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Health and Beauty
14 October 2021

5 Vaping Facts You Need to Know


1: Vaping Is Less Harmful Than Smoking, but It’s Still Not Safe

E-cigarettes heat nicotine (extracted from tobacco), flavorings and other chemicals to create an aerosol that you inhale. Regular tobacco cigarettes contain 7,000 chemicals, many of which are toxic. While we don’t know exactly what chemicals are in e-cigarettes, Blaha says “there’s almost no doubt that they expose you to fewer toxic chemicals than traditional cigarettes.”

However, there has also been an outbreak of lung injuries and deaths associated with vaping. As of Jan. 21, 2020, the Centers for Disease Control and Prevention (CDC) confirmed 60 deaths in patients with e-cigarette, or vaping, product use associated lung injury (EVALI).

- 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.


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 external icon 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 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 external icon. 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.


- As of December 3, 2019, CDC is only reporting hospitalized EVALI cases and EVALI deaths regardless of hospitalization status. CDC has removed nonhospitalized cases from previously reported case counts.

-As of February 18, 2020, a total of 2,807 hospitalized e-cigarette, or vaping, product use-associated lung injury (EVALI) cases or deaths have been reported to CDC from 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):

- Alabama, California (4), Connecticut, Delaware, District of Columbia, Florida (2), Georgia (6), Illinois (5), Indiana (6), Kansas (2), Kentucky, Louisiana (2), Massachusetts (5), Michigan (3), Minnesota (3), Mississippi, Missouri (2), Montana, Nebraska, New Jersey, New York (4), Oregon (2), Pennsylvania, Rhode Island, South Carolina, Tennessee (2), Texas (4), Utah, Virginia and Washington (2).

- The median age of deceased patients was 49.5 years and ranged from 15-75 years (as of February 18, 2020).

- Among the 2,668 hospitalized EVALI cases or deaths reported to CDC (as of January 14, 2020):

- 66% were male

-The median age of patients was 24 years and ranged from 13–85 years.

- By age group category:

- 15% of patients were under 18 years old;

- 37% of patients were 18 to 24 years old;

- 24% of patients were 25 to 34 years old; and

- 24% of patients were 35 years or older.

- 2,022 hospitalized patients had data on substance use, of whom (as of January 14, 2020):

- 82% reported using THC-containing products; 33% reported exclusive use of THC-containing products.

- 57% reported using nicotine-containing products; 14% reported exclusive use of nicotine-containing products.

- 50% of EVALI patients who reported using THC-containing products provided data on product source (as of January 7, 2020):

- 16% reported acquiring products only from commercial sources (recreational and/or medical dispensaries, vape or smoke shops, stores, and pop-up shops).

- 78% reported acquiring products only from informal sources (family/friends, dealers, online, or other sources).

- 6% reported acquiring products from both commercial and informal sources.

- 54% of EVALI patients who reported using nicotine-containing products provided data on product source (as of January 7, 2020):

- 69% reported acquiring products only from commercial sources.

- 17% reported acquiring products only from informal sources.

- 15% reported acquiring products from both commercial and informal sources.


Outbreak of Lung Injury Associated with the Use of E-Cigarette, or Vaping, Products

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


“These cases appear to predominantly affect people who modify their vaping devices or use black market modified e-liquids. This is especially true for vaping products containing tetrahydrocannabinol (THC),” explains Blaha.

The CDC has identified vitamin E acetate as a chemical of concern among people with EVALI. Vitamin E acetate is a thickening agent often used in THC vaping products, and it was found in all lung fluid samples of EVALI patients examined by the CDC.

The CDC recommends that people:

Do not use THC-containing e-cigarette, or vaping, products

Avoid using informal sources, such as friends, family or online dealers to obtain a vaping device.

Do not modify or add any substances to a vaping device that are not intended by the manufacturer.


2: Research Suggests Vaping Is Bad for Your Heart and Lungs

Nicotine is the primary agent in both regular cigarettes and e-cigarettes, and it is highly addictive. It causes you to crave a smoke and suffer withdrawal symptoms if you ignore the craving. Nicotine is also a toxic substance. It raises your blood pressure and spikes your adrenaline, which increases your heart rate and the likelihood of having a heart attack.


Heart Attack


Aheart attack (myocardial infarction) happens when one or more areas of the heart muscle don't get enough oxygen. This happens when blood flow to the heart muscle is blocked.

Causes of a Heart Attack

The blockage is caused by a buildup of plaque in the arteries (atherosclerosis). Plaque is made up of deposits, cholesterol, and other substances. When a plaque breaks (ruptures), a blood clot quickly forms. The blood clot is the actual cause of the heart attack.

If the blood and oxygen supply is cut off, muscle cells of the heart begin to suffer damage and start to die. Irreversible damage begins within 30 minutes of blockage. The result is heart muscle affected by the lack of oxygen no longer works as it should.

Who is at risk for a heart attack?

There are two types of risk factors for heart attack.

Inherited (or genetic)

Inherited or genetic risk factors are risk factors you are born with that cannot be changed, but can be improved with medical management and lifestyle changes.


Acquired risk factors are caused by activities that we choose to include in our lives that can be managed through lifestyle changes and clinical care.

Inherited (genetic) factors: Who is most at risk?

These groups are most at risk:

People with inherited high blood pressure (hypertension)

People with inherited low levels of HDL cholesterol, high levels of LDL cholesterol, or high levels of triglycerides

People with a family history of heart disease. This is especially true if the heart disease started before age 55.

Older men and women

People with type 1 diabetes

Women who have gone through menopause. Generally, men are at risk at a younger age than women. After menopause, women are equally at risk.

Acquired risk factors: Who is most at risk?

These groups are most at risk:

People with acquired high blood pressure (hypertension)

People with acquired low levels of HDL cholesterol, high levels of LDL cholesterol, or high levels of triglycerides

Cigarette smokers

People who are under a lot of stress

People who drink too much alcohol

People who lead a sedentary lifestyle

People overweight by 30% or more

People who eat a diet high in saturated fat

People with type 2 diabetes

A heart attack can happen to anyone. When you take the time to learn which risk factors apply to you, you can take steps to eliminate or reduce them.


Managing heart attack risk factors

Here are ways to manage your risks for a heart attack:

Look at which risk factors apply to you, then take steps to eliminate or reduce them.

Learn about high blood pressure and high cholesterol levels. These may be "silent killers."

Change risk factors that aren't inherited by making lifestyle changes. Talk with your healthcare provider to find out how to do so.

Talk with your healthcare provider to find out if you have risk factors that can't be changed. These can be managed with medicine and lifestyle changes.


Prevention of Heart Attacks

You can help prevent a heart attack by knowing your risk factors for coronary artery disease and heart attack and taking action to lower those risks. Even if you’ve already had a heart attack or are told that your chances of having a heart attack are high, you can still lower your risk, most likely by making a few lifestyle changes that promote better health.

Don’t smoke. Your doctor may recommend methods for quitting, including nicotine replacement.

Eat a diet low in fat, cholesterol and salt.

See your doctor regularly for blood pressure and cholesterol monitoring.

Pursue a program of moderate, regular aerobic exercise. People over age 50 who have led a sedentary lifestyle should check with a doctor before beginning an exercise program.

Lose weight if you are overweight.

Your doctor may advise you to take a low dose of aspirin regularly. Aspirin reduces the tendency for the blood to clot, thereby decreasing the risk of heart attack. However, such a regimen should only be initiated under a doctor’s expressed recommendation.

Women at or approaching menopause should discuss the possible cardio-protective benefits of estrogen replacement therapy with their doctor.


Symptoms of a Heart Attack

The following are the most common symptoms of a heart attack. But each person may have slightly different symptoms.

Severe pressure, fullness, squeezing, pain, or discomfort in the center of the chest that lasts for more than a few minutes

Pain or discomfort that spreads to the shoulders, neck, arms, or jaw

Chest pain that gets worse

Chest pain that doesn't get better with rest or by taking nitroglycerin

Chest pain that happens along with any of these symptoms:

- Sweating, cool, clammy skin, or paleness

- Shortness of breath

- Nausea or vomiting

- Dizziness or fainting

- Unexplained weakness or fatigue

- Rapid or irregular pulse

Although chest pain is the key warning sign of a heart attack, it may be confused with other conditions. These include indigestion, pleurisy, pneumonia, tenderness of the cartilage that attaches the front of the ribs to the breastbone, and heartburn. Always see your healthcare provider for a diagnosis.


Responding to heart attack warning signs

If you or someone you know has any of the above warning signs, act right away. Call 911, or your local emergency number.

Treatment for a heart attack

The goal of treatment for a heart attack is to relieve pain, preserve the heart muscle function, and prevent death.

Treatment in the emergency department may include:

- Intravenous therapy, such as nitroglycerin and morphine

- Continuous monitoring of the heart and vital signs

- Oxygen therapy to improve oxygenation to the damaged heart muscle

- Pain medicine to decrease pain. This, in turn, decreases the workload of the heart. The oxygen demand of the heart decreases.

- Cardiac medicine such as beta-blockers to promote blood flow to the heart, improve the blood supply, prevent arrhythmias, and decrease heart rate and blood pressure

- Fibrinolytic therapy. This is the intravenous infusion of a medicine that dissolves the blood clot, restoring blood flow.

- Antithrombin or antiplatelet therapy with aspirin or clopidogrel. This is used to prevent further blood clotting.

- Antihyperlipidemic. These medicines lower lipids (fats) in the blood, particularly low density lipid (LDL) cholesterol. Statins are a group of antihyperlipidemic medicines. They include simvastatin, atorvastatin, and pravastatin. Bile acid sequestrants — colesevelam, cholestyramine, and colestipol—and nicotinic acid (niacin) are two other types of medicines that may be used to lower cholesterol levels.

You may need other procedures to restore blood flow to the heart. Those procedures are described below.


Coronary angioplasty

With this procedure, a balloon is used to create a bigger opening in the vessel to increase blood flow. This is often followed by inserting a stent into the coronary artery to help keep the vessel open. Although angioplasty is done in other blood vessels elsewhere in the body, percutaneous coronary intervention (PCI) refers to angioplasty in the coronary arteries. This lets more blood flow into the heart. PCI is also called percutaneous transluminal coronary angioplasty (PTCA).

There are several types of PTCA procedures:

- Balloon angioplasty. A small balloon is inflated inside the blocked artery to open the blocked area.

- Coronary artery stent. A tiny coil is expanded inside the blocked artery to open the blocked area. The stent is left in place to keep the artery open.

- Atherectomy. The blocked area inside the artery is cut away by a tiny device on the end of a catheter.

- Laser angioplasty. A laser used to "vaporize" the blockage in the artery.

Coronary artery bypass

This surgery is most commonly referred to as simply bypass surgery or CABG (pronounced "cabbage"). It is often done in people who have chest pain (angina) and coronary artery disease. Coronary artery disease is when plaque has built up in the arteries. During the surgery, the surgeon makes a bypass by grafting a piece of a vein above and below the blocked area of a coronary artery. This lets blood flow around the blockage. The surgeon usually takes veins from a leg, but he or she may also use arteries from the chest or an arm. Sometimes, you may need more than one bypass surgery to restore blood flow to all areas of the heart.



Is vaping bad for you? There are many unknowns about vaping, including what chemicals make up the vapor and how they affect physical health over the long term. “People need to understand that e-cigarettes are potentially dangerous to your health,” says Blaha. “Emerging data suggests links to chronic lung disease and asthma, and associations between dual use of e-cigarettes and smoking with cardiovascular disease. You’re exposing yourself to all kinds of chemicals that we don’t yet understand and that are probably not safe.”


‘Vaping’ Increases Odds of Asthma and COPD

Using data from a large federal government telephone survey of adults, Johns Hopkins Medicine researchers report evidence that inhaling heated tobacco vapor through e-cigarettes was linked to increased odds of asthma and chronic obstructive pulmonary disease (COPD), conditions long demonstrated to be caused by smoking traditional, combustible cigarettes. The data, the researchers say, also suggest that odds of developing COPD may be as much as six times greater when people report they both vape and smoke tobacco regularly, compared with those who don’t use any tobacco products at all.

Reports on the studies are published Jan. 2 in the American Journal of Preventive Medicine and on Oct. 16 in BMC Pulmonary Medicine.

For both studies, the researchers caution that they weren’t designed to show that vaping directly causes lung disease, but only whether doing so was associated with an increased likelihood of having disease. The researchers also didn’t distinguish between vaping tobacco compared with cannabis. They also cautioned that self-reports via telephone surveys may not be wholly reliable. However, they say their findings demonstrate the need for continued research with e-cigarette users over time to confirm and clarify the risks.

“Although e-cigarettes may turn out to be safer overall than traditional combustible cigarettes, our studies add to growing evidence that they carry health risks,” says Michael Blaha, M.D., M.P.H., professor of medicine at the Johns Hopkins University School of Medicine. “These studies are the first in a series of larger and long-term studies that will more definitively provide evidence to inform tobacco users and regulators.”

Asthma, marked by inflammation of the airways and shortness of breath, affects an estimated 25 million Americans, and life-threatening episodes can be triggered easily by pollution, allergies and smoking. COPD, which affects some 16 million Americans, describes a group of disorders including emphysema and chronic bronchitis that make it hard to breathe due to permanent damage to the lungs over time. Rates of asthma and COPD are rising worldwide, according to the World Health Organization. Most cases of COPD result from smoking traditional cigarettes.

A study published by Blaha earlier this year in the Annals of Internal Medicine estimated that 1.4% of people, or about 1.9 million people in the U.S., solely use e-cigarettes. Scattered reports have linked the practice to a spike in respiratory illnesses dubbed EVALI (e-cigarette, or vaping, product use-associated lung injury), affecting more than 2,500 people and associated with numerous deaths, according to the Centers for Disease Control and Prevention. Because vaping and the products inhaled with it are still relatively new to the market, its safety remains unclear.

To shed some light on the risk, the researchers took advantage of national survey data gathered by the Behavioral Risk Factor Surveillance System from 2016 and 2017. This annual survey, commissioned by the U.S. Centers for Disease Control and Prevention, consisted of telephone interviews of more than 400,000 adult participants and provides data on health-related risk behaviors and chronic medical conditions.

In the analysis published in BMC Pulmonary Medicine, the investigators analyzed data from 402,822 people who identified themselves as never smokers, meaning they said they had smoked less than 100 combustible cigarettes in their lifetimes. Of these, 3,103 reported using e-cigarettes or vaping, and separately 34,074 people reported having asthma. The average age of e-cigarette users was 18–24. About 67% of e-cigarette users were men. Approximately 57% of e-cigarette users reported that they were white, 19% were Hispanic and 12% were black.

Almost 11% of the e-cigarette users reported having asthma, compared with 8% of those who had never used e-cigarettes. Those people who reported being current e-cigarette users were 39% more likely to self-report having asthma compared with those people who said they never used e-cigarettes. Those who said they used e-cigarettes some days were 31% more likely, and daily users were 73% more likely to report asthma, compared with non-e-cigarette users.

For the study published in the American Journal of Preventive Medicine, the researchers analyzed the same data from all the questioned participants. From the more than 700,000 interviewees, about 61% reported being never smokers, about 9% were current smokers, 30% were former smokers, more than 3% said they currently used e-cigarettes, and 2% said they used both e-cigarettes and smoked. The e-cigarette users were more likely to fall in the age range of 30–34, almost 60% were men, 72% identified as white, 8% as black, 3.5% as Asian and 11% as Hispanic.

Of those who said they used e-cigarettes, about 11% said they had chronic bronchitis, emphysema or COPD, compared with 5.6% of people who said they had never used e-cigarettes. Among never smokers, current e-cigarette users were 75% more likely to report having COPD, compared with those who had never used them. Those who said they used both e-cigarettes and smoked cigarettes were almost six times more likely to report having COPD, compared with those who had never used either, whereas just using combustible cigarettes alone increased the odds by three times.

“As a physician, I am most worried about those who use both e-cigarettes and combustible cigarettes because they may end up taking in the most nicotine, which may do the most damage,” says Albert Osei, M.D., M.P.H., a postdoctoral fellow at the Johns Hopkins University School of Medicine and lead author on the study. “Through public health campaigns, we finally had smoking levels down in some populations, but now with the current vaping epidemic, I foresee a whole new previously tobacco-naïve, young generation becoming dependent on nicotine if we do not intensify public health education efforts.”

According to the CDC, of the 16 million people in the U.S. who have COPD, 38% of them still smoke.

Additional authors on these studies include Mohammadhassan Mirbolouk, Olusola Orimoloye, Omar Dzaye, S. M. Iftekhar Uddin, Zeina Dardari and Shyam Biswal of Johns Hopkins; Andrew DeFilippis and Aruni Bhatnagar of University of Louisville; Emelia Benjamin of Boston University; and Michael Hall of University of Mississippi Medical Center.

This study was supported by a grant from the American Heart Association Tobacco Regulation and Addiction Center, which is funded by the National Heart, Lung, and Blood Institute/U.S. Food and Drug Administration (2U54HL120163).


3: Electronic Cigarettes Are Just As Addictive As Traditional Ones

Both e-cigarettes and regular cigarettes contain nicotine, which research suggests may be as addictive as heroin and cocaine. What’s worse, says Blaha, many e-cigarette users get even more nicotine than they would from a tobacco product — you can buy extra-strength cartridges, which have a higher concentration of nicotine, or you can increase the e-cigarette’s voltage to get a greater hit of the substance.


4: Electronic Cigarettes Aren’t the Best Smoking Cessation Tool

Although they’ve been marketed as an aid to help you quit smoking, e-cigarettes have not received Food and Drug Administration approval as smoking cessation devices. A recent study found that most people who intended to use e-cigarettes to kick the nicotine habit ended up continuing to smoke both traditional and e-cigarettes.

In the light of the EVALI outbreak, the CDC advises adults who use e-cigarettes for smoking cessation to weigh the risks and benefits and consider use of other FDA-approved smoking cessation options.


5: A New Generation Is Getting Hooked on Nicotine

Among youth, e-cigarettes are more popular than any traditional tobacco product. In 2015, the U.S. surgeon general reported that e-cigarette use among high school students had increased by 900%, and 40% of young e-cigarette users had never smoked regular tobacco.

According to Blaha, there are three reasons e-cigarettes may be particularly enticing to young people. First, many teens believe that vaping is less harmful than smoking. Second, e-cigarettes have a lower per-use cost than traditional cigarettes. Finally, vape cartridges are often formulated with flavorings such as apple pie and watermelon that appeal to younger users.

Both youths and adults find the lack of smoke appealing. With no smell, e-cigarettes reduce the stigma of smoking.

“What I find most concerning about the rise of vaping is that people who would’ve never smoked otherwise, especially youth, are taking up the habit,” says Blaha. “It’s one thing if you convert from cigarette smoking to vaping. It’s quite another thing to start up nicotine use with vaping. And, it often leads to using traditional tobacco products down the road.”

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