge looms on the horizon – the introduction of electronic cigarettes. There are many views on vaping, smoking e-cigarettes, both positive and negative.
- Asthma Incidence and Smoking among African Immigrants in California This paper explores the association between asthma incidence and smoking among African immigrants in California.
- Asthma and Smoking Among Adult African Immigrants This study explores the association between asthma and smoking status among adult African immigrants in California using a quantitative correlational approach.
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- Tobacco and E-Cigarettes Smoking: Negative Effects Cigarette smoking is well known to have diverse health effects on humans, include chronic obstructive pulmonary disease, stroke, bronchitis and heart attack.
- Asthma Incidence and Smoking among Immigrants in California This paper analyzes relationship between smoking behaviors and asthma cases in states or regions that have multiple immigrant population groups, such as New York and California.
- Nursing Interventions for Smoking Cessation The article “Nursing Interventions for Smoking Cessation” aims to investigate the effectiveness of nursing-initiated interventions. The authors are the nursing professionals.
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- Primary and Seconary Smokers’ Health Implications Primary smokers are people who smoke directly while secondary smokers are people who inhale smoke released by other smokers.
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- The Relationship Between Asthma and Smoking This study explores the relationship between asthma and smoking among adult African Immigrants in California that are a relatively understudied group.
- Indoor Smoking Ban: Study Methodology The issue of whether or not the United States should pass a nationwide ban on indoor smoking is one that has managed to elicit a lot of debate.
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- Lowering Drinking and Smoking Age in the U.S. Some scholars indicate that lowering the minimum legal drinking age from 21 to 17 years will help to limit the number of negative consequences faced by young adults.
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- Introduction of New Legislation Regarding Smoking in Miami-Dade County Florida Health Department identifies three major risk factors of heart disease: high cholesterol, high blood pressure, and smoking.
- Acupuncture for Smoking Cessation: Research Process People want to know if acupuncture may be regarded as an effective method for smokers to quit this harmful habit considering that numerous past attempts were taken in vain.
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Home / Essay Samples / Nursing & Health / Addictions / Smoking
Why Vaping is Bad for You and Dangers of Vaping for Your Health
Nursing & Health , Sociology
Oncology , Addictions , Sociology of Generations
Cancer , Smoking , Teenagers
- Words: 2605 (6 pages)
Please note! This essay has been submitted by a student.
Table of Contents
Introduction, research: is vaping healthier than smoking, the dangers of vaping.
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Tips for talking to your teen about vaping
Set clear expectations and listen carefully.
Talking with your children about the dangers of vaping can help prevent long-lasting health problems.
Vaping nicotine or marijuana can cause long-lasting health problems for your child. So, it's important to talk with your young or teenage children about the potential dangers of vaping.
Here are some helpful tips:
- Know the facts. Be ready to answer questions your teen may have. Ask for help from your health care provider on how to talk to your teen or have your teen talk to a trusted adult.
- Have a natural discussion. Ask your teen what they think about vaping in a TV show, movie, or ad or about someone you both see vaping. Then see where the conversation goes.
- Be a good listener. Have open conversations about drug, alcohol, and tobacco/nicotine use. Talk with your teen often, but try not to lecture. Focus on how much you care about their health. Explain the potential harmful effects of tobacco/nicotine, marijuana, and vaping chemicals on the brain and lungs.
- Set clear family rules and expectations. For instance, try to establish real consequences for breaking drug and alcohol rules.
- Get to know your teen's friends and their parents. Help your teen deal with peer pressure to use vapes. Monitor and supervise your teen's activities. Talk with other parents to make sure you are on the same page about rules.
- Lead by example. If you vape or smoke traditional cigarettes, try to quit.
Source: National Institute on Drug Abuse
September 24, 2020
Health Fast Facts
More than 60% of teens say they vape to experiment and see what it's like.
Explore More on MedlinePlus.gov
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Teen vaping research is a priority as marijuana and nicotine use surge
Vaping has led to a dramatic rise in nicotine and marijuana use among young people in recent years. Marijuana vaping...
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Vaping and Its Negative Aspects Essay
Introduction, attention-arousing and orienting material.
Vaping has become a curse of the recent decade. Vapes are better than nicotine-containing cigarettes. Vapes do not harm the health of a smoker. Vapes are about vaping, not smoking. As one popular vape-producing company puts it, “live long and vape strong”. It seems that vapes create a new reality in which smoking could be safe. Well, what if I say that, in the US, in one week 12 people died because of vaping and 805 people were diagnosed with the breathing illness related to vaping (Pesce par. 1). If these statistics are not enough to give up vaping, the goal of the current speaker is to persuade that vapes are not as warm and fuzzy as companies want us to believe.
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Vaping is regarded as an escape for smokers who try to give up their addiction since the latter could substitute the former. Still, there are numerous sources that vaping is a decent and safe habit. The argument against vaping is backed by the results of the researches, the viewpoints of medical experts, and the experience of vapers. The importance of this topic is undeniable since even underaged people become addicted to vapes.
Vaping has numerous devastating effects and did not worth doing.
Preview of main points
There are two major reasons to give up a habitude of vape. Firstly, vaping is addictive and undermines the ability to self-control. Secondly, usage of a vape, even if it is nicotine-free, poses a health hazard and leads to diseases of the respiratory system.
Vaping is addictive
It is a well-known fact that there are numerous kinds of vaping liquids. They have various chemical compositions, tastes, and smells. Some of them might contain nicotine, while others are free of it. The problem is that vaping causes addiction in any case.
One of the reasons for this is that vapes are regarded as tools to socialize and make new acquaintances (Levin par. 21).
In essence, new friends and a higher circle of socialization is positive outcome of vaping.
However, the issue lies in the fact that young people that are shy to make friends, for instance, during classes, start vaping to fit in with the team.
- Vice versa, if an individual intends to give up vaping, he or she might postpone this idea because of the fear to distance herself from the friends who use vapes.
- In the interview with the 21-years old man, Levin illustrates how strong the addiction might be (par. 16). Josh Evans avows that he inhales the vapors even though sometimes it makes him feel physically bad and fail to fight against vaping (Levin par.16).
- The final point worth being mentioned is that addiction to vaping leads to more serious addictions in the long-term perspective.
In two years, the number of young adults using vaping cartridges with the flavor of cannabis or nicotine increased more than twice (Pesce para.2).
According to the President of the Campaign for Tobacco-Free Kids, Matthew Myers, people that become addicted to vapes or e-cigarettes at a young age, grow into heavily smoking adults (Lemons 17).
(Transition: The fact that vapes triggers addiction would not be that important if it were not for the health hazard.)
Vaping is dangerous for health
Blaha informs that all lung fluid samples of people ill with “e-cigarette, or vaping, product use associated lung injury (EVALI)” show the presence of vitamin E acetate (par 6.).
From this, it could be inferred that vaping liquids contain chemicals that cause diseases of the respiratory system. Thus, even nicotine-free vapes could have a devastating effect on health.
Another point of concern about vaping is that hitherto remains a lot of doubts about how certain chemicals in liquids affect health (Blaha par. 9). Nevertheless, some studies confirm that vaping leads not only to asthma but also to cardiovascular disease (Blaha par.9).
Therefore, it could be argued that vaping remains an insufficiently studied phenomenon. The absence of a clear understanding of the consequences of vaping, as well as PR campaigns of brands that produce vapes and liquids, give a reason to think that vaping does not affect health. At the same time, the growing number of young people with breathing diseases makes them think that vaping is not as good as it might seem at the first sight.
(Transition: As you can notice, vaping has a significant number of disadvantages that should motivate people either not to try it or give up the habit.)
Vaping is not only addictive but also challenges the well-being of a vaper. In the scientific community, there is no common opinion on the effect of the chemicals that are included in the composition of vaping liquids. Notwithstanding this fact, the example of people diagnosed with EVALI proves that vaping represents a threat and that life would be better without this addiction.
Still, it is important to remember that our health and quality of life depend on our own choices. Vapes were not created by nature and human beings survived for centuries without smoking and vaping. I will leave you with the question: if the necessity to vape was not put in our bodies and minds by nature, do we need it?
Blaha, Michael Joseph. “5 Vaping Facts You Need to Know.” Health Conditions and Diseases , 2020. Web.
Lemons, Jane Fullerton. E-Cigarette Dilemma . CQ Press, 2019. Web.
Levin, Dan. “Vaping on Campus: No Parents, No Principals, a Big Problem.” The New York Times , 2019. Web.
Pesce, Nicole Lyn. “These Charts Show the Shocking Number of High School and College Students Who Vape.” Market Watch , 2019. Web.
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