E-cigarettes are marketed as a healthier alternative to traditional cigarettes, but how factual is this claim?
Traditional Cigarettes at a Glance
It is no secret that traditional cigarettes are detrimental to human health. There are approximately 600 ingredients and over 7,000 chemicals in a single cigarette, and at least 69 of the chemicals are known to cause cancer1American Lung Association, “What’s In a Cigarette?,” www.lung.org, May 31, 2023. https://www.lung.org/quit-smoking/smoking-facts/whats-in-a-cigarette. Many of the carcinogens found in tobacco are present in everyday items. Cadmium is an active component of battery acid, arsenic is used in rat poison, and carbon monoxide is released in car exhaust fumes.
In 2008, the Tobacco Products Directive2“Implementing the Tobacco Products Directive (Directive 2014/40/EU),” health.ec.europa.eu, Feb. 21, 2023. https://health.ec.europa.eu/tobacco/product-regulation/implementing-tobacco-products-directive-directive-201440eu_en (TPD) mandated all EU countries to display images depicting potential smoking-related consequences on cigarette packets. Since then, smokers in Austria, Belgium, and anywhere else that falls under the remit of the European Union have seen depictions of tooth decay, throat cancer, and diabetes on their cigarette packets.
Despite the negative health effects being widely publicized, cigarettes continue to be one of the most popular vices. According to Tobacco Atlast, 1.1 billion smokers across the globe consume nearly 5 trillion cigarettes each year3“Tobacco Atlas,” Tobaccoatlas.org, 2019. https://tobaccoatlas.org/.
Use of Cigarettes in the U.S.
The Centers for Disease Control and Prevention (CDC) reports that 11.5% of the adult population in the U.S. currently smoke cigarettes4CDCTobaccoFree, “Burden of Tobacco Use in the U.S.,” Centers for Disease Control and Prevention, Aug. 08, 2022. https://www.cdc.gov/tobacco/campaign/tips/resources/data/cigarette-smoking-in-united-states.html[/mfn], totaling 28.3 million individuals. Additionally, the 2023 National Youth Tobacco Survey (NYTS) found that 10% of middle and high school students currently use tobacco4J. Birdsey, “Tobacco Product Use Among U.S. Middle and High School Students — National Youth Tobacco Survey, 2023,” MMWR. Morbidity and Mortality Weekly Report, vol. 72, no. 44, 2023, doi: https://doi.org/10.15585/mmwr.mm7244a1.
Health Impact of Cigarettes in the USA
Here are a few of the known outcomes of smoking cigarettes5“Health Effects of Smoking and Tobacco Use,” Centers for Disease Control and Prevention, Apr. 28, 2020. https://www.cdc.gov/tobacco/basic_information/health_effects/index.htm.
- Cancer
- Heart disease
- Stroke
- Lung disease
- Diabetes
- Chronic Obstructive Pulmonary Disease (COPD), which includes emphysema and chronic bronchitis
- Tuberculosis
- Eye diseases
- Rheumatoid arthritis
The statistics do not lie; cigarettes are the leading cause of preventable death in the USA. The 2014 Surgeon General’s Report found that smoking cigarettes and inhaling secondhand smoke kills more than 480,000 Americans each year6CDCTobaccoFree, “2014 SGR: The Health Consequences of Smoking—50 Years of Progress,” Centers for Disease Control and Prevention, Jun. 02, 2021. https://www.cdc.gov/tobacco/sgr/50th-anniversary/index.htm, which is more than AIDs, alcohol, car accidents, drugs, murders, and suicides combined.
The same report highlighted the following:
- Smoking causes 90% of all lung cancer deaths
- Smoking causes 80% of all deaths from COPD
- Smoking has killed more than 10 times as many U.S. citizens than all the wars fought by the U.S.
The same report outlined how many premature deaths have been caused by smoking and exposure to secondhand smoke from 1965 to 2014.
| Cause of Death | Total |
| Smoking-related cancers | 6,587,000 |
| Cardiovascular and metabolic diseases | 7,787,000 |
| Pulmonary diseases | 3,804,000 |
| Conditions related to pregnancy and birth | 108,000 |
| Residential fires | 86,000 |
| Lung cancers caused by exposure to secondhand smoke | 263,000 |
| Coronary heart disease caused by exposure to secondhand smoke | 2,194,000 |
| Total | 20,830,000 |
E-Cigarettes at a Glance
Chinese pharmacist Hon Lik invented e-cigarettes in 2003. E-cigarettes are comprised of a cartridge containing an e-liquid, an atomizer, and a battery.
Unlike cigarettes, e-cigarettes do not contain tobacco. To achieve the same great-tasting nicotine hit, manufacturers extract nicotine from tobacco leaves. They add nicotine to e-liquid and dispose of the leaves along with most of the harmful carcinogens.
E-cigarettes are frequently advertised as healthier substitutes for cigarettes. The CDC concedes that e-cigarettes contain fewer toxic chemicals than cigarettes, but emphasizes that “e-cigarette aerosol is not harmless.”7CDC, “Smoking and Tobacco Use; Electronic Cigarettes,” Centers for Disease Control and Prevention, Nov. 16, 2020. https://www.cdc.gov/tobacco/basic_information/e-cigarettes/about-e-cigarettes.html
In recent years, e-liquids, coils, and other hardware have come under scrutiny, with some scientists suggesting that there is more to e-cigarettes than meets the eye.
Use of E-Cigarettes in the U.S.
In 2021, the National Center for Health Statistics found that 4.5% of adults aged 18 and over reported current use of e-cigarettes. The 2023 National Youth Tobacco Survey8FDA, “Results from the Annual National Youth Tobacco Survey,” FDA, Nov. 2023, Available: https://www.fda.gov/tobacco-products/youth-and-tobacco/results-annual-national-youth-tobacco-survey also found that 2.1 million young people currently use e-cigarettes.
E-Liquids Explained
All e-liquids have a base mixture that is made from vegetable glycerin and propylene glycol.
- Vegetable glycerin (VG): Thick, sweet liquid that creates big clouds. It is commonly found in soaps, candles, deodorants, and makeup.
- Propylene glycol (PG): Odorless, flavorless liquid that acts as a preservative. It is commonly found in cosmetics, dog food, hygiene products, and even salad dressing.
During an interview addressing vaping-related illnesses9B. S. / P. Sept 30 and 2019, “Public health expert discusses the dangers of vaping and e-cigarettes,” The Hub, Sep. 30, 2019. https://hub.jhu.edu/2019/09/30/vaping-related-illness-public-health-expert-qa/, Joanna Cohen, Director of the Institute for Global Tobacco Control at Johns Hopkins, said, “The propylene glycol and/or vegetable glycerin that form the basis of e-liquids are generally regarded as safe for ingestion, but we do not yet know the effects when inhaled.”
Like the other elements of a typical e-cigarette, vegetable glycerin and propylene glycol are assumed, rather than proven, to be relatively safe for consumption. However, it is widely accepted that 1 in 10 vapers have an allergic reaction to propylene glycol, which might manifest in swollen gums, a red rash around the mouth, or coughing.
Health Impact of E-Cigarettes in the U.S.
The health impact of e-cigarettes is relatively unknown. There are plenty of concerns about the health implications of e-liquid, but science has not caught up to the e-cigarette boom. Although there are very few studies on the long-term impact of e-cigarettes, clinicians have identified a link between vaping and lung injuries.
EVALI stands for e-cigarette or vaping use-associated lung injury. In 2019, images of CT scans of EVALI patients were published. The images showed acute inflammation that often led to acute respiratory distress, followed by the patient being put on a ventilator.
The main outbreak happened in 2020, when the CDC reported a total of 2,807 hospitalization cases for EVALI10Cdc. O. on S. and Health, “Smoking and Tobacco Use; Electronic Cigarettes,” Centers for Disease Control and Prevention, Feb. 25, 2020. https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html, resulting in 68 deaths in a single year. These fatalities created an understandable hysteria around e-cigarettes, but the outbreak was soon attributed to the presence of vitamin E acetate11B. C. Blount et al., “Vitamin E Acetate in Bronchoalveolar-Lavage Fluid Associated with EVALI,” New England Journal of Medicine, vol. 382, no. 8, Dec. 2019, doi: https://doi.org/10.1056/nejmoa1916433 in e-liquid.
Although this outbreak appeared to fade into the background, medical records show that vaping-induced lung injuries continue to be a concern in the U.S. In 2020, the National Center for Health Statistics created U07.0, a diagnostic code for EVALI12“New ICD-10-CM code for vaping-related disorder to be implemented,” 2020. Available: https://www.cdc.gov/nchs/data/icd/vaping-announcement-final-12-09-19.pdf.
- In the last three months of 2020, EVALI cases reached 11,300
- In 2021, EVALI cases hit 22,000
- In 2022, EVALI cases hit 31,600
Sceptics might argue that EVALI cases are not necessarily a result of e-cigarette vapor, but medical professionals disagree. Karen M. Wilson, a pediatric hospitalist at the University of Rochester Medical Center in New York, is quick to differentiate between traditional cigarettes and e-cigarettes. “You might find some microvascular changes with normal inhaling of smoke or aerosol,”13L. Gillespie, “Forgotten but Not Gone: Epidemic of Vaping Illness Continues,” WebMD. https://www.webmd.com/lung/news/20230425/epidemic-of-vaping-illness-continues Wilson said, “but you’re not going to find macro changes like we see with EVALI.”
It looks like EVALI is here to stay, making it the first long-term e-cigarette-induced condition that is distinct from conditions associated with traditional cigarette use.
Health Impact of Metals in E-Cigarettes
In a seminal 2018 study, researchers surveyed 56 e-cigarette devices from daily e-cigarette users14P. Olmedo et al., “Metal Concentrations in e-Cigarette Liquid and Aerosol Samples: The Contribution of Metallic Coils,” Environmental Health Perspectives, vol. 126, no. 2, p. 027010, Feb. 2018, doi: https://doi.org/10.1289/ehp2175 and found:
- Cadmium in 55.1% of the tank samples
- Arsenic in 10.7% of the dispenser samples
To ensure a fair trial, researchers took samples from the devices before and after the e-liquid came into contact with the coil. They found metals in both samples.
This 2018 study is indicative of a wider pattern. One paper analyzed 24 studies on metals and metalloids in e-liquids15D. Zhao et al., “Metal/Metalloid Levels in Electronic Cigarette Liquids, Aerosols, and Human Biosamples: A Systematic Review,” Environmental Health Perspectives, vol. 128, no. 3, p. 036001, Mar. 2020, doi: https://doi.org/10.1289/ehp5686, e-cigarette aerosols, and human biosamples of e-cigarette users.
- 12 studies found metals and metalloids in e-liquids
- 12 studies found metals and metalloids in e-cigarette aerosols
- 4 studies found metals and metalloids in human biosamples
The presence of metals in e-liquids is not contested. However, the extent of their impact on human health remains unclear.
It is no surprise that metalloids like arsenic are detrimental to our health. Still, there are no studies that definitively link e-liquids to arsenic-induced illnesses such as bladder cancer, lung cancer, and arsenic poisoning. We can assume that vapers who inhale arsenic will face some consequences, but it is not clear how.
Health Impact of E-Cigarette Flavorings
According to the National Academies of Sciences, Engineering, and Medicine, there are over 7,000 e-liquid flavors on the market.
Researchers at Harvard T.H. Chan School of Public Health analyzed 51 types of flavored e-cigarette brands that appeal to youth and found diacetyl in more than 75% of the samples16J. G. Allen et al., “Flavoring Chemicals in E-Cigarettes: Diacetyl, 2,3-Pentanedione, and Acetoin in a Sample of 51 Products, Including Fruit-, Candy-, and Cocktail-Flavored E-Cigarettes,” Environmental Health Perspectives, vol. 124, no. 6, pp. 733–739, Jun. 2016, doi: https://doi.org/10.1289/ehp.1510185. Acetoin and 2,3-pentanedione were also detected in 46 and 23 of the flavors, respectively.
Diacetyl has been plausibly linked to popcorn lung17P. Harber, K. Saechao, and C. Boomus, “Diacetyl-Induced Lung Disease,” Toxicological Reviews, vol. 25, no. 4, pp. 261–272, 2006, doi: https://doi.org/10.2165/00139709-200625040-00006, also known as bronchiolitis obliterans. This condition gained its name when workers at a popcorn plant developed lung issues. To create the buttery popcorn flavor, manufacturers used diacetyl. When inhaled, diacetyl scars the tiny air sacs in the lungs, thickening and narrowing the airways. It is considered a life-threatening disease, though there are no figures that show how many people have died from e-cigarette-induced popcorn lung.
Since this 2015 study, TRPR and TPD regulations have banned diacetyl in e-liquids made in the EU. Unfortunately, diacetyl has not yet been banned in the U.S and manufacturers continue to use it to this day.
Cigarettes vs. E-Cigarettes: Expert Opinions
Dr Anthony Alberg18“Anthony Alberg Ph.D., M.P.H. – Arnold School of Public Health | University of South Carolina,” sc.edu. https://sc.edu/study/colleges_schools/public_health/faculty-staff/alberg_anthony.php, Professor and Chair of the Department of Epidemiology and Biostatistics at the University of South Carolina, researches the health effects of tobacco and tobacco control. In a Q&A with Cancer.Net19A. Alberg, “How Does Smoking Increase Your Cancer Risk? An Expert Q&A,” Cancer.net, Jul. 27, 2021. https://www.cancer.net/blog/2021-07/how-does-smoking-increase-your-cancer-risk-expert-qa, Alberg was asked whether vaping increases the risk of cancer.
“We know so much about the cancer risks of smoking because the epidemic of smoking started in the early 1900s, so we have decades’ worth of research studies that have advanced our understanding,” Alberg said. “In contrast, e-cigarettes have been around for about 10 years […] it usually takes many more years of data and lots of research to determine if being exposed to something like e-cigarettes can confidently be labeled a risk factor for cancer.”
Despite the relatively small amount of research into e-cigarettes, Alberg has drawn a few conclusions from his career and knowledge of carcinogens. “We do know that cancer-causing chemicals, such as nickel and cadmium, have been identified in the vapor from e-cigarettes”, meaning “it is highly likely that vaping e-cigarettes could be expected to increase the cancer risk in people.”
Joanna Cohen who, as we mentioned before, is the Director of the Institute for Global Tobacco Control at Johns Hopkins, said, “The only group who should use vaping products are cigarette smokers who are trying to quit smoking, or former smokers who have successfully switched to vaping.”20B. S. / P. Sept 30 and 2019, “Public health expert discusses the dangers of vaping and e-cigarettes,” The Hub, Sep. 30, 2019. https://hub.jhu.edu/2019/09/30/vaping-related-illness-public-health-expert-qa She goes on to say that those who have fully switched and quit smoking should “try to get off vaping products as well because these products are not safe.”
Traditional Cigarettes vs. E-Cigarettes: Harmful Chemicals
The consensus is that traditional cigarettes have a far worse impact on health than e-cigarettes, despite both containing dangerous chemicals.
Cigarettes contain 69 known carcinogens, whereas scientists are just beginning to discover how many chemicals are present in e-liquids and e-cigarettes. The revelation that most e-cigarettes contain metalloids like arsenic was met with shock, but it is common knowledge that traditional cigarettes contain arsenic.
Again, the scientific community was shocked to discover that most e-cigarettes contain diacetyl. Mass media has made e-cigarettes and popcorn lung synonymous with one another, but many studies show that the level of diacetyl in traditional cigarettes21K. Fujioka and T. Shibamoto, “Determination of toxic carbonyl compounds in cigarette smoke,” Environmental Toxicology, vol. 21, no. 1, pp. 47–54, 2006, doi: https://doi.org/10.1002/tox.20153 is much higher than the level of diacetyl found in e-cigarettes.
Traditional Cigarettes vs. E-Cigarettes: Fatalities
The 68 deaths from EVALI in 2020 do not even scratch the surface of the fatalities caused by cigarettes. In 2014, cigarettes killed more than 480,000 people in the U.S., and we can assume that there are many more deaths to come.
Smokers vs. Vapers: Long-Term Impact
The long-term impact of smoking cigarettes has been widely publicized.
According to the 2014 Surgeon General’s Report22CDCTobaccoFree, “2014 SGR: The Health Consequences of Smoking—50 Years of Progress,” Centers for Disease Control and Prevention, Jun. 02, 2021. https://www.cdc.gov/tobacco/sgr/50th-anniversary/index.htm, people who consistently smoke cigarettes have:
- 2-4 times the chance of developing coronary heart disease
- 2-4 times the chance of having a stroke
Interestingly, one study has found that long-term cigarette use also has a psychological impact. The study checked in with adults at 4, 8, and 12-year intervals. Researchers found that smokers are more likely to be lonely and socially isolated than non-smokers23K. E. Philip et al., “Relationship of smoking with current and future social isolation and loneliness: 12-year follow-up of older adults in England,” The Lancet Regional Health – Europe, vol. 14, p. 100302, Mar. 2022, doi: https://doi.org/10.1016/j.lanepe.2021.100302, less likely to engage with the community and cultural activities, and more likely to live alone.
E-cigarettes have been available since 2003, so researchers are only just beginning to publish (or even plan for) long-term studies. However, overviews give us a good indication of current scientific thoughts. One overview concludes that e-cigarette consumption “seems” less toxic than tobacco smoking24P. Marques, L. Piqueras, and M.-J. Sanz, “An Updated Overview of e-cigarette Impact on Human Health,” Respiratory Research, vol. 22, no. 1, May 2021, doi: https://doi.org/10.1186/s12931-021-01737-5, but is quick to mention that e-cigarettes are not free from hazardous effects.
Many of the adverse effects of e-cigarettes are shared by cigarettes but multiplied ten-fold. Adolescents who consume nicotine are shown to have reduced cognitive function as adults, with reduced attention spans and enhanced impulsivity25D. S. Counotte et al., “Lasting synaptic changes underlie attention deficits caused by nicotine exposure during adolescence,” Nature Neuroscience, vol. 14, no. 4, pp. 417–419, Apr. 2011, doi: https://doi.org/10.1038/nn.2770. But when we consider that cigarettes contain 69 known carcinogens on top of nicotine, e-cigarettes still appear to be the better option.
Final Thoughts
Comparing traditional cigarettes and e-cigarettes may seem unfair, and for good reason. The lack of research is a crucial sticking point. At best, we can use tentative research to speculate about the long-term impact of e-cigarettes.
For now, e-cigarettes are a healthier alternative to traditional cigarettes. As time passes and scientific research catches up to the e-cigarette boom, we will have a more accurate idea of the advantages and disadvantages of vaping instead of smoking.
