Vaping: The new wave of nicotine addiction

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Release date: December 1, 2019
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Vaping devices, introduced to the US market in 2007 as aids for smoking cessation, have become popular among youth and young adults because of their enticing flavors and perceived lack of negative health effects. However, evidence is emerging that vaping may introduce high levels of dangerous chemicals into the body and cause severe lung injury and death. This article reviews the history and prevalence of vaping and available research on its health effects and efficacy in smoking cessation, and proposes recommendations for clinicians and legislators to reduce harms associated with vaping.


  • Vaping is a common gateway to tobacco and marijuana use for adolescents and adults.
  • The Juul vaping device delivers high nicotine concentrations that may pose a higher risk of nicotine addiction.
  • Vaping has had unintended consequences that include poisoning of children who swallowed liquid nicotine, fires and explosions from defective batteries in the devices, and effects on the developing brain.
  • Vaping is associated with respiratory illness and, in rare cases, death, likely due to vaporized agents introduced into the lungs. Small amounts of heavy metals, acetone, and other carcinogenic compounds in the vaping aerosol may cause lung damage.



Electronic cigarettes and other “vaping” devices have been increasing in popularity among youth and adults since their introduction in the US market in 2007.1 This increase is partially driven by a public perception that vaping is harmless, or at least less harmful than cigarette smoking.2 Vaping fans also argue that current smokers can use vaping as nicotine replacement therapy to help them quit smoking.3

We disagree. Research on the health effects of vaping, though still limited, is accumulating rapidly and making it increasingly clear that this habit is far from harmless. For youth, it is a gateway to addiction to nicotine and other substances. Whether it can help people quit smoking remains to be seen. And recent months have seen reports of serious respiratory illnesses and even deaths linked to vaping.4

In December 2016, the US Surgeon General warned that e-cigarette use among youth and young adults in the United States represents a “major public health concern,”5 and that more adolescents and young adults are now vaping than smoking conventional tobacco products.

This article reviews the issue of vaping in the United States, as well as available evidence regarding its safety.


Retail sales of e-cigarettes and vaping devices approach an annual $7 billion.6 A 2014–2015 survey found that 2.4% of the general US population were current users of e-cigarettes, and 8.5% had tried them at least once.3

Table 1. Tobacco use among US high school students, 2018
Youth are particularly at risk. In a 2018 survey,7 20.8% of high school students reported using e-cigarettes on more than 1 day in the previous 30 days (Table 1), a significant increase from 1.5% in 2011. Additionally, 11.3% of high school students reported using 2 or more types of tobacco products; in middle school students, the number was 4.9%—nearly 1 in 20—up from 0.6% in 2011.8

In 2014, for the first time, e-cigarette use became more common among US youth than traditional cigarettes.5

The odds of taking up vaping are higher among minority youth in the United States, particularly Hispanics.9 This trend is particularly worrisome because several longitudinal studies have shown that adolescents who use e-cigarettes are 3 times as likely to eventually become smokers of traditional cigarettes compared with adolescents who do not use e-cigarettes.10–12

If US youth continue smoking at the current rate, 5.6 million of the current population under age 18, or 1 of every 13, will die early of a smoking-related illness.13


As of November 5, 2019, there had been 2,051 cases of vaping-associated lung injury in 49 states (all except Alaska), the District of Columbia, and 1 US territory reported to the US Centers for Disease Control and Prevention (CDC), with 39 confirmed deaths.4 The reported cases include respiratory injury including acute eosinophilic pneumonia, organizing pneumonia, acute respiratory distress syndrome, and hypersensitivity pneumonitis.14

Most of these patients had been vaping tetrahydrocannabinol (THC), though many used both nicotine- and THC-containing products, and others used products containing nicotine exclusively.4 Thus, it is difficult to identify the exact substance or substances that may be contributing to this sudden outbreak among vape users, and many different product sources are currently under investigation.

One substance that may be linked to the epidemic is vitamin E acetate, which the New York State Department of Health has detected in high levels in cannabis vaping cartridges used by patients who developed lung injury.15 The US Food and Drug Administration (FDA) is continuing to analyze vape cartridge samples submitted by affected patients to look for other chemicals that can contribute to the development of serious pulmonary illness.


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