Globally, tobacco kills 8.2 million people per year.¹ Of those preventable deaths, 7 million people who die are direct users of tobacco products. The remaining 1.2 million preventable deaths come from exposure to secondhand smoke.

A modern version of the old-fashioned cigarette is attracting smokers into a new era of nicotine use. Electronic cigarettes, also known as e-cigs or electronic nicotine delivery systems (ENDS), were introduced in Europe and the United States in the mid-2000s. Since then, they have been marketed as a safe alternative to smoking. E-cigs have even been promoted as a cessation tool.

But a growing body of research finds that while e-cigarettes contain fewer harmful elements than tobacco, they’re far from being a healthy alternative to smoking. Evidence suggests that e-cigarette use is actually a threat to public health.

Smoking versus vaping

A traditional tobacco cigarette is ignited by fire at one end and then allowed to smolder. Smoke from the smoldering tobacco is inhaled through a paper tube and passed into the body through the airways and lungs.

Tobacco smoke contains tar, nicotine, and 7,000 chemicals, over 70 of which the Canadian and U.S. governments identify as cancer-causing.^2,3 The chemicals are almost immediately absorbed into the bloodstream, and 70 percent of the inhaled tar sticks to the throat and lungs, killing healthy lung cells.

Tar damage narrows the small tubes in the lungs, or bronchioles, which absorb oxygen. Tar also damages the small hair-like projects, or cilia, that clean up dirt and debris in the airways.⁴

Tobacco smoke also produces fine particle matter pollution, or PM2.5. Even short-term exposure to PM2.5 can result in breathing difficulties.^5,6 Exposure to PM2.5 resulted in 160,000 deaths in the world’s five most populous cities in 2020.

Smoking presents numerous, potentially fatal health threats to the body, including:

• carbon monoxide exposure
• increased asthma attacks
• heart disease
• pneumonia and respiratory infection
• stroke
• chronic obstructive pulmonary disease (COPD)
• emphysema
• cancer

Instead of burning tobacco, e-cigs use a battery-operated heating element to turn a nicotine solution into a vapor that users inhale. The solution, or “juice” as users call it, contains propylene glycol and vegetable glycerin. It also contains chemical flavorings and food preservatives.⁷

While e-cigarettes are the product sold to users, “vaping” refers to use of e-cigarettes. Because e-cigarettes don’t produce smoke or contain tobacco, users vape rather than smoke e-cigarettes.

E-cigarettes are not safe

Currently, evidence suggests that e-cigarettes may be somewhat safer than regular cigarettes. Since nothing is burned in the process, e-cig vapor lacks the tar and carbon monoxide found in cigarette smoke. Most of the 7,000 chemicals in cigarette smoke are also missing from e-cig vapor.

However, e-cigarettes are far from safe.

E-cigarette users do inhale chemicals that are known to be toxic and, in some cases, carcinogenic. When heated, ingredients in the nicotine solution can turn into formaldehyde, a volatile organic compound (VOC) known to cause cancer. Newer e-cigs allow users to adjust the temperature to a point where the formaldehyde level can be as high — or even higher — than in traditional cigarettes.^8,9

A 2013 study published in PLOS ONE has also found that the vapor can include chemicals released by the devices themselves.¹⁰ These include:

• silicate particles
• aluminum
• lead
• tin
• silver
• nickel
• iron
• chromium

Not a cessation tool

When e-cigs first hit the U.S. market, some advocates viewed them as a way for smokers to wean themselves off of traditional cigarettes. However, the FDA has not approved e-cigarettes as a safe or effective way to quit smoking because it exposes users to several of the same toxic chemicals found in traditional cigarettes.¹¹

A 2020 study published in Addictive Behaviors found that participant smokers from the United Kingdom who use e-cigarettes are no more likely to succeed than those who didn’t. When compared with nicotine replacement therapy participants, e-cigarette users were also no more likely to quit smoking.¹²

In fact, e-cigarettes may be having the opposite effect.

For example, the Centers for Disease Control and Prevention (CDC) found that more than a quarter of a million young people who had never smoked traditional cigarettes used e-cigs in 2013.¹³ This was three times as many as in 2011. And nearly half of those young people said they have intentions to smoke traditional cigarettes within the next year.

Vaping’s second-hand dangers

Just as with cigarette smokers, e-cig users aren’t the only ones who should be concerned about exposure to toxic chemicals from vaping.

A 2013 study conducted by the Bavarian Health and Food Safety Authority concluded that secondhand vapor released detectable levels of nicotine, particulate matter, chemicals, and metals into the air.¹⁴

While the levels are lower than those found in secondhand tobacco smoke, any amount of these toxic compounds puts the health of non-users at risk.

Does vaping pollute the air?

When it comes to indoor air quality, it may seem like vaping is a “cleaner” alternative to tobacco smoking. But a 2020 study published in Indoor Air concluded that e-cigarette air pollution is a “significant source of indoor pollution.”¹⁵

The liquids vaporized in an electronic cigarette are heated and then inhaled. Aerosols are emitted from an e-cigarette from both exhaled breath and unintended emissions from the device. These aerosols include propylene glycol and glycerol, the visible clouds of exhaled vapor.

Vapor, once supersaturated in respiratory air, becomes fine and ultrafine liquid particles. Supersaturation, when a substance in a solution exceeds the amount needed for saturation, raises PM2.5 and ultrafine (UFP) pollution concentrations in an enclosed space. The World Health Organization recommends limiting exposure to PM2.5 to less than 10 microns per cubic meter (μg/m³), no amount of exposure to PM2.5 is safe.

A 2014 scientific review published in Circulation supports the concern that vaping delivers high levels of nanoparticles.¹⁶ These tiny particles are able to enter the lungs’ smallest airways. They cause inflammation linked to asthma, stroke, heart disease, and diabetes.

As a result, researchers are finding diminished lung function, airway resistance, and cellular changes in e-cigarette users. Even the lungs of users who used nicotine-free juice showed airway resistance and other signs of inflammation.

Calls for regulation

In an effort to prevent a repeat of the public health crisis caused by traditional cigarettes, groups including the American Lung Association and the WHO have called for the regulation of e-cigs.^17,18 These organizations are demanding that e-cigs be subject to the same rules and regulations as traditional cigarettes and that governments discourage consumption of both tobacco and e-cigarettes.

Regulatory efforts include banning the use of e-cigarettes anywhere that cigarette smoking is not allowed. It also means outlawing fruit- and candy-flavored e-cig juice, which they feel are marketed directly to children and young adults, and strictly enforcing youth access age restrictions.

E-cigarettes were regulated or banned in 100 countries as of 2020.¹⁹ An estimated 18 countries effectively ban the sale of e-cigarettes, including:

• Argentina
• Brazil
• India
• Syria
• Thailand
• Uganda

Egypt, Mexico, and Turkey ban e-cigarette sales, but their policies are either being changed through legislation (Egypt), have been overturned in courts (Mexico), or are inconsistent with other laws (Turkey).

In 2020, the United States signed into law a bill which increased the minimum age of sale for all tobacco products, including e-cigarettes, to 21. In that same year, The U.S. Food and Drug Administration issued an enforcement policy on flavored cartridge-based e-cigarette products.²⁰

The takeaway

E-cigarettes aren’t a healthy or effective alternative for smoking cessation. Apart from putting the health of the user at risk, e-cigarettes pose secondhand health risks and degrade indoor air quality.

To best protect against the potentially harmful health effects of e-cigs, consider taking the following actions:

• Avoid both first- and secondhand exposure to e-cigarette vapor.
• Instead of using e-cigs as a means to quit smoking traditional cigarettes, consult a doctor or quit coach when deciding on cessation tools or methods. These may include over-the-counter medications such as gums, lozenges, and patches as well as prescription drugs such as pills, nasal sprays, and inhalers.
• Contact your political leadership and voice your support for further regulation of e-cigarettes.
• If someone in your home vapes indoors, consider running an air purifier for vaping or a high-performance air purifier with an optional gas and odor filter included.
• If someone in your home also vapes and drives, run a car air purifier to reduce exposure to pollutants in your car.