The commercial success of e-cigarettes and the understandable concern about their popularity with youth make a balanced assessment of medical risks challenging. Researchers have increasingly been providing information that helps in that assessment.

Problematic use

On the clearly problematic side, e-cigarettes have triggered a reversal of the steady decline in nicotine use by youth. Having moved away from tobacco cigarettes, youth have been drawn to the use of e-cigarettes. The Monitoring the Future project at the University of Michigan documented the dramatic rise in use by high school students from 2017 to 2020. The negative attention that this generated contributed to a reduction in use in the subsequent two years. The U.S. Food and Drug Administration, having recognized the important contribution of sweet flavoring to e-cigarette popularity, succeeded in limiting their use in some but not all types of vaping devices.

Even at the lower rates, vaping nicotine use remains the most common drug used by 8th and 10th graders. Its use is even more prevalent among 12th graders, although for them it is surpassed by alcohol.¹ Concern about this trend is magnified by increasing evidence that nicotine can act as one of the “gateway drugs” increasing the risk of later opioid use and other addictions. (Learn more about vaping and youth.)

Uncertainties around potential harm reduction

When looking at the arguments for e-cigarettes as agents of harm reduction, the interpretation of the data is more complex. The international public health community is divided about whether to recommend that cigarette smokers shift to vaping. While the Centers for Disease Control and Prevention (CDC) in the U.S. maintains that there is not enough data to make such a recommendation, the National Health Service (NHS) of the U.K. looks at the same data and disagrees strongly with the CDC. Unlike the U.S. and Canada, the NHS actively encourages smokers to vape and provides vaping devices at no cost. Australia has another approach – vaping devices are only available by prescription. In some countries, vaping devices are banned entirely.

The harm reduction disagreement is further complicated by the tobacco industry having entered the e-cigarette market. Their history of skillfully misrepresenting the dangers of tobacco understandably raises concerns that they will apply their promotional expertise to vaping devices. Dr. Joanna Cohen, Professor of Disease Prevention at the Johns Hopkins Bloomberg School of Public Health, has produced a video cautioning professionals in the field to be careful to avoid language which implicitly downplays the danger of vaping.

Finally, there is a potentially positive aspect to e-cigarettes – that vaping devices could be used therapeutically. In 2022, a Cochrane Review concluded that there is “high-certainty evidence” that e-cigarettes were superior to traditional nicotine replacement therapy such as patches, gum, and lozenges in assisting tobacco users to discontinue nicotine use entirely.² However, the difference was only an additional 4 people who quit among 100 participants, and authors noted that the small number of randomized trials available posed a significant limitation in the review. Additional studies are underway examine the use of e-cigarettes for nicotine cessation.

What has not yet emerged are satisfactory models of effective treatment intervention. Youthful users have been disinclined to accept professional help in their efforts to stop vaping. Further exploration in this vulnerable population is sorely needed.

Learn more about E-cigarettes and Vaping and resources to help quit.

Image: Istock photo, credit Liudmila Chernetska