Clearing the air about the harms of vaping and e-cigarette use among youth and adults
by Rachael Joyner, DNP, FNP-BC, Duke Smoking Cessation Program
Working in tobacco treatment, I get asked about e-cigarettes all the time. Patients, colleagues, even family members have a lot of questions.
“Are e-cigarettes a good way to quit smoking?” or “Does vaping cause health problems?”
Here is what I share with people who ask me about e-cigarettes.
Addiction: E-cigarettes are just as addictive as cigarettes. In fact, nicotine dependence scores are slightly higher in e-cigarette users.
Harm: Evidence shows that e-cigarette vapor has lower toxin levels than tobacco smoke. Studies also show that switching from smoking to an e-cigarette leads to improvements in lung function. However, e-cigarettes do cause harm—just less harm than smoking. There are some studies suggesting that dual use of both cigarettes and e-cigarettes leads to increased toxin exposure. Long-term studies are needed to understand the long-term harms of e-cigarette use.
Quitting Smoking: Large meta-analyses now show that under medical supervision, e-cigarettes are effective for stopping or reducing smoking. However, most people who use an e-cigarette to quit smoking become addicted to e-cigarette use. It is best to try to quit smoking by using FDA-approved medications. E-cigarettes are not an FDA-approved treatment for smoking cessation. They are a tobacco product sold by tobacco companies.
The number of patients I’m seeing for help with e-cigarette use has gone up exponentially in the last few years. Some of these are people who never smoked cigarettes and who picked up vaping in their teens or early 20s. Others are people who have smoked cigarettes for many years and who have tried to quit smoking using an e-cigarette. Now they cannot stop vaping, and some are smoking and vaping together.
Here is a deeper dive into some of the current research and data on e-cigarette use in the U.S.
E-cigarettes are the most commonly used tobacco product among youth.
In September, the US Food and Drug Administration (FDA) and Centers for Disease Control and Prevention (CDC) released findings from the 2024 National Youth Tobacco Survey (NYTS) on e-cigarette and nicotine pouch use among U.S. youth. While youth e-cigarette use dropped for the first time in recent history – from 2.13 million (7.7%) in 2023 to 1.63 million (5.9%) in 2024 – e-cigarettes are still the most popular tobacco product used by youth. In fact, e-cigarettes have been the top tobacco product used by youth since 2014.
Let that sink in a minute. For the last decade, millions of middle and high school students have been introduced to a highly addictive tobacco product, who maybe would never have smoked a conventional cigarette. With attractive fruit flavors, increasing levels of nicotine in these devices, and misinformation about the true health harms of e-cigarettes abounding, it is no wonder e-cigarette use continues among youth and young adults.
Between 2017 and 2022, disposable e-cigarettes nearly tripled in nicotine strength, quintupled in e-liquid capacity, and dramatically dropped in price. This is troubling because the nicotine in e-cigarettes is addictive and harmful to developing human brains—linked to issues with learning, memory, and emotional regulation. Additionally, youth who use e-cigarettes are three times more likely to become daily cigarette smokers as adults, according to a recent large study.
E-cigarettes are harmful for health.
E-cigarettes do not just create a “harmless water vapor.” Evidence is mounting, including from a recent American Heart Association report, that e-cigarettes cause damage to the cardiovascular system and lung tissue, leading to conditions like heart failure, high blood pressure, heart attacks, and increased asthma exacerbations. Besides being addictive, nicotine is also a sympathetic nervous system stimulant. It raises blood pressure and can lead to abnormal heart rhythms. Nicotine is also harmful for pregnant women and fetuses, increasing the risk of preterm labor and lung and brain development issues.
Though e-cigarettes contain fewer chemicals than a conventional combustible cigarette, there are harmful substances in the aerosols created by these devices. These chemicals not only cause harm to those who use e-cigarette but also the people nearby exposed to the e-cigarette smoke. These chemicals include heavy metals, such as lead and nickel—produced form the hardware used to heat the e-cigarette liquid. The liquid itself contains propylene glycol and glycerol, which create toxic compounds when heated—formaldehyde, or embalming fluid, is one example.
There are also more than 7,000 different flavors used in e-cigarettes. While these are considered generally safe as a food additive, most have not been studied as an inhaled product. A few studies looking at flavors, such as vanilla, have shown that they are at best respiratory irritants and at worst cause tissue damage. Then, of course, there are conditions such as popcorn lung, known to be caused by diacetyl, a buttery-flavored chemical additive. One 2015 study examining 51 different products sold by leading e-cigarette brands found that almost 92% of e-cigarettes tested contained diacetyl or similarly harmful chemicals.
More long-term studies are needed on the impact of e-cigarettes and health, but short-term studies do show harmful health consequences.
Photos below show (L to R) normal lungs, popcorn lung, and lungs with Vaping-Associated Pulmonary Injury (EVALI).
E-cigarettes are not an FDA-approved method to quit smoking.
There are currently seven FDA-approved medications for smoking cessation: varenicline (formerly Chantix), bupropion, nicotine patch, and short-acting nicotine replacement (gum, lozenges, inhaler, and nasal spray). E-cigarettes are not FDA-approved for smoking cessation. While some research has shown that people using e-cigarettes have higher quit rates when compared to products like nicotine patches, the issue remains that the majority of people who used an e-cigarette to quit smoking combustible cigarettes continue to smoke e-cigarettes. They have basically traded one tobacco product for another, and, in some cases, deepened their nicotine addiction. A great example of this is a randomized controlled trial from 2019 comparing nicotine replacement to e-cigarettes for smoking cessation. While the abstinence rate was higher in the e-cigarette group at 12 months, 80% of the e-cigarette users were still using their e-cigarettes.
Research has shown that in self-directed smoking quit attempts, e-cigarette use does not increase smoking abstinence rates. The majority of self-directed quit attempts lead to dual use, which is when someone continues to smoke some combustible cigarettes while also using an e-cigarette. I see this in my practice a lot. This is concerning, considering that almost 89% of daily e-cigarette users reported using e-cigarettes as a way of cutting down on cigarette smoking. Authors from another study published in 2022 that used national data from the large Population Assessment of Tobacco and Health (PATH) Study concluded that “in a real-world scenario, dual e-cigarette and cigarette use may hinder rather than facilitate smoking cessation among those interested in quitting.”
I think it’s also worth mentioning that the majority of e-cigarettes being used by people are flavored e-cigarettes. None of these have been studied or approved by the FDA. To date, the FDA has only authorized 34 e-cigarette products and devices – all tobacco or menthol flavored – to be officially marketed and sold in the U.S.
To learn more about e-cigarette use and how to help patients quit, check out one of our upcoming trainings:
Comprehensive Tobacco Treatment Specialist Training Program (offered three times per calendar year)
Tobacco Treatment in Adolescent and Young Adult Populations CE Short Course (offered January 14, 2025)
Visit www.dukeunctts.com for more information or to register.
About the Author
Rachael Joyner, DNP, FNP-BC, APRN, is a family nurse practitioner with the Duke Smoking Cessation Program. She holds a National Certification in Nicotine and Tobacco Treatment and received her Doctorate in Nursing Practice from the University of Florida. She loves working collaboratively with patients to help them become tobacco free.
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