Doctor’s Note: Blazin’ A Trail — E-cigarette Use in the U.S.

E-cigarettes. Vapes. Juuls. Pens. Pod-Mods. Elf Bars. Electronic nicotine delivery systems (ENDS). There are so many different names, it can make your head spin. The U.S. government uses the term “e-cigarette or vaping products” for all of the above.

No matter what you call them, these devices are small, widely available, and have clear advantages over cigarettes. They don’t require a lighter, their vapor is far cleaner and less pungent than smoke, and they don’t leave behind a dirty fire hazard of a butt.

Vape products have greatly increased in popularity over the past decade, with weekly U.S. sales tripling from 7.7 million in 2014 to 22.7 million in 2022 with a projected annual revenue of $8.8 billion. This is still a far smaller market than traditional cigarettes, which sold 723 million monthly packs for $82.7 billion. However, vape use has greatly surpassed cigarette use in middle- and high-school-age children. As those children grow up, it’s plausible that vaping will eventually surpass smoking as the most popular tobacco product.

Part of the reason that vapes are so popular in schools is that they’re discreet. You couldn’t light up a cigarette in the middle of class, but you can sneakily puff a vape without the teacher noticing. Some vapes are designed to look like a pen or a marker so that they’re even easier to sneak. The FDA has even banned some vapes for looking like “youth-appealing” drinks or toys.

These factors have led to vapes being the most common way that youths are first exposed to nicotine. Nicotine is a powerful stimulant, it’s addictive, and like other psychoactive drugs it is more harmful to immature brains than to adults. There’s evidence that nicotine exposure in adolescence, whether through cigarettes or vapes, increases the risk of a variety of learning disorders and mental illnesses.

Kids should not vape, and I support the anti-youth-vaping efforts of organizations like the American Lung Association, Truth Initiative, Tobacco-Free Kids, and others.

That said, many people are interested in using vaping as a form of harm reduction. If we could convince cigarette smokers to switch to vapes, maybe it would decrease the burden of smoking-related disease such as heart attacks, strokes, and lung cancer. It certainly seems plausible that vapor should be less toxic than smoke. Vapor doesn’t stain clothes, upholstery, or ceilings. It’s far less irritating to the throat and the eyes. Surely this means vaping is a healthy alternative to smoking, just like nicotine patches and gums. Right?

Not so fast. While vapes do not produce tar or soot, they can sometimes expose their users to toxic carbonyl compounds like formaldehyde and acetaldehyde at a level comparable to combustible cigarettes. The chemical composition of vapor can change based on the device’s power settings, the condition of the coil/wick, how hard you puff, how often you puff, how much liquid is left in the tank, etc. Some vape devices have less reliable temperature and power control than others, especially disposable “pod-mods,” and device overheating correlates with higher carbonyl emissions.

And then there’s the question of flavorings and additives. Vape liquid comes with a far wider variety of flavors than combustible cigarettes. Many substances that are perfectly safe to ingest can be highly toxic when inhaled. And unlike nicotine gums or patches, vape liquid is not regulated as a drug. Manufacturers can change its formulation without formal safety testing of each component. So, when you puff on a flavored vape, you’re doing an uncontrolled clinical trial on yourself.

In 2019, 64 vape users were killed and nearly 3,000 hospitalized in the E-cigarette or Vaping Associated Lung Injury (EVALI) outbreak. EVALI was eventually traced to the presence of Vitamin E Acetate in vape cartridges. Nobody could have predicted that it would cause such severe lung injuries, because no one was inhaling large quantities of Vitamin E prior to its inclusion in vapes. Now that we know, it’s not allowed in vapes. But it’s possible for some other food-grade components to cause lung injury in the future.

Ultimately, the human lung isn’t meant to breathe anything other than air and water vapor. Anything else we put in there is a health risk. Neither smoking nor vaping is safe, and as a physician I recommend you don’t do it.