E-cigarettes, or electronic cigarettes, are battery-operated smoking devices. They often look like cigarettes, but work differently. Using an e-cigarette is called vaping. The user puffs on the mouthpiece of a cartridge. This causes a vaporizer to heat the liquid inside the cartridge. The liquid contains nicotine, flavorings, and other chemicals. The heated liquid turns into the vapor that is inhaled.

Some people think that e-cigarettes are safer than cigarettes, and that they can be used to help people quit smoking. But not much is known about the health risks of using them, or whether they do help people quit smoking. However we do know about some dangers of e-cigarettes:

• They contain nicotine, which is addictive
• They contain other potentially harmful chemicals
• There is a link between e-cigarette use and tobacco cigarette use in teens
• The liquid in e-cigarettes can cause nicotine poisoning if someone drinks, sniffs, or touches it

What are vaping devices?

Vaping devices are battery-operated devices that people use to inhale an aerosol, which typically contains nicotine (though not always), flavorings, and other chemicals. They can resemble traditional tobacco cigarettes (cig-a-likes), cigars, or pipes, or even everyday items like pens or USB memory sticks. Other devices, such as those with fillable tanks, may look different. Regardless of their design and appearance, these devices generally operate in a similar manner and are made of similar components. More than 460 different e-cigarette brands are currently on the market.

How do vaping devices work?

Most e-cigarettes consist of four different components, including:

• a cartridge or reservoir or pod, which holds a liquid solution (e-liquid or e-juice) containing varying amounts of nicotine, flavorings, and other chemicals
• a heating element (atomizer)
• a power source (usually a battery)
• a mouthpiece that the person uses to inhale

In many e-cigarettes, puffing activates the battery-powered heating device, which vaporizes the liquid in the cartridge. The person then inhales the resulting aerosol or vapor (called vaping).

Vaping Among Teens

Vaping devices are popular among teens and are now the most commonly used form of nicotine among youth in the United States. Some research shows that many teens do not even realize that vaping cartridges contain nicotine, and assume the pods contain only flavoring. The easy availability of these devices, alluring advertisements, various e-liquid flavors, and the belief that they're safer than cigarettes have helped make them appealing to this age group. In addition, they are easy to hide from teachers and parents because they do not leave behind the stench of tobacco cigarettes, and are often disguised as flash drives. Further, a study of high school students found that one in four teens reported using e-cigarettes for dripping, a practice in which people produce and inhale vapors by placing e-liquid drops directly onto heated atomizer coils. Teens reported the following reasons for dripping: to create thicker vapor (63.5 percent), to improve flavors (38.7 percent), and to produce a stronger throat hit—a pleasurable feeling that the vapor creates when it causes the throat to contract (27.7 percent). More research is needed on the risks of this practice.

In addition to the unknown health effects, early evidence suggests that vaping might serve as an introductory product for preteens and teens who then go on to use other nicotine products, including cigarettes, which are known to cause disease and premature death. A study showed that students who had used e-cigarettes by the time they started 9th grade were more likely than others to start smoking cigarettes and other smokable tobacco products within the next year. Another study supports these findings, showing that high school students who used e-cigarettes in the last month were about 7 times more likely to report that they smoked cigarettes when asked approximately 6 months later, as compared to students who said they didn't use e-cigarettes. Notably, the reverse was not true—students who said they smoked cigarettes were no more likely to report use of e-cigarettes when asked approximately 6 months later. Like the previous study, these results suggest that teens using e-cigarettes are at a greater risk for smoking cigarettes in the future. Another study has shown an association between e-cigarette smoking and progression to smoking actual cigarettes. This study suggests that vaping nicotine might actually encourage cigarette smoking in adolescents.

Additionally, a study of adult smokers in Europe found those who vaped nicotine were less like to have stopped smoking than those who did not. Those who used e-cigarettes also smoked more cigarettes than those who didn’t. In another study of more than 800 people who said they vaped to help them quit traditional cigarette smoking, only nine percent reported having quit when asked a year later. However, more research is still needed to understand if experimenting with e-cigarettes leads to regular use of smokable tobacco.

Under U.S. Food and Drug Administration (FDA) regulations designed to protect the health of young Americans, minors can no longer buy e-cigarettes in stores or online (see "Government Regulation of E-cigarettes"). The FDA now regulates the manufacture, import, packaging, labeling, advertising, promotion, sale, and distribution of e-cigarettes. This includes components and parts of e-cigarettes but excludes accessories.

Government Regulation of E-cigarettes

In 2016, the FDA established a rule for e-cigarettes and their liquid solutions. Because e-cigarettes contain nicotine derived from tobacco, they are now subject to government regulation as tobacco products. In December 2019, the federal government raised the legal minimum age of sale of tobacco products from 18 to 21 years, and in January 2020, the FDA issued a policy on the sale of flavored vaping cartridges.

How does vaping affect the brain?

The nicotine in e-liquids is readily absorbed from the lungs into the bloodstream when a person vapes an e-cigarette. Upon entering the blood, nicotine stimulates the adrenal glands to release the hormone epinephrine (adrenaline). Epinephrine stimulates the central nervous system and increases blood pressure, breathing, and heart rate. As with most addictive substances, nicotine activates the brain’s reward circuits and also increases levels of a chemical messenger in the brain called dopamine, which reinforces rewarding behaviors. Pleasure caused by nicotine’s interaction with the reward circuit motivates some people to use nicotine again and again, despite risks to their health and well-being.

What are the health effects of vaping? Is it safer than smoking tobacco cigarettes?

Research so far suggests that vaping devices might be less harmful than combustible cigarettes when people who regularly smoke switch to them as a complete replacement. But nicotine in any form is a highly addictive drug. Research suggests it can even prime the brain’s reward system, putting vapers at risk for addiction to other drugs.

Also, e-cigarette use exposes the lungs to a variety of chemicals, including those added to e-liquids, and other chemicals produced during the heating/vaporizing process. A study of some e-cigarette products found the vapor contains known carcinogens and toxic chemicals, as well as potentially toxic metal nanoparticles from the device itself. The study showed that the e-liquids of certain cig-a-like brands contain high levels of nickel and chromium, which may come from the nichrome heating coils of the vaporizing device. Cig-a-likes may also contain low levels of cadmium, a toxic metal also found in cigarette smoke that can cause breathing problems and disease. More research is needed on the health consequences of repeated exposure to these chemicals. There are also reports of lung illnesses and deaths related to inhalation of certain vaping oils into the lungs, which have no way to filter out toxic ingredients.

Reports of Deaths Related to Vaping

The Food and Drug Administration has alerted the public to thousands of reports of serious lung illnesses associated with vaping, including dozens of deaths. They are working with the Centers for Disease Control and Prevention (CDC) to investigate the cause of these illnesses. Many of the suspect products tested by the states or federal health officials have been identified as vaping products containing THC, the main psychotropic ingredient in marijuana. Some of the patients reported a mixture of THC and nicotine; and some reported vaping nicotine alone. While the CDC and FDA continue to investigate possible other contributing substances, CDC has identified a thickening agent—Vitamin E acetate—as a chemical of concern among people with e-cigarette or vaping associated lung injuries. They recommend that people should not use any product containing Vitamin E acetate, or any vaping products containing THC; particularly from informal sources like friends, family, or in-person and online dealers. They also warn against modifying any products purchased in stores, or using any vaping products bought on the street. People, including health professionals, should report any adverse effects of vaping products.

Health Effects for Teens

The teen years are critical for brain development, which continues into young adulthood. Young people who use nicotine products in any form, including e-cigarettes, are uniquely at risk for long-lasting effects. Because nicotine affects the development of the brain's reward system, continued nicotine vaping can not only lead to nicotine addiction, but it also can make other drugs such as cocaine and methamphetamine more pleasurable to a teen's developing brain.

Nicotine also affects the development of brain circuits that control attention and learning. Other risks include mood disorders and permanent problems with impulse control—failure to fight an urge or impulse that may harm oneself or others.

Can vaping help a person quit smoking?

Some people believe e-cigarettes may help lower nicotine cravings in those who are trying to quit smoking. However, e-cigarettes are not an FDA-approved quit aid, and there is no conclusive scientific evidence on the effectiveness of vaping for long-term smoking cessation. It should be noted that there are seven FDA-approved quit aids that are proven safe and can be effective when used as directed.

Vaping nicotine has not been thoroughly evaluated in scientific studies. For now, not enough data exists on the safety of e-cigarettes, how the health effects compare to traditional cigarettes, and if they are helpful for people trying to quit smoking.

Points to Remember

• People vape with battery-operated devices used to inhale an aerosol, which can contain nicotine, marijuana, flavorings, and other chemicals. In many e-cigarettes, puffing activates the battery-powered heating device, which vaporizes the liquid in the cartridge or reservoir. The person then inhales the resulting aerosol or vapor (called vaping).
• Vaping is popular among teens. Under U.S. Food and Drug Administration (FDA) regulations designed to protect the health of young Americans, minors can no longer buy e-cigarettes in stores or online.
• Nicotine stimulates the adrenal glands to release the hormone epinephrine (adrenaline) and increases the levels of a chemical messenger in the brain called dopamine. Pleasure caused by nicotine’s interaction with the brain’s reward system motivates some people to use nicotine again and again, despite possible risks to their health and well-being.
• Research so far suggests that vaping is less harmful than combustible cigarettes when people who regularly smoke switch to them as a complete replacement. But e-cigarettes can still damage a person's health.
• Vaping can lead to nicotine addiction and increased risk for addiction to other drugs.
• Vaping also exposes the lungs to a variety of chemicals, including those added to e-liquids, and other chemicals produced during the heating/vaporizing process.
• More research is needed to determine if vaping nicotine can be as effective as smoking cessation aids already approved by the FDA.

What's the bottom line?

• E-cigarettes have the potential to benefit adult smokers who are not pregnant if used as a complete substitute for regular cigarettes and other smoked tobacco products.
• E-cigarettes are not safe for youth, young adults, pregnant women, as well as adults who do not currently use tobacco products.
• While e-cigarettes have the potential to benefit some people and harm others, scientists still have a lot to learn about whether e-cigarettes are effective in helping adults quit smoking.
• If you’ve never smoked or used other tobacco products or e-cigarettes, don’t start.
• Additional research can help understand long-term health effects.

E-cigarettes are not safe for youth, young adults, and pregnant women, as well as adults who do not currently use tobacco products.

What are e-cigarettes?

• E-cigarettes come in many shapes and sizes. Most have a battery, a heating element, and a place to hold a liquid.
• E-cigarettes produce an aerosol by heating a liquid that usually contains nicotine—the addictive drug in regular cigarettes, cigars, and other tobacco products—flavorings, and other chemicals that help to make the aerosol. Users inhale this aerosol into their lungs. Bystanders can also breathe in this aerosol when the user exhales into the air.
• E-cigarettes are known by many different names. They are sometimes called “e-cigs,” “e-hookahs,” “mods,” “vape pens,” “vapes,” “tank systems,” and “electronic nicotine delivery systems (ENDS).”
• Some e-cigarettes are made to look like regular cigarettes, cigars, or pipes. Some resemble pens, USB sticks, and other everyday items. Larger devices such as tank systems, or “mods,” do not resemble other tobacco products.
• Using an e-cigarette is sometimes called “vaping.”
• E-cigarettes can be used to deliver marijuana and other drugs.

Some e-cigarettes are made to look like regular cigarettes, cigars, or pipes.
Some resemble pens, USB sticks, and other everyday items.

What is in e-cigarette aerosol?

The e-cigarette aerosol that users breathe from the device and exhale can contain harmful and potentially harmful substances, including:

• Nicotine
• Ultrafine particles that can be inhaled deep into the lungs
• Flavoring such as diacetyl, a chemical linked to a serious lung disease
• Volatile organic compounds
• Cancer-causing chemicals
• Heavy metals such as nickel, tin, and lead

It is difficult for consumers to know what e-cigarette products contain. For example, some e-cigarettes marketed as containing zero percent nicotine have been found to contain nicotine.

What is in e-cigarette aerosol?

What are the health effects of using e-cigarettes?

E-cigarettes are still fairly new, and scientists are still learning about their long-term health effects. Here is what we know now.

Most e-cigarettes contain nicotine, which has known health effects.

• Nicotine is highly addictive.
• Nicotine is toxic to developing fetuses.
• Nicotine can harm adolescent and young adult brain development, which continues into the early to mid-20s.
• Nicotine is a health danger for pregnant women and their developing babies.

Besides nicotine, e-cigarette aerosol can contain substances that harm the body.

• This includes cancer-causing chemicals and tiny particles that reach deep into lungs. However, e-cigarette aerosol generally contains fewer harmful chemicals than smoke from burned tobacco products.

E-cigarettes can cause unintended injuries.

• Defective e-cigarette batteries have caused fires and explosions, some of which have resulted in serious injuries. Most explosions happened when the e-cigarette batteries were being charged.
  • The Food and Drug Administration (FDA) collects data to help address this issue. You can report an e-cigarette explosion, or any other unexpected health or safety issue with an e-cigarette.
• In addition, acute nicotine exposure can be toxic. Children and adults have been poisoned by swallowing, breathing, or absorbing e-cigarette liquid through their skin or eyes.

What are the risks of e-cigarettes for youth, young adults, and pregnant women?

Most e-cigarettes contain nicotine, which is addictive and toxic to developing fetuses. Nicotine exposure can also harm adolescent and young adult brain development, which continues into the early to mid-20s. E-cigarette aerosol can contain chemicals that are harmful to the lungs. And youth e-cigarette use is associated with the use of other tobacco products, including cigarettes.

Are e-cigarettes less harmful than regular cigarettes?

Yes—but that doesn’t mean e-cigarettes are safe. E-cigarette aerosol generally contains fewer toxic chemicals than the deadly mix of 7,000 chemicals in smoke from regular cigarettes. However, e-cigarette aerosol is not harmless. It can contain harmful and potentially harmful substances, including nicotine, heavy metals like lead, volatile organic compounds, and cancer-causing agents.

Can e-cigarettes help adults quit smoking cigarettes?

E-cigarettes are not currently approved by the FDA as a quit smoking aid. The U.S. Preventive Services Task Force, a group of health experts that makes recommendations about preventive health care, has concluded that evidence is insufficient to recommend e-cigarettes for smoking cessation in adults, including pregnant women.

However, e-cigarettes may help non-pregnant adult smokers if used as a complete substitute for all cigarettes and other smoked tobacco products.

• To date, the few studies on the issue are mixed. A Cochrane Review found evidence from two randomized controlled trials that e-cigarettes with nicotine can help smokers stop smoking in the long term compared with placebo (non-nicotine) e-cigarettes. However, there are some limitations to the existing research, including the small number of trials, small sample sizes, and wide margins of error around the estimates.
• A recent CDC study found that many adults are using e-cigarettes in an attempt to quit smoking. However, most adult e-cigarette users do not stop smoking cigarettes and are instead continuing to use both products (known as “dual use”). Dual use is not an effective way to safeguard your health, whether you’re using e-cigarettes, smokeless tobacco, or other tobacco products in addition to regular cigarettes. Because smoking even a few cigarettes a day can be dangerous, quitting smoking completely is very important to protect your health.

Who is using e-cigarettes?

E-cigarettes are the most commonly used tobacco product among youth.

• In the United States, youth are more likely than adults to use e-cigarettes.
• In 2021, 2.06 million U.S. middle and high school students used e-cigarettes in the past 30 days, including 2.8% of middle school students and 11.3% of high school students.
• In 2019, 4.5% of U.S. adults were current e-cigarette users.
• In 2019, among current adult e-cigarette users overall, 36.9% also currently smoked cigarettes, 39.5% formerly smoked cigarettes, and 23.6% had never smoked cigarettes.
• Among current adult e-cigarette users, the percentage who have never smoked cigarettes is highest among those aged 18–24 years (56.0%), and is lower in older age groups.

What are tobacco, nicotine, and vaping (e-cigarette) products?

Tobacco is a leafy plant grown around the world, including in parts of the United States. There are many chemicals found in tobacco leaves but nicotine is the one that can lead to addiction. Other chemicals produced by smoking tobacco, such as tar, carbon monoxide, acetaldehyde, and nitrosamines, also can cause serious harm to the body. For example, tar causes lung cancer and other serious diseases that affect breathing, and carbon monoxide can cause heart problems.

These toxic chemicals can be dangerous. In fact, tobacco use is the leading preventable cause of disease, disability, and death in the United States. According to the Centers for Disease Control and Prevention (CDC), cigarettes cause more than 480,000 premature deaths in the United States each year—from smoking or exposure to secondhand smoke. This represents about 1 in every 5 U.S. deaths, or 1,300 deaths every day. An additional 16 million people suffer with a serious illness caused by smoking. So, for every 1 person who dies from smoking, 30 more suffer from at least 1 serious tobacco-related illness.

How Tobacco and Nicotine Products Are Used

Tobacco and nicotine products come in many forms. People can smoke, chew, sniff them, or inhale their vapors.

• Smoked tobacco products.
  • Cigarettes: These are labeled as regular, light, or menthol, but no evidence exists that “lite” or menthol cigarettes are safer than regular cigarettes.
  • Cigars and pipes: ​Some small cigars are hollowed out to make room for marijuana, known as "blunts," often done to hide the fact that they are smoking marijuana. Either way, they are inhaling toxic chemicals.
  • Bidis and kreteks (clove cigarettes): Bidis are small, thin, hand-rolled cigarettes primarily imported to the United States from India and other Southeast Asian countries. Kreteks—sometimes referred to as clove cigarettes—contain about 60-80% tobacco and 20-40% ground cloves. Flavored bidis and kreteks are banned in the United States because of the ban on flavored cigarettes.
  • Hookahs or water pipes: Hookah tobacco comes in many flavors, and the pipe is typically passed around in groups. A recent study found that a typical hookah session delivers approximately 125 times the smoke, 25 times the tar, 2.5 times the nicotine, and 10 times the carbon monoxide as smoking a cigarette.
• Smokeless tobacco products. The tobacco is not burned with these products:
  • Chewing tobacco. It is typically placed between the cheek and gums.
  • Snuff: Ground tobacco that can be sniffed if dried or placed between the cheek and gums.
  • Dip: Moist snuff that is used like chewing tobacco.
  • Snus: A small pouch of moist snuff.
  • Dissolvable products: These include lozenges, orbs, sticks, and strip.
• Vaping/electronic cigarettes (also called e-cigarettes, electronic nicotine delivery systems, vaping devices, e-cigs, or JUULing). Vaping products are battery-operated devices that deliver nicotine and flavorings without burning tobacco. In most products, puffing activates the battery-powered heating device, which vaporizes the liquid in the cartridge. The resulting vapor is then inhaled (called “vaping”).

Government Regulation of Tobacco Products

In 2016, the FDA announced that nationwide tobacco regulations be extended to all tobacco products, including:

• e-cigarettes and their liquid solutions
• cigars
• hookah tobacco
• pipe tobacco

In December 2019, the federal government raised the legal minimum age of sale of tobacco products from 18 to 21 years, and in January 2020, the FDA issued a policy on the sale of flavored vaping cartridges. Therefore:

• It is illegal to sell vaping products (e-cigarettes), hookah tobacco, or cigars in person or online to anyone under age 21.
• Buyers have to show their photo ID to purchase vaping products (e-cigarettes), hookah tobacco, or cigars, verifying that they are 21 years or older.
• These products cannot be sold in vending machines (unless in an adult-only facility).
• It is illegal to hand out free samples.

FDA regulation also means that the Federal government will now have a lot more information about what is in vaping products, the safety or harms of the ingredients, how they are made, and what risks need to be communicated to the public (for example, on health warnings on the product and in advertisements). They will also be able to stop manufacturers from making statements about their products that are not scientifically proven.

Regulation does not mean that vaping products are necessarily safe for all adults to use, or that all of the health claims currently being made in advertisements by manufactures are true. But it does mean that vaping products, hookah tobacco, and cigars now have to follow the same type of rules as cigarette manufacturers.

What happens in the brain when you use tobacco and nicotine?

Like many other drugs, nicotine increases levels of a neurotransmitter called dopamine. Dopamine is released naturally when you experience something pleasurable like good food, your favorite activity, or spending time with people you care about. When a person uses tobacco products, the release of dopamine causes similar “feel-good” effects. This effect wears off quickly, causing people who smoke to get the urge to light up again for more of that good feeling, which can lead to addiction.

A typical smoker will take 10 puffs on a cigarette over the period of about 5 minutes that the cigarette is lit. So, a person who smokes about a pack of 25 cigarettes a day gets 250 “hits” of nicotine.

Studies suggest that other chemicals in tobacco smoke, such as acetaldehyde, may increase the effects of nicotine on the brain.

When smokeless tobacco is used, nicotine is absorbed through the mouth tissues directly into the blood, where it goes to the brain. Even after the tobacco is removed from the mouth, nicotine continues to be absorbed into the bloodstream. Also, the nicotine stays in the blood longer for users of smokeless tobacco than for smokers.

What happens to your body when you use tobacco and nicotine?

Short-Term Effects

When nicotine enters the body, it initially causes the adrenal glands to release a hormone called adrenaline, which stimulates the body and gives it a pleasurable “kick.” But the rush of adrenaline also causes the following:

• increased blood pressure
• increased heart rate
• faster breathing

Long-Term Effects

The nicotine is addictive, and as people keep using tobacco, they are continually exposed to many toxic chemicals found in the tobacco (or produced by burning it). These include carbon monoxide, tar, formaldehyde, cyanide, and ammonia. Tobacco use harms every organ in the body and can cause many serious health problems, listed below.

Smoking Tobacco

• Cancers. Cigarette smoking can be blamed for about one-third of all cancer deaths, including 90% of lung cancer cases. Tobacco use is also linked with cancers of the mouth, pharynx, larynx, esophagus, stomach, pancreas, cervix, kidney, ureter, bladder, and bone marrow (leukemia).
• Lung Problems. Bronchitis (swelling of the air passages to the lungs), emphysema (damage to the lungs), and pneumonia have been linked to smoking. People who smoke can’t exercise or play sports for as long as they once did.
• Heart disease and stroke. Smoking increases the risk for stroke, heart attack, and other diseases of the blood’s heart and circulation system that can lead to death.
• Cataracts. People who smoke can get cataracts, which is clouding of the eye that causes blurred vision.
• Loss of sense of smell and taste. This also includes bad breath.
• Aging skin and teeth. After smoking for a long time, people find their skin ages faster and their teeth discolor.
• Risk to unborn baby. Pregnant women who smoke are at increased risk for delivering their baby early, having smaller babies, or suffering a miscarriage, stillbirth, or experiencing other problems with their pregnancy. Smoking by pregnant women also may be associated with learning and behavior problems in children.
• Fire-related deaths. Smoking is the leading cause of fire-related deaths—more than 600 deaths each year, in some cases caused by people falling asleep with a lit cigarette that causes a house fire.

Secondhand Smoke

People who do not smoke but live or hang out with smokers are exposed to secondhand smoke—smoke that is exhaled or given off by the burning end of tobacco products. Just like smoking, regularly standing near smokers increases your risk for disease. The Centers for Disease Control and Prevention reports that there is no risk-free level of exposure to secondhand smoke. Each year, an estimated 58 million Americans are regularly exposed to secondhand smoke and more than 42,000 nonsmokers die from diseases caused by secondhand smoke exposure. Since the 1964 Surgeon General’s Report, 2.5 million adults who were nonsmokers died because they breathed secondhand smoke. It is unclear what long- term side effects there are from exposure to e-cigarette vapor, but one in four U.S. middle and high school students say they've been exposed to unhealthy secondhand aerosol from e-cigarettes.Long-term effects can include:

• Cancer. People exposed to secondhand smoke increase their risk for lung cancer by 20% to 30%. About 7,300 lung cancer deaths occur per year among people who do not smoke but were exposed to second hand smoke.
• Lung problems. Secondhand smoke causes breathing problems in people who do not smoke, like coughing, phlegm, and lungs not working as well as they should.
• Heart disease: Secondhand smoke increases the risk for heart disease by 25% to 30%. It is estimated to contribute to as many as 34,000 deaths related to heart disease.
• Health problems for children: Children exposed to secondhand smoke are at an increased risk for sudden infant death syndrome, lung infections, ear problems, and more severe asthma.

Smokeless Tobacco

The health effects of smokeless tobacco are somewhat different from those of smoked tobacco, but both can cause cancer and other effects:

• Cancers. Close to 30 chemicals in smokeless tobacco have been found to cause cancer. People who use smokeless tobacco are at increased risk for oral cancer (cancers of the mouth, lip, tongue, and pharynx) as well as esophageal and pancreatic cancers.
• Heart disease and stroke. Recent research shows smokeless tobacco may play a role in causing heart disease and stroke.
• Mouth problems. Smokeless tobacco increases the chance of getting cavities, gum disease, and sores in the mouth that can make eating and drinking painful.

Can you die if you use tobacco, nicotine, and vaping (e-cigarette) products?

Reports of Deaths Related to Vaping

The Food and Drug Administration (FDA) has alerted the public to thousands of reports of serious lung illnesses associated with vaping, including dozens of deaths. They’re working with the Centers for Disease Control and Prevention (CDC) to investigate the cause of these illnesses.Many of the suspect products tested by the states or federal health officials have been identified as vaping products containing THC, the main psychotropic (mind-altering) ingredient in marijuana. Some of the patients reported vaping a mixture of THC and nicotine; and some reported vaping nicotine alone.While the CDC and FDA continue to investigate possible other contributing substances, CDC has identified a thickening agent—Vitamin E acetate—as a chemical of concern among people with e-cigarette or vaping associated lung injuries. They recommend that people should not use any product containing Vitamin E acetate, or any vaping products containing THC; particularly from informal sources like friends, family, or in-person and online dealers. They also warn against modifying any products purchased in stores, or using any vaping products bought on the street. The FDA is asking people, including health professionals, to report any adverse (negative) effects of vaping products.

Yes. Tobacco use (both smoked and smokeless) is the leading preventable cause of death in the United States. It is a known cause of cancer. Smoking tobacco cigarettes also can lead to early death from heart disease, health problems in children, and accidental home and building fires caused by dropped cigarettes. In addition, the nicotine in smokeless tobacco may increase the risk for sudden death from a condition where the heart does not beat properly (ventricular arrhythmias); as a result, the heart pumps little or no blood to the body’s organs.

According to the Centers for Disease Control and Prevention (CDC), cigarette smoking results in more than 480,000 premature deaths in the United States each year—about 1 in every 5 U.S. deaths, or 1,300 deaths every day. On average, smokers die 10 years earlier than nonsmokers. People who smoke are at increased risk of death from cancer, particularly lung cancer, heart disease, lung diseases, and accidental injury from fires started by dropped cigarettes.

The good news is that people who quit may live longer. A 24-year-old man who quits smoking will, on average, increase his life expectancy (how long he is likely to live) by 5 years.

Are tobacco, nicotine, and vaping (e-cigarette) products addictive?

Yes. It is the nicotine in tobacco that is addictive. Each cigarette contains about 10 milligrams of nicotine. A person inhales only some of the smoke from a cigarette, and not all of each puff is absorbed in the lungs. The average person gets about 1 to 2 milligrams of nicotine from each cigarette.

Studies of widely used brands of smokeless tobacco showed that the amount of nicotine per gram of tobacco ranges from 4.4 milligrams to 25.0 milligrams. Holding an average-size dip in your mouth for 30 minutes gives you as much nicotine as smoking 3 cigarettes. A 2-can-a-week snuff dipper gets as much nicotine as a person who smokes 1½ packs a day.

Whether a person smokes tobacco products or uses smokeless tobacco, the amount of nicotine absorbed in the body is enough to make someone addicted. When this happens, the person continues to seek out the tobacco even though he or she understands the harm it causes. Nicotine addiction can cause:

• Tolerance: Over the course of a day, someone who uses tobacco products develops tolerance—more nicotine is required to produce the same initial effects. In fact, people who smoke often report that the first cigarette of the day is the strongest or the “best.”
• Withdrawal: When people quit using tobacco products, they usually experience uncomfortable withdrawal symptoms, which often drive them back to tobacco use. Nicotine withdrawal symptoms include:
  • irritability
  • problems with thinking and paying attention
  • sleep problems
  • increased appetite
  • craving, which may last 6 months or longer, and can be a major stumbling block to quitting

What about vaping (e-cigarettes)?

Vaping products, also called e-cigarettes, are fairly new products. They’ve only been around for about ten years, so researchers are in the early stage of studying how they affect your health.

How Vaping Products Work

Vaping products are designed to deliver nicotine without the other chemicals produced by burning tobacco leaves. Puffing on the mouthpiece of the cartridge activates a battery-powered inhalation device (called a vaporizer). The vaporizer heats the liquid inside the cartridge which contains nicotine, flavors, and other chemicals. The heated liquid turns into an aerosol (vapor) which the user inhales—referred to as "vaping.”

How Vaping Affects the Brain

Nicotine from vaping products activates the brain’s reward circuits and increases levels of a chemical messenger in the brain called dopamine. Dopamine causes the brain to remember the behavior associated with that increase and reinforces the desire to vape nicotine. This can cause a person to seek out nicotine and use it again and again, despite the risks to their health.

Why Do Teens Vape?

Public health experts have been studying why so many teens are vaping. One recent study showed that teens are enticed by the flavors offered by the vaping companies---especially mint and fruity flavors like mango. NIDA’s 2019 Monitoring the Future survey asked teens why they vape and more than 40% said they tried it for the flavors. Others said they tried vaping just to experiment, or to have a good time with friends. However, more than 8% said they tried it because they are “hooked.”

The government has taken steps to discourage teens from using vaping products. In early 2020, the government banned mint and fruity flavors in hopes of discouraging teens from using vaping products. At about the same time, the government raised the legal age to purchase all tobacco products to 21.

Is Vaping Worse Than Smoking?

Regardless of how vaping compares to cigarette smoking, it is important to recognize that nicotine vaping has its own risks, which include addiction and other potentially harmful health effects. Research so far suggests that nicotine vaping might be less harmful than cigarettes when people who regularly smoke switch to them completely and no longer use tobacco cigarettes.

However, nicotine in any form is a highly addictive drug, and health experts have raised many questions about the safety of vaping devices, particularly for teens:

• Testing of some vaping products found the aerosol (vapor) to contain known cancer-causing and toxic chemicals. The health effects of repeated exposure to these chemicals are not yet clear.
• Some research suggests that nicotine vaping may increase the likelihood that teens will try other tobacco products, including cigarettes. A study showed that students who have vaped nicotine by the time they start 9th grade are more likely than others to start smoking traditional cigarettes and other smoked tobacco products within the next year. Another study has also shown a connection between vaping nicotine and smoking traditional cigarettes.These studies suggest that using vaping products can lead to cigarette smoking in adolescents.
• Some research suggests that certain vaping products contain metals like nickel and chromium, possibly coming from the heating of coils, that may be harmful when inhaled.

How many teens use tobacco, nicotine, and vaping (e-cigarette) products?

The chart below shows the percentage of teens who say they use tobacco, nicotine, and vaping (e-cigarette) products.

* Data in brackets indicate statistically significant change from the previous year.

What do I do if I want to quit using tobacco, nicotine, and vaping (e-cigarette) products?

Teens and young adults who smoke but want to quit have good options for help. If you or someone you know needs more information or is ready to quit, read more about quitting the use of tobacco and nicotine. If you have a friend who smokes, it puts you at higher risk for starting, because your friend is likely to pressure you into trying it. You might decide to step away from the friendship for a while to protect your own health. Even secondhand smoke is bad for your health.

Nearly 70 percent of people who smoke want to quit. Most who try to quit on their own relapse (go back to smoking)—often within a week. Most former smokers have had several failed quit attempts before they finally succeed.

Some people believe e-cigarette products may help smokers lower nicotine cravings while they are trying to quit smoking cigarettes. However, several research studies show that using electronic devices to help quit cigarette smoking does not usually work in the long term, and might actually discourage people from quitting.²² One recent study showed that only nine percent of people using e-vaporizers to quit smoking cigarettes had actually stopped smoking a year later.²³

If you or someone you know needs more information or is ready to quit, check out these resources:

Teens

• Visit teen.smokefree.gov/.

Adults

• Call 1-800-QUIT-NOW (1-800-784-8669), a national toll-free number that can help people get the information they need to quit smoking.
• Visit SmokeFree.gov.

Overview

About 2.4 million middle and high school students were current (past 30-day) users of electronic cigarettes, or e-cigarettes, in 2014. Most e-cigarettes contain nicotine, which causes addiction, may harm brain development, and could lead to continued tobacco product use among youth. Tobacco product advertising can entice youth to use tobacco, and spending to advertise e-cigarettes has increased rapidly since 2011. About 69% of middle and high school students were exposed to e-cigarette advertisements in retail stores, on the Internet, in magazines/newspapers, or on TV/movies. Exposure to e-cigarette advertisements may be contributing to increases in e-cigarette use among youth. Efforts by states, communities, and others could reduce this exposure.

States and communities can:

• Fund tobacco prevention and control programs at CDC-recommended levels to prevent youth use of all tobacco products, including e-cigarettes.
• Work to limit where and how all tobacco products, including e-cigarettes, are sold to reduce youth e-cigarette use, as well as ad exposure.
• Support efforts to implement and sustain proven youth tobacco prevention actions such as tobacco price increases, comprehensive smoke-free laws, and high-impact mass media campaigns.

More than 18 million (7 in 10) US middle and high school youth were exposed to e-cigarette ads in 2014.

More than 1 in 2 middle and high school youth were exposed to e-cigarette ads in retail stores.

Nearly 2 in 5 middle and high school youth saw e-cigarette ads online.

Problem

Youth are vulnerable to e-cigarette ads.

18 million youth were exposed to e-cigarette ads in 2014.

• More than 10 million high school students and nearly 8 million middle school students were exposed to e-cigarette ads in 2014.
• More than half of high school students (about 8 million) saw e-cigarette ads in retail stores, and more than 6 million saw them on the Internet.
• More than half of middle school students (6 million) saw e-cigarettes ads in retail stores, and more than 4 million saw them on the Internet.
• About 15% of all students reported seeing e-cigarette ads from all four sources, including retail stores, the Internet, magazines/newspapers, and TV/movies.

Exposure to e-cigarette ads may contribute to youth e-cigarette use:

• E-cigarette companies have rapidly increased advertising spending, from $6.4 million in 2011 to $115 million in 2014.
• Many of the themes used in advertising for cigarettes are also now used to advertise e-cigarettes – including sex, independence, and rebellion.
• During the time e-cigarette ads have increased, there are also increases in e-cigarette use among US youth. From 2011-2014, e-cigarette use in the past 30 days increased from less than 1% to almost 4% among middle school students and from less than 2% to 13% among high school students.

What Can Be Done

The Federal government is

• Supporting state tobacco prevention and control programs to prevent any youth use of tobacco products, including e-cigarettes.
• Tracking e-cigarette use; supporting research on the health effects and factors contributing to youth e-cigarette use; and providing information to the public, including health care providers.
• Developing regulations for e-cigarettes and other currently unregulated tobacco products to reduce the disease and death from tobacco use, including by preventing youth tobacco use.
• Funding and promoting campaigns that inform people about the dangers of tobacco use, such as FDA’s The Real Cost and Fresh Empire for youth and CDC’s Tips From Former Smokers for adults.

States and communities can

• Fund tobacco prevention and control programs at CDC-recommended levels to prevent youth use of all tobacco products, including e-cigarettes.
• Work to limit where and how all tobacco products, including e-cigarettes, are sold to reduce youth e-cigarette use, as well as ad exposure. This may include:
  • Requiring age verification to enter e-cigarette vendors’ websites, make purchases, and accept deliveries of e-cigarettes.
  • Restricting the number of stores that sell tobacco and how close they can be to schools.
  • Requiring that e-cigarettes be sold only through face-to-face transactions, not on the Internet.
  • Limiting tobacco product sales to facilities that never admit youth.
• Support efforts to implement and continue proven youth tobacco prevention approaches, including tobacco price increases, comprehensive smoke-free laws, and high-impact mass media campaigns.

Pediatricians, nurses, and other health care providers can

• Ask about youths’ e-cigarette use and counsel them about the dangers of nicotine, e-cigarettes, and all other tobacco use.
• Ask all patients whether they use tobacco products, encourage those who do to quit, and provide help with quitting.
• Ask about youths’ media and Internet use. Advise parents and caregivers to take an active role in deciding which websites and media children may view and teaching critical viewing skills.

Parents and caregivers can

• Set a positive example by being tobacco-free. For free help, call 1-800-QUIT-NOW or visit www.smokefree.gov
• Talk to youth about why they shouldn’t use any tobacco products, including e-cigarettes.
• Know what media their children are viewing, and decide what programs and websites are appropriate for their age. Watch programs together and discuss content.

As students go back to school, parents, teachers, administrators, and coaches can help them make smart choices for their health, including avoiding e-cigarettes.

About 1 in 5 high school students and 1 in 20 middle school students reported using e-cigarettes in 2020. Now is an important time to help students understand the serious health risks of e-cigarette use.

Why It Matters

Any tobacco use by youth and young adults, including e-cigarettes, is unsafe.

Nearly all e-cigarette products sold contain nicotine, which is the same addictive drug found in other tobacco products, including cigarettes and cigars. The nicotine content information on e-cigarette packaging is often misleading or inaccurate.

Nicotine is highly addictive and can harm adolescent brain development, which continues into the mid-20s. Compared with older adults, the brains of youth and young adults are more vulnerable to nicotine’s harmful health effects. These include nicotine addiction and potentially reduced impulse control, mood disorders, and poor attention and thinking skills.

Many youth and young adults who use e-cigarettes also smoke regular cigarettes or use other tobacco products. Young people who use e-cigarettes may be more likely to smoke regular cigarettes later in life. E-cigarette use can also increase the risk for future addiction to other drugs.

Youth E-cigarette Use

Parents, teachers, counselors, and coaches should know that in 2020:

• About 3.6 million US youth reported current e-cigarette use.
• E-cigarettes were the most commonly used tobacco product among US middle and high school students.
• 1 in 5 high school students and nearly 1 in 10 middle school students who used e-cigarettes reported using them every day.

What You Can Do

Learn about e-cigarette products.

Having an informed discussion about e-cigarettes with youth begins with knowing what to watch for. If you spend time with young people, you may have seen an e-cigarette device without even knowing it. E-cigarettes come in many shapes and sizes, as tobacco companies use new technologies to develop new products. The two most common types of e-cigarettes used by youth are prefilled pods or cartridges and disposables. They may look like a small USB flash drive, pen, highlighter, or other everyday items. They are easy to hide among school supplies.

Some e-cigarette products also come in a variety of flavors, including fruit, candy, mint, dessert, and menthol. These flavors make the addictive product more appealing to kids. In 2020, about 8 in 10 middle and high school students who used e-cigarettes reported using a flavored product.

Set a good example by not using tobacco products.

Youth and young adults look to parents and teachers as role models. It’s important to set a good example by being tobacco-free and ensure that youth and young adults are not exposed to the secondhand emissions from any tobacco products, including e-cigarettes. For free support in quitting tobacco products, including quit coaching, a quit plan, educational materials, and referrals to local resources, call 1-800-QUIT-NOW.

Talk to Kids Today

Heading back to school is a time of transition for kids and an opportunity for parents, teachers, and other adults who interact with youth to talk to them about the serious short-term and long-term health risks associated with e-cigarettes. Don’t miss this chance to talk with kids about these dangers—their health may depend on it.

Find free resources to help guide an informed e-cigarette discussion with youth.

Find more information, including fact sheets and free downloadable resources, at CDC.gov/e-cigarettes.

CDC, the U.S. Food and Drug Administration (FDA), state and local health departments, and other clinical and public health partners are investigating a national outbreak of e-cigarette, or vaping, product use-associated lung injury (EVALI).

Overview

• Emergency department (ED) visits related to e-cigarette, or vaping, products continue to decline, after sharply increasing in August 2019 and peaking in September.
• National and state data from patient reports and product sample testing show tetrahydrocannabinol (THC)-containing e-cigarette, or vaping, products, particularly from informal sources like friends, family, or in-person or online dealers, are linked to most EVALI cases and play a major role in the outbreak.
• Vitamin E acetate is strongly linked to the EVALI outbreak. Vitamin E acetate has been found in product samples tested by FDA and state laboratories and in patient lung fluid samples tested by CDC from geographically diverse states. Vitamin E acetate has not been found in the lung fluid of people that do not have EVALI.
• Evidence is not sufficient to rule out the contribution of other chemicals of concern, including chemicals in either THC or non-THC products, in some of the reported EVALI cases.

CDC will continue to update guidance related to EVALI as appropriate.

What We Know

About the Outbreak:

• As of February 18, 2020, a total of 2,807 hospitalized EVALI cases or deaths have been reported to CDC from all 50 states, the District of Columbia, and two U.S. territories (Puerto Rico and U.S. Virgin Islands).
  • Sixty-eight deaths have been confirmed in 29 states and the District of Columbia (as of February 18, 2020).
• Emergency department (ED) visits related to e-cigarette, or vaping, products continue to decline, after sharply increasing in August 2019 and peaking in September.
  • National ED data and active case reporting from state health departments around the country show a sharp rise in symptoms or cases of EVALI in August 2019, a peak in September 2019, and a gradual, but persistent decline since then.
  • Reasons for the decline are likely multifactorial and may be related to the following:
    • Increased public awareness of the risk associated with THC-containing e-cigarette, or vaping, product use as a result of the rapid public health response.
    • Removal of vitamin E acetate from some products.
    • Law enforcement actions related to illicit products.
• Laboratory data show that vitamin E acetate, an additive in some THC-containing e-cigarette, or vaping, products, is strongly linked to the EVALI outbreak.
  • A recent study analyzed samples from 51 EVALI cases from 16 states and a comparison group of samples from 99 comparison individuals without EVALI for vitamin E acetate, plant oils, medium chain triglyceride (MCT) oil, coconut oil, petroleum distillates, and diluent terpenes.
  • Vitamin E acetate was identified in bronchoalveolar lavage (BAL) fluid samples (fluid samples collected from the lungs) from 48 of the 51 EVALI patients, but not in the BAL fluid from the healthy comparison group.
  • No other toxicants were found in BAL fluid from either group, except for coconut oil and limonene (1 EVALI patient each).

• In August 2019, CDC started collecting data from states on EVALI cases using a standardized case report form. The data were voluntarily collected and submitted by each state to CDC on a routine basis. Due to the subsequent identification of the primary cause of EVALI, and the considerable decline in EVALI cases and deaths since a peak in September 2019, CDC stopped collecting these data from states as of February 2020.
  • However, CDC continues to monitor EVALI-related trends using emergency department data from the National Syndromic Surveillance Program’s BioSense/ESSENCE platform. These data do not suggest a resurgence of EVALI at this time.
  • CDC encourages clinicians to continue to report possible cases of EVALI to their local or state health department for further investigation.
• CDC will continue to provide assistance to states, as needed, related to EVALI and will provide any updates at: www.cdc.gov/EVALI.

What CDC Recommends

• CDC and FDA recommend that people not use THC-containing e-cigarette, or vaping, products, particularly from informal sources like friends, family, or in-person or online dealers.
• Vitamin E acetate should not be added to any e-cigarette, or vaping, products. Additionally, people should not add any other substances not intended by the manufacturer to products, including products purchased through retail establishments.
• Adults using nicotine-containing e-cigarette, or vaping, products as an alternative to cigarettes should not go back to smoking; they should weigh all available information and consider using FDA-approved smoking cessation medications. If they choose to use e-cigarettes as an alternative to cigarettes, they should completely switch from cigarettes to e-cigarettes and not partake in an extended period of dual use of both products that delays quitting smoking completely. They should contact their healthcare professional if they need help quitting tobacco products, including e-cigarettes, as well as if they have concerns about EVALI.
• E-cigarette, or vaping, products (nicotine- or THC-containing) should never be used by youths, young adults, or women who are pregnant.
• Adults who do not currently use tobacco products should not start using e-cigarette, or vaping, products.
• THC use has been associated with a wide range of health effects, particularly with prolonged frequent use. The best way to avoid potentially harmful effects is to not use THC-containing e-cigarette, or vaping, products.
• Persons engaging in ongoing cannabis use that leads to significant impairment or distress should seek evidence-based treatment by a healthcare professional.

Key Facts about Use of E-Cigarette, or Vaping, Products

• Electronic cigarettes—or e-cigarettes—are also called vapes, e-hookahs, vape pens, tank systems, mods, and electronic nicotine delivery systems (ENDS).
• Using an e-cigarette is commonly called vaping.
• E-cigarettes work by heating a liquid to produce an aerosol that users inhale into their lungs.
• The liquid can contain: nicotine, tetrahydrocannabinol (THC) and cannabinoid (CBD) oils, and other substances, flavorings, and additives. THC is the psychoactive mind-altering compound of marijuana that produces the “high.”

Key Facts about Vitamin E Acetate

• Vitamin E acetate is used as an additive, most notably in THC-containing e-cigarette, or vaping, products.
• Vitamin E is a vitamin found in many foods, including vegetable oils, cereals, meat, fruits, and vegetables. It is also available as a dietary supplement and in many cosmetic products, like skin creams.
• Vitamin E acetate usually does not cause harm when ingested as a vitamin supplement or applied to the skin. However, previous research suggests that when vitamin E acetate is inhaled, it may interfere with normal lung functioning.

You’ve probably heard a lot about vaping lately. You might also know about the recent outbreak of lung injuries and deaths linked to vaping in the U.S. But those aren’t the only risks that come with vaping. Here’s what you need to know.

Vaping devices, also known as e-cigarettes, vape pens, and e-hookahs among other terms, come in many shapes and sizes. Some look like traditional cigarettes, cigars, or pipes. Others are shaped like every-day objects, such as pens or USB memory sticks.

While they may look different, most vaping devices work in a similar way. Puffing activates a battery-powered heating device. This heats the liquid in a cartridge, turning it into vapors that are inhaled.

Vaping exposes the lungs to a variety of chemicals. These may include the main active chemicals in tobacco (nicotine) or marijuana (THC), flavorants, and other ingredients that are added to vaping liquids. Plus, other chemicals can be produced during the vaporizing process.

“If the liquid has nicotine in it, then the user is inhaling nicotine along with the other ingredients in the liquid,” explains Dr. Thomas Eissenberg, an expert on tobacco research at Virginia Commonwealth University.

While vaping devices work similarly, some are more powerful than others. They create more vapor and deliver more chemicals.

So how safe is vaping? Studies suggest nicotine vaping may be less harmful than traditional cigarettes when people who regularly smoke switch to them as a complete replacement. But nicotine vaping could still damage your health.

“Your lungs aren’t meant to deal with the constant challenge of non-air that people are putting into them—sometimes as many as 200 puffs a day—day after day, week after week, year after year,” Eissenberg says.

“You’re inhaling propylene glycol, vegetable glycerin, flavorants that were meant to be eaten but not inhaled, and nicotine,” he explains. “And all of those are heated up in this little reactor, which is an e-cigarette. When they get heated up, those components can turn into other potentially dangerous chemicals.”

One harmful chemical may be a thickening agent called Vitamin E acetate, which is sometimes used as an additive in THC-containing vape products. The CDC identified it as a “chemical of concern” among people with vaping-associated lung injuries. They recommend avoiding any vaping product containing Vitamin E acetate or THC, particularly those from informal sources like friends, family, or in-person or online dealers.

Vaping is now more popular among teens than smoking traditional cigarettes. One in four high school seniors say they vaped nicotine in the past month. And studies have found that teens who vape nicotine may be more likely to go on to smoke traditional cigarettes.

Marijuana vaping has also increased dramatically among teens. About 20% of high school seniors vaped marijuana in the past year. The rates have more than doubled in the past two years.

New laws are aimed at curbing vaping among teens. People must now be 21 to buy any tobacco product, including vaping products. And companies can no longer produce and sell flavors that appeal to children like fruit and mint.

If you’ve already started vaping or smoking cigarettes, it’s never too late to quit. See the Wise Choices box for tips on stopping.

Ready to Quit?

Here are some tips to help you stop using nicotine:

• Know why you’re quitting. Ask yourself if nicotine is getting in the way of what matters to you.
• Quit completely. If you use different tobacco products, now is a good time to quit those too.
• Set your quit date.
• Understand your triggers, so you can avoid them.
• Imagine your life without nicotine. Picture the positives of quitting.
• Build a team of people who will support you while you quit.
• Get free help online at smokefree.gov, at 1-800-QUIT-NOW (1-800-784-8669), or by texting QUIT to 47848.