E-cigarette use is a health concern, but long-term consequences remain unknown

Recently, I happened to take a route home that led me through my local high school as the students were dismissed for the day. There was some traffic because of dismissal as students traveled home in their vehicles or were picked up by parents/guardians. As I inched along the path to the main road, the car ahead of me was being driven by a student, and I noticed he was vaping. With two small kids, I don’t get the privilege of observing teenagers too often, so it made me pause a bit to witness this. When I think back to my high school days, cigarette smoking was one of the salient issues with youth and substance use, and there were huge campaigns to limit tobacco use among adolescents. I was all too familiar with the D.A.R.E (drug abuse resistance education) program at every step of my education as an adolescent! But today, cigarette smoking is less common among adolescents than nearly 20 years ago.

As a cardiovascular epidemiologist, I’m aware of the available evidence and conflicting messages we receive about the costs and benefits of e-cigarette use among adults. But what is the message for youth? Is vaping as addictive as cigarettes, and does it offer similar health threats? And if so, are there programs in place to limit vaping? One thing is for sure, compared with our knowledge and evidence on decades of cigarette smoking, e-cigarette use and vaping research are still in their infancy, but a more explicit message is making its way through all the vapors.

The increasing use of electronic cigarettes (e-cigarettes or electronic nicotine delivery systems (ENDS)) and vaping products among youth continues to be recognized as a significant public health challenge. Severe cardiopulmonary disease and related deaths have been associated with the use of electronic cigarettes. To emphasize the importance of stronger public health policies and guide therapeutic strategies on the short- and long-term risks of vaping, the recent AHA scientific statement provides background on the cardiopulmonary consequences of e-cigarette use (vaping) in adolescents. Vaping may pose longer-term health threats like nicotine addiction and cardiopulmonary damage.


Figure 1. What is in E-cigarette Aerosol? CDC: https://www.cdc.gov/tobacco/basic_information/e-cigarettes/Quick-Facts-on-the-Risks-of-E-cigarettes-for-Kids-Teens-and-Young-Adults.html

Vaping involves heating a liquid — typically containing nicotine or cannabis, flavorings, and other substances and additives — to produce an aerosol inhaled through a battery-powered device. E-cigarettes have grown into a multi-billion-dollar industry since entering the U.S. market in 2007 as a potential smoking cessation tool. Still, they also appealed to youth – with fruity flavor additives and nicotine salts, making it less harsh on the throat and easier to use by adolescents. Over the years, e-cigarette use among US teenagers showed a 19% increase between 2011 and 2018. Vaping is still prevalent among adolescents, but we have seen a decline in 2019, some of which may be due to reduced access or disease-related concerns during the COVID-19 pandemic. The Centers for Disease Control and Prevention (CDC) reports that in 2020, at least 3.6 million US youth, including about 1 in 5 high school students and about 1 in 20 middle school students, used e-cigarettes in the past 30 days. Notably, public health has made significant strides over the past decade in lowering the prevalence of cigarette smoking among adolescents to its lowest rates in history – fewer than 6% of high school students have smoked a cigarette in the past 30 days, and fewer than 3% report being daily users. Although the benefits won’t be realized for about 30 years, this accomplishment is enormous and portends reductions in smoking-related disabilities and death for generations to come.

On the other hand, the big question is whether e-cigarettes and vaping will have a deleterious effect on youth. In November 2019, we saw the impact of acute vaping-associated lung injuries and confirmed vaping-related deaths linked to vitamin E acetate – a chemical additive in the production of e-cigarette products. These events warned that additives could be involved in adverse health effects of vaping. Besides nicotine, vaping liquids contain vegetable glycerin and propylene glycol, which are on the FDA’s generally recognized as safe (GRAS) list. However, these components were not evaluated for inhalation toxicology. Like vitamin E acetate, these GRAS components may be associated with adverse health outcomes once inhaled. Thus, the long-term effects of vaping on the lungs in youth and young adults are worrisome and need to be better understood.

Studies have found higher rates of wheezing, greater prevalence of asthma, and increased incidence of respiratory disease in youth who were e-cigarette users. Among young adults, e-cigarette use is associated with higher arterial stiffness, impaired endothelial function, increased blood pressure, heart rate, and sympathetic tone, increased levels of oxidative stress biomarkers, and pro-inflammatory white blood cells that increase the risk of cardiovascular disease. Subclinical cardiopulmonary disease can likely start early in adolescence among youth who vape. Overall, lung development continues into the early 20s. Therefore, adolescents who vape are potentially stunting or altering their lung development, limiting their full lung function potential, and increasing their risk of pulmonary disorders.

Statistically, the population health risk of vaping-related disease among adolescents depends on the prevalence and frequency of vaping. Many adolescents experiment with vaping or may vape only occasionally or socially, conferring in possible low health risk. But as informed by evidence from cigarette use, vaping for 20+ days per month may suggest a degree of dependence and greater health risks. Youth may also multiply their risk by smoking other substances like marijuana. Collectively, continued research into the cardiopulmonary health consequences of vaping in youth needs to weigh the contribution of marijuana smoking or vaping with e-cigarette use.

Primary care and public health strategies should protect young people and limit unnecessary exposure.

The AHA scientific statement concludes with several major recommendations for reducing and preventing youth vaping:


  • Developing better measures to reduce youth access, including strict age verification at places of sale
  • Prohibiting the marketing of e-cigarettes to youth
  • Education of healthcare stakeholders, students, and their parents regarding realistic concerns about e-cigarette use

The recommendations do come with some controversy. Dr. Neal L. Benowitz mentions in his commentary of the scientific statement that “to limit access [among youth] could be even stronger if e-cigarette sales were limited to adult-only tobacco specialty stores.” He also offers that AHA’s recommendation to ban e-cigarette flavors, including menthol, is concerning because it would “reduce use by smokers wishing to switch, particularly since tobacco flavorings are constant reminders to former smokers of cigarette smoking.”

In conclusion, there is still plenty that we do not know yet about the effects of e-cigarettes and vaping on cardiopulmonary health. Evidence is building and suggests that efforts need to be taken to reduce possible long-term risks, especially for youth and those who were previous non-smokers. The evidence is not nearly as rich as the generations of work done to understand the harms of cigarette smoking. Still, clues taken from that long history help set the framework of the approaches and guidelines needed to protect public health. Although risk reduction is highly recommended, the evidence is still in its infancy. It is crucial to recognize that the science and guidelines regarding e-cigarettes and youth is a challenging process. The key to this process will be balancing the concerns about health risks to youth with the potential benefits of smoking cessation in adults.


Wold LE, Tarran R, Crotty Alexander LE, Hamburg NM, Kheradmand F, St. Helen G, PhD; Wu JC; on behalf of the American Heart Association Council on Basic Cardiovascular Sciences; Council on Arteriosclerosis, Thrombosis and Vascular Biology; Council on Hypertension; and Stroke Council. Cardiopulmonary consequences of vaping in adolescents: a scientific statement from the American Heart Association [published online ahead of print June 21, 2022]. Circ Res. doi: 10.1161/RES.0000000000000544




Fadus, M. C., Smith, T. T. & Squeglia, L. M. The rise of e-cigarettes, pod mod devices, and JUUL among youth: Factors influencing use, health implications, and downstream effects. Drug Alcohol Depend. 201, 85–93 (2019).




Lyzwinski, L.N., Naslund, J.A., Miller, C.J. et al. Global youth vaping and respiratory health: epidemiology, interventions, and policies. npj Prim. Care Respir. Med. 32, 14 (2022). https://doi.org/10.1038/s41533-022-00277-9

“The views, opinions, and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness, and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions, or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your health matters. If you think you are having a heart attack, stroke, or another emergency, please call 911 immediately.”


What Does Tobacco 21 Mean for Adolescent Tobacco Use?

We’ve come a long way from the Joe Camel commercials I remember watching as a kid on TV. As a culture, we’ve become a lot less tobacco friendly. Indoor smoking bans, stricter advertising restrictions (meaning no more cartoon characters advertising cigarettes), and other policies have been enacted to curb tobacco use across the country. Despite these changes, teen smoking is still a big problem.

In 2015, the Institute of Medicine reported that raising the legal age for using tobacco products from 18 years to 21 years would significantly decrease, delay, or differ adolescent tobacco use [1]. Just last month Congress decided to test this prediction by passing House Resolution 1865 – Further Consolidated Appropriations Act, 2020 which was subsequently signed into law by President Trump. This spending package includes an amendment to the Federal Food, Drug, and Cosmetic Act, raising the minimum age for purchase of tobacco products to 21 years [2]. This certainly signals a bipartisan effort to curb adolescent tobacco use, but only time will tell the lasting impact of this and other new policies.

Despite laws existing to restrict tobacco sales to adults, there is limited evidence of interventions able to achieve high levels of adherence with these laws [3]. In fact, a majority of smokers endorse first using tobacco products before being of age. While the is ample evidence that exposure to tobacco advertising is related to youth picking up smoking, there are no randomized clinical trials (RCTs) that assess the effectiveness of different advertising restrictions or bans on adolescent tobacco use [4]. What percentage of potential under-age smokers are deterred by age restrictions? What effect would increasing the tobacco tax have on youth sales? What effect could flavor restrictions have on youth smoking? One approach to better understand the health effects of possible tobacco legislation could be to incorporate RCTs into this new law’s implementation.

Last year the Nobel Memorial Prize in Economics was awarded to three researcher who used RCTs to better understand the effects of economic policies on people’s lives [5]. This approach to policy interventions has allowed developmental economists inform legislation aimed at alleviating poverty and its negative externalities. Using these same standards to assess the efficacy of policies aimed at preventing youth tobacco use could have a lasting impact on the health of our nation.

The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.


  1. Committee on the Public Health Implications of Raising the Minimum Age for Purchasing Tobacco Products; Board on Population Health and Public Health Practice; Institute of Medicine; Bonnie RJ, Stratton K, Kwan LY, editors. Public Health Implications of Raising the Minimum Age of Legal Access to Tobacco Products. Washington (DC): National Academies Press (US); 2015 Jul. https://www.ncbi.nlm.nih.gov/pubmed/26269869
  2. R.1865 – Further Consolidated Appropriations Act, 2020 (Subtitle E, Section 603: Minimum age of sale of tobacco products) https://www.congress.gov/bill/116th-congress/house-bill/1865/text#toc-H1CB3CAE840AA412285E15A86531C8446
  3. Stead LF, Lancaster T. Interventions for preventing tobacco sales to minors. Cochrane Database of Systematic Reviews 2005, Issue 1. Art. No.: CD001497. DOI: 10.1002/14651858.CD001497.pub2. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001497.pub2/information
  4. Lovato C, Watts A, Stead LF. Impact of tobacco advertising and promotion on increasing adolescent smoking behaviours. Cochrane Database of Systematic Reviews 2011, Issue 10. Art. No.: CD003439. DOI: 10.1002/14651858.CD003439.pub2. (Page 1, 12) https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD003439.pub2/abstract
  5. The Prize in Economic Sciences 2019. https://www.nobelprize.org/prizes/economic-sciences/2019/press-release/

Pharmacological Smoking Cessation Aides And Cardiovascular Safety

Pharmacological smoking cessation therapies have had their challenges. For example, varenicline previously had a US Food and Drug Administration black box warning regarding neuropsychiatric risks.

The EAGLES study, published 2016, was an industry sponsored, randomized, placebo-controlled trial of nicotine, varenicline, and bupropion that sought to address the neuropsychiatric risk profile of these medications.1 They randomized participants with and without known psychiatric comorbidities to these medications and found that these agents were not associated with an increased risk of neuropsychiatric adverse events. Further, the study found varenicline to be more effective than nicotine, bupropion, and placebo for smoking cessation.

The FDA black box warning for varenicline was removed. However, concerns regarding the cardiovascular safety persisted. Apart from abundant observational data on this topic, there have been several randomized trials as well. For example, in 2015, a randomized clinical trial of varenicline versus placebo for patients hospitalized with acute coronary syndrome demonstrated efficacy for cessation and did not raise a safety signal.2

Further, a secondary analysis of the EAGLES study regarding cardiovascular safety was recently published.3 They compared rates of major adverse cardiovascular events, and changes in blood pressure and heart rate, among participants randomized to placebo, varenicline, bupropion, and nicotine replacement. They found very low rates of major cardiovascular events and did not find differences between drugs. Of course, these were not patients with recent or significant cardiovascular comorbidities, so the results do not generalize beyond the general population of smokers.

There is thus mounting evidence for both the psychiatric and cardiovascular safety of pharmacological smoking cessation therapies. While it can be argued that an adequately powered safety trial in patients in acute and/or significant cardiovascular disease has yet to be performed, it may nonetheless be time to create gold standard cessation programs for patients with cardiovascular disease. It may be premature, however, to do the same for patients with cerebrovascular disease – more evidence may be needed.


  1. Anthenelli RM, Benowitz NL, West R, et al. Neuropsychiatric safety and efficacy of varenicline, bupropion, and nicotine patch in smokers with and without psychiatric disorders (EAGLES): a double-blind, randomised, placebo-controlled clinical trial. Lancet. 2016:387;2507-2520.
  2. Eisenberg MJ, Windle SB, Roy N, et al. Varenicline for Smoking Cessation in Hospitalized Patients With Acute Coronary Syndrome. Circulation. 2015:137; https://doi.org/10.1161/CIRCULATIONAHA.115.019634.
  3. Benowitz NL, Pipe A, West R, et al. Cardiovascular Safety of Varenicline, Bupropion, and Nicotine Patch in SmokersA Randomized Clinical Trial. JAMA Internal Medicine. 2018; doi:10.1001/jamainternmed.2018.0397.

Neal Parikh Headshot

Neal S. Parikh, MD, earned his MD from Weill Cornell Medical College and completed residency training in neurology at the same institution. He is now an NIH T32 neuro-epidemiology and vascular neurology fellow at New York-Presbyterian Hospital/Columbia University Medical Center. He tweets @NealSParikhMD and contributes to Blogging Stroke as a blogger.