A Public Health Experiment in Real Time
When e-cigarettes entered the market, they were promoted as a safer alternative to traditional cigarettes and a tool for smoking cessation. Millions of people, including a generation of teenagers and young adults who might never have smoked conventional cigarettes, adopted vaping with the assumption that it was relatively harmless. But as years of data accumulate, the emerging picture is far more troubling than the marketing suggested.
At Zimmer Medical Group, we are seeing the health effects of vaping in our patient population, and we believe patients deserve clear information about what the science actually shows rather than what vape manufacturers claim.
What Is in Vape Liquid?
E-cigarettes heat a liquid (often called e-liquid or vape juice) to create an aerosol that users inhale. While this aerosol is not the same as cigarette smoke, it is far from harmless water vapor. Vape liquid typically contains:
Nicotine
Most e-liquids contain nicotine, and many contain far more than users realize. A single JUUL pod, for example, contains roughly as much nicotine as a pack of 20 cigarettes. Newer devices and high-strength e-liquids can deliver nicotine more efficiently than traditional cigarettes, making them intensely addictive.
Propylene Glycol and Vegetable Glycerin
These are the base liquids that create the visible vapor. While generally recognized as safe for oral consumption, their safety when heated and inhaled repeatedly into the lungs has not been established. When heated, propylene glycol can break down into formaldehyde, a known carcinogen.
Flavoring Chemicals
Thousands of flavoring chemicals are used in e-liquids. Many are approved for food use but have never been tested for inhalation safety. Diacetyl, a buttery flavoring chemical, was linked to "popcorn lung" (bronchiolitis obliterans) in factory workers who inhaled it occupationally. While some manufacturers have removed diacetyl, many other flavoring chemicals remain untested for pulmonary safety.
Heavy Metals
The heating coils in e-cigarettes can leach heavy metals including nickel, lead, chromium, and manganese into the aerosol. These metals accumulate in lung tissue and are associated with respiratory and cardiovascular toxicity. A study published in Environmental Health Perspectives found significantly elevated levels of these metals in the urine and saliva of e-cigarette users.
Other Toxic Compounds
Independent laboratory analyses have identified formaldehyde, acrolein (a toxic compound that damages lung tissue), benzene, and ultrafine particles in e-cigarette aerosol. The concentrations of these compounds vary by device, temperature settings, and e-liquid composition, but their presence is consistent across products.
EVALI: E-Cigarette or Vaping Product Use-Associated Lung Injury
In 2019, a nationwide outbreak of severe lung injuries linked to vaping products brought the risks into sharp focus. EVALI (E-cigarette or Vaping product use-Associated Lung Injury) sickened thousands and killed dozens of people, many of them young and previously healthy.
According to the Centers for Disease Control and Prevention, EVALI was primarily linked to vitamin E acetate, a thickening agent used in THC-containing vape products. However, cases also occurred in patients who reported using only nicotine products, suggesting that other components of e-cigarette aerosol can also cause acute lung injury.
EVALI symptoms include cough, shortness of breath, chest pain, nausea, vomiting, diarrhea, fever, and fatigue. Severe cases required mechanical ventilation and intensive care. While the acute outbreak was largely controlled by removing vitamin E acetate from products, EVALI demonstrated that inhaling heated chemical mixtures into the lungs carries serious and sometimes life-threatening risks.
Cardiovascular Effects
Emerging research shows that vaping has significant cardiovascular effects:
- Nicotine from e-cigarettes increases heart rate and blood pressure, acutely stressing the cardiovascular system with each use
- E-cigarette aerosol impairs blood vessel function, reducing the ability of arteries to dilate properly (endothelial dysfunction), a key early step in atherosclerosis
- Vaping increases arterial stiffness, a marker of cardiovascular aging
- Platelet activation increases after vaping, raising the risk of blood clot formation
- Sympathetic nervous system activation from nicotine promotes chronic stress on the heart
A study from the American Heart Association found that daily e-cigarette use was associated with a 34 percent increased risk of heart attack and a 25 percent increased risk of coronary artery disease compared to non-users. While these numbers are lower than the risks associated with combustible cigarettes, they are far from negligible, especially for young people who may vape for decades.
Nicotine Addiction: Especially Concerning in Young Adults
Nicotine is one of the most addictive substances known, and e-cigarettes deliver it efficiently and pleasurably. This is particularly concerning for adolescents and young adults:
- The adolescent brain is uniquely vulnerable to addiction. Nicotine exposure during brain development (which continues until approximately age 25) alters the reward system and increases the likelihood of lifelong addiction.
- E-cigarettes are a gateway to nicotine dependence. Many young people who start vaping develop a nicotine addiction they never would have acquired through cigarettes, which are increasingly socially unacceptable.
- Withdrawal symptoms are real and significant. Irritability, anxiety, difficulty concentrating, insomnia, and intense cravings make quitting extremely difficult once addiction is established.
- Dual use is common. Many people who vape also smoke traditional cigarettes, either because they could not fully quit or because they started smoking after becoming addicted to nicotine through vaping. According to the Truth Initiative, dual use may be more harmful than exclusive use of either product.
Comparison to Traditional Cigarettes
It is important to contextualize the risks:
- E-cigarettes likely expose users to fewer toxic compounds than combustible cigarettes, which produce thousands of chemicals through combustion, including tar and carbon monoxide.
- E-cigarettes are NOT safe. "Safer than cigarettes" is a low bar. Being less toxic than one of the most dangerous consumer products ever sold does not make something harmless.
- The long-term effects of vaping are unknown. Cigarettes were widely considered safe for decades before the full extent of their harm was understood. E-cigarettes have only been widely used for about 15 years, and the chronic diseases they may cause (cancer, COPD, cardiovascular disease) take decades to develop.
- For non-smokers, there is no benefit to vaping. If you do not currently smoke cigarettes, starting to vape introduces health risks with zero benefits.
The Dual Use Problem
Many smokers who switch to e-cigarettes continue to smoke conventional cigarettes as well. This dual use pattern is problematic because:
- It may not reduce health risks meaningfully compared to smoking alone
- It maintains nicotine addiction at high levels
- It reduces the motivation to quit nicotine entirely
- Some research suggests dual users may have worse respiratory outcomes than exclusive smokers
For e-cigarettes to serve as a genuine harm reduction tool, complete switching from cigarettes to e-cigarettes is necessary, but even then, the goal should ultimately be to quit nicotine entirely.
Cessation Resources
If you vape and want to quit, or if you smoke and are considering e-cigarettes as a quitting tool, talk to your healthcare provider first. Evidence-based cessation methods include:
- Nicotine replacement therapy (NRT): Patches, gum, and lozenges provide controlled nicotine doses to manage cravings and withdrawal
- Prescription medications: Varenicline (Chantix) and bupropion (Wellbutrin) are FDA-approved medications that significantly improve quit rates
- Behavioral counseling: Individual or group counseling addresses the psychological and behavioral aspects of addiction
- Quitlines: Free telephone and text-based support (1-800-QUIT-NOW) provides accessible help
- Truth Initiative: Offers a free text-based program specifically designed for young people who want to quit vaping
- American Lung Association: Provides comprehensive resources, support programs, and a free helpline
The most effective approach typically combines medication with behavioral support. Your doctor can help you develop a personalized quit plan that addresses your specific patterns, triggers, and needs.
What We Tell Our Patients
Our guidance at Zimmer Medical Group is straightforward:
- If you do not vape or smoke, do not start. There is no health benefit to inhaling any substance into your lungs beyond air.
- If you smoke cigarettes, quitting entirely is the best option. FDA-approved cessation methods have the strongest evidence. If you cannot quit cold turkey, discuss all options with your doctor, including whether a temporary transition to e-cigarettes might be appropriate as part of a structured quit plan.
- If you vape, work toward quitting. The long-term risks are unknown, the addiction is real, and the known short-term effects on your lungs and cardiovascular system are concerning.
- Be honest with your doctor about vaping. We cannot help you manage health risks we do not know about.
Trying to quit vaping or smoking? Contact Zimmer Medical Group to discuss evidence-based cessation strategies tailored to your situation. Quitting is hard, but you do not have to do it alone.
