E-Cigarettes: A Modern Alternative or a New Public Health Threat?

Despite widespread anti-smoking campaigns at the population level, 28% of adults (aged ≥15 years) in Europe still smoke. The use of electronic cigarettes (e-cigarettes) has emerged and gained significant popularity in response to the well-known harmful effects of tobacco smoking, although their safety remains in question.

The modern device innovation is attributed to Hon Lik, a Chinese pharmacist who in 2003 developed this method of inhaling aerosols (vaping) and patented the device in 2007. Advocates present these devices as a “less harmful” option or as an aid to smoking cessation. However, the reality is much more complex and requires thorough scientific and public health analysis.

In many countries, e-cigarettes are not subject to the same strict regulations as conventional tobacco products. As a result, their promotion in media and online is often permitted, reaching not only adults but also young people. While the popularity of specific types of e-cigarettes varies across time and countries, it is universally recognized that an increasing number of children, adolescents, and adults are using them. E-cigarettes are often promoted as a safer alternative to smoking traditional cigarettes and as a way to reduce or quit smoking. However, evidence suggests they are not harmless.

What Are E-Cigarettes and How Do They Work?

E-cigarettes are devices that heat a liquid—so-called e-liquid—to produce an aerosol inhaled by the user. This liquid typically contains nicotine, propylene glycol or vegetable glycerin, and flavorings available in a wide variety (fruit, mint, chocolate, desserts, etc.). Although nicotine-free e-liquids exist, those containing nicotine are far more common.

Two main types exist:

1. Disposable and refillable devices resembling traditional cigarettes

2. Tank systems and vaporizers

Unlike conventional cigarettes, e-cigarettes involve no combustion, meaning users are less exposed to tar and carbon monoxide. Still, this does not mean they are risk-free.

Prevalence of E-Cigarette Use

Between 2015–2019, e-cigarette use varied widely across countries—from virtually nonexistent (Egypt, 0%) to very high (Lithuania, 56.6%). In Poland, 35% of young people reported using e-cigarettes in the previous 30 days.

The sharpest increase has been among youth. Studies show an exponential rise in prevalence, from 5% to as high as 25% between 2013 and 2019. E-cigarettes have become a social trend, seen as “cool” or even a “healthier option.”

Youth and E-Cigarettes

Young people are especially vulnerable to e-cigarettes. Flavors such as strawberry, candy, or menthol make them attractive, and social media marketing amplifies their reach. Research shows that youth who never smoked but use e-cigarettes are twice as likely to later begin smoking traditional cigarettes.

In addition to fostering nicotine addiction, e-cigarettes may:

• Negatively affect cognitive development in adolescents (attention, memory, emotional regulation)

• Contribute to respiratory conditions such as asthma

• Harm pregnancy and fetal development, since nicotine interferes with placental circulation and blood vessel growth

Cardiovascular Risks: Lower Than Cigarettes, but Still Present

Although e-cigarettes are promoted as less harmful to the cardiovascular system because they lack combustion products, nicotine and other aerosol components can still have adverse effects.

Research indicates:

• Increased blood pressure and heart rate after use

• Greater arterial stiffness (linked to higher heart attack risk)

• Impaired endothelial function

• Increased oxidative stress and autonomic nervous system changes

Currently, there is no direct clinical trial evidence or long-term cohort data on cardiovascular outcomes of e-cigarettes, and the consequences of chronic use remain largely unknown.

Epidemiological data from two large U.S. surveys (National Health Interview Survey, 2014 [N=36,697] and 2016 [N=33,028]) suggest an elevated risk of myocardial infarction among e-cigarette users (odds ratio 1.79; 95% CI 1.20–2.66), though lower than among cigarette smokers (2.72; 95% CI 2.29–3.24).

Do E-Cigarettes Help with Smoking Cessation?

The evidence is mixed. Some randomized clinical trials show e-cigarettes may aid cessation when combined with psychological support. However, real-world outcomes differ:

• Many users continue using both e-cigarettes and conventional cigarettes

• In practice, e-cigarettes are no more effective than nicotine patches or gums

• Long-term data on sustained abstinence are limited

Overall, available evidence does not allow a definitive conclusion on whether e-cigarettes reliably help smokers quit. Limitations of current studies include inconsistent exposure measurement, inclusion of non-cessation users, confounding factors, and varied definitions of “quit success.”

Some studies suggest e-cigarettes combined with behavioral therapy may improve abstinence rates, but they also emphasize the need for intensive, repeated counseling. Use outside professional supervision may undermine cessation attempts for many adult smokers. More high-quality research—particularly pragmatic randomized trials—is needed.

For now, experts recommend that e-cigarettes should not be considered a first-line tool for smoking cessation.

Regulatory Challenges

E-cigarette legislation is relatively new, and no global consensus exists on their regulation. While most nicotine-containing e-cigarettes can be included under tobacco laws, nicotine-free products present a regulatory gray area.

As of now, 98 countries have some form of e-cigarette regulation, but with wide variation:

• Some countries (e.g., Brazil, Turkey) enforce a total ban

• In the EU, most countries regulate them as tobacco-related products, with limits on nicotine concentration, advertising, and packaging

• Many online sellers lack age verification

• Influencer-driven advertising often circumvents regulations

The rapid evolution of the e-cigarette market continues to outpace legislation, enabling frequent loopholes and abuses.

Recommendations from the European Association of Preventive Cardiology (EAPC)

• Healthcare professionals should remain cautious and avoid recommending e-cigarettes without a defined cessation strategy and support.

• E-cigarettes should be considered only as part of an official smoking cessation program.

• Regulations should be as strict as for conventional tobacco, especially regarding youth-targeted marketing.

• Flavors appealing to children (e.g., candy, fruit, dessert) should be banned.

• Strict age verification should be enforced for online and retail sales.

• Education campaigns in schools and on social media should highlight potential dangers.

• As with cigarettes, complete abstinence during pregnancy should be advised.

Conclusion

Although e-cigarettes may expose users to fewer harmful substances than conventional cigarettes, their growing popularity—particularly among youth—cannot be viewed as harmless. Their long-term health effects, including on cardiovascular disease, brain development, and nicotine addiction, remain insufficiently studied.

Continued research, stronger regulation, and above all, protection of vulnerable groups—especially children and adolescents—are essential to prevent addiction and counter misleading industry messages.

Adapted from: Maryam Kavousi, et al. Electronic cigarettes and health with special focus on cardiovascular effects: position paper of the European Association of Preventive Cardiology (EAPC). Eur J Prev Cardiol. 2021;28(14):1552–1566. doi:10.1177/2047487320941993.