A Complete Guide to

E-Cigarettes and Vaping

Medically reviewed by Dr. Maroof Ahmed, MD on September 5, 2018

The rise of e-cigarettes has sparked intense debate over whether these trendy new devices are a public health miracle or disaster.

Nowadays, vaping (the inhalation of e-cigarette vapour) is extremely common, with over 20 million users worldwide, and 460 brands marketing e-cigarettes around the globe.

The largest market for e-cigarettes is in the United States, yet many other countries are also reporting sharp increases in the use of these products. Meanwhile, worldwide use of traditional cigarettes and other tobacco products is slowly beginning to decline.

What are e-cigarettes?

E-cigarettes, also known as e-cigs, vape pens or electronic nicotine delivery systems, are battery-operated smoking devices, originally designed to mimic traditional cigarettes.

They’re available in a wide range of flavours, and while most contain nicotine, some are marketed for their flavour alone. For this reason, these products are often referred to as e-hookah, or e-shisha pens.

For the standard e-cigarette, nicotine is extracted from tobacco and mixed with a liquid base like propylene glycol or glycerol, along with other chemicals and flavourings. This solution is then added to a cartridge that can be fitted to an e-cigarette device.

Most e-cigarettes are rechargeable, and use refillable or replaceable e-liquid (or e-juice) cartridges. When the user puffs on the mouthpiece attached to the cartridge, a heating element is activated, and the liquid is vapourised. The resulting aerosol solution, or vapour, is inhaled.

E-cigarettes were originally designed to mimic traditional cigarettes.

Are e-cigarettes regulated?

Currently, in the UK and USA, e-cigarettes are not considered a medical nicotine replacement therapy (NRT), and so aren’t available on prescription.

The Food and Drug Administration (FDA) regulates certain aspects of the e-cigarette market, like the labelling, promotion and distribution of e-cigarette-related products. However, since the FDA doesn’t classify them as medical products and therefore doesn’t regulate their safety.

Globally, there has been a lot of debate surrounding the use and regulation of e-cigarettes, with many arguments against their use stemming from potential long-term health risks and the trend of vaping amongst young people (particularly high school students).

Nevertheless, reputable organisations, such as Public Health England and the Royal College of Physicians, continue to push for e-cigarettes to be licensed as medicinal products. They’re basing their arguments on increasing evidence suggesting e-cigarettes can be powerful smoking cessation aids for adult smokers, and are likely to be far less damaging than regular cigarettes in the long-term.

Who should use them?

Because no smoke is produced, e-cigarettes don’t contain tar and carbon monoxide — two harmful substances present in regular cigarettes. Since the puffing, the hand-to-mouth action, the delivery of nicotine and the cigarette smoke-like vapour all mimic regular smoking, e-cigarettes can be helpful for many people who are trying to quit smoking.

As nicotine-replacement aids, e-cigarettes provide a dose of nicotine that would usually be sourced from cigarettes, and thereby help to minimise the nicotine withdrawal symptoms you’d likely experience if you chose to quit using the ‘cold turkey method’.

Because most people continue to smoke tobacco due to a nicotine addiction, e-cigarettes can help to tackle the physical side of a smoking habit.

Unlike other smoking cessation aids like gums and patches, the resemblance of e-cigarettes to regular cigarettes can also help to combat some of the psychological, or behavioural aspects of smoking.

Despite this, in order to maximise your chances of success on your quit-smoking journey, the use of these products should be combined with traditional therapy sessions or use of an evidence-based, virtual therapy such as the Quit Genius app.

If you haven’t yet given up regular cigarettes, e-cigarettes probably aren’t for you just now. Don’t begin to use these products until your quit date, as they won’t offer any benefits before this time, unless you are swapping some of the cigarettes you smoke each day for use of an e-cigarette.

If so, you should seek advice from a medical professional to ensure you don’t end up taking in more nicotine, which would have a negative impact on your ability to eventually quit cigarette smoking altogether.

Non-smokers or ex-smokers should avoid the use of e-cigarettes, as this could kick-start a nicotine addiction which could then be very difficult to break.

If you’re a pregnant or breastfeeding woman, it’s crucial that you seek medical advice before using these products, to ensure that the health of your baby won’t be compromised.

E-cigarettes as a quit-smoking aid

You should start to use your e-cigarette on your quit day, at the time when you would usually smoke your first cigarette. Continue to use throughout the day, in line with your normal smoking routine. Be careful not to use the device more frequently than you would smoke cigarettes in an average day.

Since e-cigarettes contain nicotine, they can be addictive and have the ability to worsen your nicotine addiction if improperly used.

As with other smoking cessation products, e-cigarettes are not intended for long-term use. They are designed to help you transition to a smoke-free life, but in order to break the addiction completely, e-cigarette use must be gradually reduced over time.

Consult your doctor before beginning to use these devices. They will help you to create a schedule which will detail the frequency and duration of e-cigarette use as you progress through your quit-smoking journey.

Methods for weaning yourself off e-cigarettes may include reducing the number of times you use the device throughout the day, reducing the nicotine strength of the e-liquid you use, or swapping nicotine-containing e-liquids for nicotine-free e-liquids from time to time.

Side effects

Some people notice minor side effects with the use of e-cigarettes. Commonly reported symptoms include:

  • Increased saliva production
  • Sore/dry throat or nasal passages
  • Nausea/dizziness
  • Headaches

If any of these side effects become troublesome, seek medical advice.

Health risks associated with e-cigarettes

Despite not containing tar or carbon monoxide, e-cigarettes are not free of toxic substances, and therefore questions have been raised about their long-term health effects.

With so many products available — with different ingredients, strengths and modes of action — it’s difficult to classify what an e-cigarette really is. That makes it extremely difficult for researchers to study their safety and potential health risks.

In addition, as relatively new products, there aren’t any studies investigating the long-term use of e-cigarettes, so their effects over a lifetime remain unknown.

Moreover, many of the studies that have been conducted either contain too few participants to enable researchers to make generalisations for entire populations, or are funded by e-cigarette companies, creating significant research bias.

Concerns surrounding e-liquid additives

One widely reported concern about the long-term use of e-cigarettes was centred around the chemicals used to create e-liquid flavours. It was suggested that the chemical diacetyl, used to produce some of the sweet e-liquid flavours, could have serious health consequences.

Diacetyl is a naturally-occurring compound, and is often added to food and drink as an additive. Ingested in this way, it doesn’t cause any harm. However, added to products that generate aerosols, it could be very damaging.

Evidence for this effect dates back a decade, when workers from a popcorn factory contracted bronchiolitis obliterans, an obstructive lung disease. Researchers found that those who developed the disease had been in closer contact with diacetyl — which was used to create the butter flavour of the popcorn — and had therefore inhaled greater amounts of the chemical. The lung condition has since been commonly referred to as ‘popcorn lung’.

After discovering that certain e-liquid flavours contain diacetyl, it was suggested that long-term e-cigarette vapour inhalation could be associated with the development of popcorn lung.

In the UK, it’s now illegal to add diacetyl to e-liquid. But if you’re purchasing products online or other countries, it’s worth checking the retailer’s safety legislation.

Safety risks of e-cigarette devices

The majority of research focuses on the consequences of inhaling e-cigarette vapour, but what about the risks associated with the devices themselves?

There have been several reports, from e-cigarette users and health officials, of e-cigarette devices exploding. In some instances, this has led to chemical or flame burns, while in others, the devices have caused fires.

According to experts, these events tend to be associated with the lithium-ion batteries in e-cigarettes, and usually occur when the devices have been misused.

When using these products, follow these precautions:

  1. Purchase devices from reputable vape shops — check whether the safety of these products is regulated in your country and do your research when making online purchases.
  2. Use only the cable provided when charging your device.
  3. Don’t use e-cigarettes while they are charging.
  4. Don’t modify your device in any way.
  5. Avoid overcharging your device/leaving it charging overnight.
  6. Discard the batteries if they become wet or damaged in any way. Purchase replacements from a reputable supplier.

E-cigarettes and the risk of addiction

As previously mentioned, e-cigarettes contain nicotine, the addictive substance in cigarettes. In order to work as an effective quit-smoking aid, e-cigarettes should not be used as a long-term solution to smoking. If e-cigarette users don’t wean themselves off these products as they progress through their smoking cessation programme, they are at risk of becoming completely reliant on e-cigarettes, and therefore unable to break their addiction.

By design, e-cigarettes mimic traditional cigarettes, with the aim of making the transition away from tobacco smoking smoother and more achievable. The problem comes when these products are made so attractive to ex-smokers that a new addiction ends up forming.

As a multi-billion-dollar industry, it’s no surprise that e-cigarette companies are utilising technologies to develop the most cigarette-like smoking experiences possible.

American company, Juul, is a brand that does just that. It creates high-quality e-cigarettes that deliver powerful nicotine hits and aim to provide the same satisfaction as tobacco cigarettes.

Users of Juul products may praise the quality, but many also admit that they have become heavily reliant on e-cigarettes as a result.

What’s more, Juul’s e-liquid pods only come in one nicotine strength. This could have a negative impact on a user’s ability to wean themselves off e-cigarettes, as their only option would be to vape less, while using a product that’s been expertly designed to make you want more!

So, when considering using e-cigarettes as a quit-smoking aid, it’s important to face the facts: they could help you to make the transition to a smoke-free life, if used on a short-term basis. But if used without medical guidance and support, they could ultimately make tackling your addiction a whole lot more complicated.

Is vaping safer than smoking?

If scientific evidence is lacking, can e-cigarettes safely be recommended as a healthier alternative to regular cigarettes?

That’s the question that tends to divide expert opinion. Without studies that investigate the long-term health risks of e-cigarettes, inferences must be made from the little evidence that is available.

In 2015, Public Health England published a report which concluded that e-cigarettes are 95% safer than regular cigarettes, and they are able to help adult smokers quit.

A more recent review of the most relevant scientific studies to date concluded that at present, there is no available evidence whether or not e-cigarette usage is associated with respiratory or cardiovascular diseases. Although there is substantial evidence that some toxic chemicals present in e-cigarette vapour are able to cause DNA damage — and therefore could potentially increase the risk of cancer — it remains unclear whether the levels of these chemicals are high enough to cause these effects in humans.

In contrast, smoking regular cigarettes is proven to increase the risk of developing respiratory disease, cardiovascular disease and lung cancer.

So, although the long-term effects of inhaling the flavourings, base liquids (propylene glycol and glycerine), and toxins present in the e-liquid must continue to be studied, many public health officials agree that if people haven’t been successful with other quit-smoking aids like nicotine gum, e-cigarettes could be the next logical step.

Despite the unknown long-term potential dangers, more and more experts and organisations are taking the view that e-cigarettes are far safer than regular cigarettes.

Take home message

In recent years, e-cigarettes have become increasingly popular with people who are trying to quit smoking. The look, feel and method of smoking e-cigarettes is similar to that of regular cigarettes, and this can make the transition to a smoke-free life considerably easier.

Although e-cigarettes don’t contain tar or carbon monoxide, they are not free of toxins, and as such may not be completely safe. At present, there is a lack of reliable scientific research investigating the health effects of e-cigarettes, and the long-term implications remain unknown.

Nevertheless, if you haven’t had success with other smoking cessation aids like gums or patches, it’s worth talking to your doctor about using e-cigarettes as part of your quit-smoking programme. Despite the unknown risks, if it’s your only option, it’s likely that switching to these products will be far less damaging than continuing to smoke regular cigarettes.

But remember, as nicotine-containing products, e-cigarettes can become addictive, and are therefore not intended as a long-term solution. The use of e-cigarettes should be gradually phased out over time, to enable you to completely break your nicotine addiction.

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