ENDS Respiratory System

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This page will include information on vapor products and heated tobacco products.

Studies

Asthma

2020: Vaping effects on asthma: results from a web survey and clinical investigation

• Almost all of the asthmatics who previously smoked would recommend switching to e-cig, and vaping did not worsen their asthma symptoms. Furthermore, switching from tobacco smoking to e-cigs showed a significant improvement in asthma control and quality of life, not showing, in the period studied, to affect pulmonary function tests.
• PDF Version

2016: Persisting long term benefits of smoking abstinence and reduction in asthmatic smokers who have switched to electronic cigarettes

• This prospective study confirms that EC use ameliorates objective and subjective asthma outcomes and shows that these beneficial effects may persist in the long term. EC use can reverse harm from tobacco smoking in asthma patients who smoke. The evidence-based notion that substitution of conventional cigarettes with EC is unlikely to raise significant respiratory concerns, can improve counseling between physicians and their asthmatic patients who are using or intend to use ECs.

2015: Counseling patients with asthma and allergy about electronic cigarettes: an evidence-based approach

• Smoking cessation should be strongly encouraged in patients with asthma who smoke, and they should be offered effective personalized strategies. In addition to pharmacotherapy and behavioral support, other options should be made available to manage smokers who frequently relapse and for those who are unable or unwilling to quit. A realistic alternative is to encourage these smokers to switch to ECs, a much less harmful source of nicotine.
• PDF (full paper)

2014: Effect of Smoking Abstinence and Reduction in Asthmatic Smokers Switching to Electronic Cigarettes: Evidence for Harm Reversal

• Here, we show for the first time improvements in asthma control, AHR and pulmonary function in asthmatic smokers who quit or dramatically reduced their tobacco consumption by switching to e-cigs.

COPD

2023: Health impact of e-cigarettes and heated tobacco products in chronic obstructive pulmonary disease: Current and emerging evidence

• Compared with conventional cigarettes, HTPs and ECs offer substantial reduction in exposure to toxic chemicals and have the potential to reduce harm from cigarette smoke when used as tobacco cigarette substitutes. In this review, we examine the available clinical studies and population surveys on the respiratory health effects of ECs and HTPs in COPD patients.
• As many COPD smokers prefer to smoke, conventional cigarette substitution should be considered as a valuable solution to the persistent problem of smoking, and combustion-free nicotine delivery technologies should be weight as a component of this strategy.
• Our analysis of existing human studies on the respiratory health impact of ECs/HTPs substitution for COPD patients who smoke, fails to reach a clear conclusion because of the discordant findings and unreliable interpretations driven from surveys and clinical studies of modest quality.
• This review article highlights the need for large, carefully designed, adequately controlled, long- term follow-up clinical trials to assess the true potential of combustion-free nicotine delivery technologies for sustained smoking cessation and reducing risk of harm from smoking, particularly among smokers with chronic obstructive pulmonary disease (COPD).

2022: Association of tobacco product use with chronic obstructive pulmonary disease (COPD) prevalence and incidence in Waves 1 through 5 (2013–2019) of the Population Assessment of Tobacco and Health (PATH) Study

• E-cigarettes and all use categories involving cigarettes were associated with higher COPD prevalence compared to never use, reflecting, in part, the high burden of cigarette exposure in these groups. Cigarette—but not exclusive e-cigarette—use was also strongly associated with higher COPD incidence. Compared to cigarette use, only quitting tobacco was protective against COPD development.

2022: Electronic cigarettes as a harm reduction strategy among patients with COPD: protocol for an open-label two arm randomized controlled pilot trial

• A harm reduction approach with the goal of achieving CC switching may be a more pragmatic approach, making EC use particularly appropriate with COPD. EC represent a potentially effective harm reduction tool that is safer than smoking CC [18, 23, 24]. Smokers with COPD, however, tend to be older and may have a higher level of addiction to nicotine than the average smoker and the feasibility and preliminary effectiveness of an EC harm-reduction strategy in a COPD population has not been explored.
• Our study protocol has a few limitations. First, as a pilot study the protocol is not powered to detect small differences in CPD or CAT Scores between the NRT and EC arms. Second, CAT Score is not the gold standard for the assessment of respiratory health.

2021: Health outcomes in COPD smokers using heated tobacco products: a 3-year follow-up

• This study is the first to describe the long-term health effects of HTP use in COPD patients. Consistent improvements in respiratory symptoms, exercise tolerance, quality of life, and rate of disease exacerbations were observed in patients with COPD who abstained from smoking or substantially reduced their cigarette consumption by switching to HTP use.
• Nearly 60% of COPD patients using HTPs abstained completely from cigarette smoking throughout the duration of the study, whereas those continuing to smoke (dual users) showed a consistent decline in their daily cigarette consumption from the baseline of at least 70% at all study visits.

2020: COPD smokers who switched to e-cigarettes: health outcomes at 5-year follow up

• The present study suggests that EC use may ameliorate objective and subjective COPD outcomes, and that the benefits gained appear to persist long term. EC use for abstinence and smoking reduction may ameliorate some of the harm resulting from tobacco smoking in COPD patients.

2018: Health effects in COPD smokers who switch to electronic cigarettes: a retrospective-prospective 3-year follow-up

• The present study suggests that EC use may ameliorate objective and subjective COPD outcomes and that the benefits gained may persist long-term. EC use may reverse some of the harm resulting from tobacco smoking in COPD patients.

2018: In vitro RNA-seq-based toxicogenomics assessment shows reduced biological effect of tobacco heating products when compared to cigarette smoke

• The relationship between the identified RNA features and gene ontologies were mapped showing a strong association with stress response, xenobiotics metabolism, and COPD-related terms for 3R4F [combustible cigarette]. In contrast, fewer ontologies were found enriched for the THPs [heated tobacco product] aerosols. “Response to wounding” was a common COPD-related term over-represented for the two THPs but at a reduced significance. Quantification of a cytokine panel post-exposure confirmed a pro-inflammatory effect of cigarette smoke but not for THPs. In conclusion, THPs have a reduced impact on gene expression compared to 3R4F.

2017: E-cigarettes in patients with COPD: current perspectives

• Although ECs are not risk free, they are much less harmful than conventional tobacco smoking. The emerging clinical evidence suggests that ECs are unlikely to raise significant health concerns for the respiratory tract under normal conditions of use, even in smokers with preexisting lung disease. In particular, recent studies in COPD and chronic asthma suggest that substitution of conventional tobacco cigarettes for ECs can ameliorate subjective and objective disease-related outcomes and exacerbation rates as well as improving success in abstaining from smoking long term.

2016: Evidence for harm reduction in COPD smokers who switch to electronic cigarettes

• Conclusion: “These findings suggest that ECs use may aid smokers with COPD reduce their cigarette consumption or remain abstinent, which results in marked improvements in annual exacerbation rate as well as subjective and objective COPD outcomes.”

Lung Cancer/Lung Cancer Screening

2020: Benefits of e-cigarettes in smoking reduction and in pulmonary health among chronic smokers undergoing a lung cancer screening program at 6 months

• The study is a double-blind randomized controlled trial. Two hundred and ten smokers were randomized into three groups: nicotine e-cigarette (8 mg/mL nicotine concentration), nicotine-free e-cigarettes (placebo), and control with 1:1:1 ratio. All participants received a 3 months cessation program that included a cognitive-behavioral intervention aimed at supporting people in changing their behavior and improving motivation to quit.
• After 6 months about 20% of the entire sample stopped smoking. Participants who used e-cigarettes with nicotine smoked fewer tobacco cigarettes than any other group after 6 months.
• Our data add to the efficacy and safety of e-cigarettes in helping smokers reducing tobacco consumption and improving pulmonary health status.
• Pulmonary health, assessed with self-reported measures, clinical evaluations and the Leicester Cough Questionnaire, improved in participants who stopped smoking compared to their own baseline. Moreover, participants in this group [nicotine e-cigarettes] showed the lowest level of exhaled carbon monoxide, and the lowest level of dependence compared to the nicotine-free e-cigarette and control conditions.

2020: Cancer potencies and margin of exposure used for comparative risk assessment of heated tobacco products (HTPs) and electronic cigarettes (ECs) aerosols with cigarette smoke

• Even if they should not be considered as risk-free products, however, HTPs and ECs lead to an appreciable risk reduction in comparison to cigarettes, both for cancer and non-cancer diseases. According to the current knowledge, and more specifically to the data presented here, HTPs and ECs might be considered as an acceptable reduced risk substitute for cigarettes for legal-age smokers who would otherwise continue smoking cigarettes.
• A more pronounced cancer risk reduction was observed when comparing the mean lifetime cancer risk for the considered ECs with that for cigarette smoke. This reduction was about two orders of magnitude (ratio of 0.009 and 0.014) with 2.42·10–4 and 3.95·10–4 for ECs compared to 2.73·10–2 for cigarettes. In terms of consumers, this would mean that 1 out of 36 cigarette smokers vs. 1 out of 4132 or 1 out of 2531 EC consumers may develop a cancer if the cancer root cause would be only associated with exposure to the considered HPHCs.

2018 Measurements of electronic cigarette-generated particles for the evaluation of lung cancer risk of active and passive users

• In this study, we have demonstrated that no clinically relevant, product-related safety findings were observed for smokers of Combustible Cigarettes (CC) switching to an Electronic Vapor Product (EVP) for 12 weeks under real-life settings. Adverse Effects (AEs) reported by subjects switching to the EVP occurred primarily within the first week after switching, and only 1.3% of all AEs reported were considered to be almost definitely related to the product. Up to a third of all reported AEs in the EVP group were related to nicotine withdrawal symptoms, which were observed to decrease after the first two weeks from product switch. EVP use was associated with significant decreases in exposure to nicotine and other chemicals such as benzene and acrolein, typically found in CC smoke. Changes were also observed in the level of WBC, haemoglobin, RBC and LDL cholesterol, which although minor, were consistent with those observed after smoking cessation. The data presented in this study shows the potential that EVPs may offer to smokers looking for an alternative to CCs.
• PDF Version

2017: Reduced biological effect of e-cigarette aerosol compared to cigarette smoke evaluated in vitro using normalized nicotine dose and RNA-seq-based toxicogenomics

• Here, we assessed the transcriptional response of a primary 3D airway model acutely exposed to e-cigarette aerosol and cigarette (3R4F) smoke.
• Based on equivalent or higher nicotine delivery, an acute exposure to e-cigarette aerosol had a reduced impact on gene expression compared to 3R4F smoke exposure in vitro.
• Therefore, we can conclude that the data strongly supports the adverse effect of acute exposure to cigarette smoke on MucilAir™ cells with functional enrichment for cancer, inflammation and fibrosis genes. In contrast, RNA-seq-based toxicogenomics showed a reduced impact of e-cigarette aerosols acute exposure on MucilAir™ cells compared with 3R4F reference cigarette at equivalent or higher dose of nicotine exposure.

2017: Comparing the cancer potencies of emissions from vapourised nicotine products including e-cigarettes with those of tobacco smoke

• “Most e-cigarette analyses indicate cancer potencies <1% that of tobacco smoke and <10% that of a heat-not-burn prototype, although a minority of analyses indicate higher potencies.”
• Optimal combinations of device settings, liquid formulation and vaping behaviour normally result in e-cigarette emissions with much less carcinogenic potency than tobacco smoke.
• Article in Lung Disease News: E-Cigarettes Carry Much Less Risk of Lung Cancer Than Cigarette Smoke, Study Finds

2017: Have combustible cigarettes met their match? The nicotine delivery profiles and harmful constituent exposures of second-generation (G2) and third-generation (G3) electronic cigarette users

• While not harmless, electronic cigarettes (e-cigarettes) have demonstrated a much more favourable toxicological profile than combustible cigarettes—the worldwide leading cause of preventable death. Average eCO levels (ppm) were significantly higher in smokers than in e-cigarette users. Compared with cigarettes, G2 and G3 e-cigarettes resulted in significantly lower levels of exposure to a potent lung carcinogen and cardiovascular toxicant.

2016: Patients with lung cancer: Are electronic cigarettes harmful or useful?

• Based on current knowledge, for patients with lung or other forms of cancer who would otherwise continue to smoke, e-cigarettes offer an alternative way to quit smoking while they undergo medical treatment. The option to switch to e-cigarettes should be considered by healthcare practitioners with patients with cancer who would otherwise continue to smoke.

2012: Comparison of the effects of e-cigarette vapor and cigarette smoke on indoor air quality

• Comparisons of pollutant concentrations were made between e-cigarette vapor and tobacco smoke samples. Pollutants included VOCs, carbonyls, PAHs, nicotine, TSNAs, and glycols.
• Non-cancer risk analysis revealed “No Significant Risk” of harm to human health for vapor samples from e-liquids.
• With regard to cancer risk analysis, no vapor sample from e-liquids exceeded the risk limit for either children or adults.

General

2021: Effect of an electronic nicotine delivery system with 0, 8, or 36 mg/mL liquid nicotine versus a cigarette substitute on tobacco-related toxicant exposure: a four-arm, parallel-group, randomised, controlled trial

• Use of an ENDS with cigarette-like nicotine delivery can reduce exposure to a major pulmonary carcinogen, NNAL, even with concurrent smoking.

2020: E-Cigarettes and Respiratory Disease: A Replication, Extension, and Future Directions

• The statistical associations between e-cigarette use and respiratory disease are driven by e-cigarette users who are also current or former smokers of combustible tobacco.
• A striking feature of the data is that almost all e-cigarette users were either current or former smokers of combustible tobacco.
• Among respondents who had never smoked combustible tobacco, we find no evidence that current or former e-cigarette use is associated with respiratory disease.
• Link to PDF

2020: Exclusive e-cigarette users report lower levels of respiratory symptoms relative to dual e-cigarette and cigarette users

• Findings suggest that differences in respiratory symptoms between dual and exclusive e-cigarette users appear to be attributable to combustible cigarette smoking, rather than more intense or frequent e-cigarette use across groups.

2020: Investigation on the antibacterial activity of electronic cigarette liquids (ECLs): a proof of concept study

• Our results have shown that flavors considerably enhance antibacterial activity.
• This study provides important evidence that should be taken into consideration in further investigative approaches, to clarify the different sensitivity of the various bacterial species to e-liquids, including the respiratory microbiota, to highlight the possible role of flavors and nicotine.

2020: SACCHARIN TRANSIT TIME IN EXCLUSIVE E-CIGARETTES AND HEATED TOBACCO PRODUCTS USERS: A CROSS-SECTIONAL STUDY

• Ex-smokers who have switched to exclusive regular use of combustion-free nicotine delivery systems (i.e. ECs/e-cigarettes and HTPs/heated tobacco products) exhibit similar saccharin transit time as never and former smokers. This suggests that combustion-free nicotine delivery technologies are unlikely to have detrimental effects on MCC (mucociliary clearance) function

2019: The effect of e-cigarette aerosol emissions on respiratory health: a narrative review.

• Expert opinion: There is growing evidence to support the relative safety of E-Cigarette (EC) emission aerosols for the respiratory tract compared to tobacco smoke. Public Health England estimated, on the basis of a review of 185 studies, that vaping an e-cigarette is likely to be at least 95% less harmful than smoking a regular cigarette. In 2016, the Royal College of Physicians reaffirmed this figure, estimating the risk of long-term inhalation of e-cigarette aerosol to be unlikely to exceed 5% of the risk associated with long-term cigarette smoking. This review article shows that although some potential effects on respiratory cell types can be shown in vitro, and low levels of chronic irritation of the respiratory tract can be anticipated at certain levels of vaping, these effects are much less than those of smoking. The clinical evidence confirms that ECs are unlikely to raise significant health concerns for the respiratory tract under normal conditions of use. Former smokers using and smokers intending to use ECs as a substitute for smoking should receive correct information about residual risks and potential benefits of these products. Promoting further access to ECs may offer an opportunity to reduce or prevent some of the otherwise inevitable burden of respiratory morbidity and mortality caused by tobacco smoking
• In an Expert Review in Respiratory Medicine article published about 7 years ago [Caponnetto P, Campagna D, Papale G, et al. The emerging phenomenon of electronic cigarettes. Expert Rev Respir Med. 2012 Feb; 6(1):63–74.., we discussed several important research developments and future avenues for e-cigarette science. In the authors’ view, those expert opinions have been substantiated by the growing body of evidence. We therefore reiterate our prediction that EC use is the most effective method of substituting tobacco cigarettes for those smokers who are unable or unwilling to quit and we are now confident that current vaping products are much less harmful than conventional cigarettes as well as earlier EC designs.

2017: Health impact of E-cigarettes: a prospective 3.5-year study of regular daily users who have never smoked

• In a small sample of young-adult never-smoking, daily EC users who were carefully followed for approximately 3½ years, we found no decrements in spirometric indices, development of respiratory symptoms, changes in markers of lung inflammation in exhaled air or findings of early lung damage on HRCT, when compared with a carefully matched group of never-smoking non-EC users. Even the heaviest EC users failed to exhibit any evidence of emerging lung injury as reflected in these physiologic, clinical or inflammatory measures. Moreover, no changes were noted in blood pressure or heart rate. Since the EC users who we studied were never smokers, potential confounding by inhalation of combustion products of tobacco were obviated.

2017: Reduced biological effect of e-cigarette aerosol compared to cigarette smoke evaluated in vitro using normalized nicotine dose and RNA-seq-based toxicogenomics

• Here, we assessed the transcriptional response of a primary 3D airway model acutely exposed to e-cigarette aerosol and cigarette (3R4F) smoke.
• Based on equivalent or higher nicotine delivery, an acute exposure to e-cigarette aerosol had a reduced impact on gene expression compared to 3R4F smoke exposure in vitro.
• Therefore, we can conclude that the data strongly supports the adverse effect of acute exposure to cigarette smoke on MucilAir™ cells with functional enrichment for cancer, inflammation and fibrosis genes. In contrast, RNA-seq-based toxicogenomics showed a reduced impact of e-cigarette aerosols acute exposure on MucilAir™ cells compared with 3R4F reference cigarette at equivalent or higher dose of nicotine exposure.

2017: Electronic cigarette vapor alters the lateral structure but not tensiometric properties of calf lung surfactant

• While both e-cigarette vapor and conventional cigarette smoke affect surfactant lateral structure, only cigarette smoke disrupts surfactant interfacial properties. The surfactant inhibitory compound in conventional cigarettes is tar, which is a product of burning and is thus absent in e-cigarette vapor.

2016: Changes in breathomics from a 1‐year randomized smoking cessation trial of electronic cigarettes

• Conclusion: “Smokers invited to switch to electronic cigarettes who completely abstained from smoking showed steady progressive improvements in their exhaled breath measurements and symptom scores. FeNo and eCO normalization is highly supportive of improved respiratory health outcomes and adds to the notion that quitting from tobacco smoking can reverse harm in the lung.”

2016: Changes in the Frequency of Airway Infections in Smokers Who Switched To Vaping: Results of an Online Survey

• The switch from smoking to vaping was associated with a reduced incidence of self-reported respiratory infections.
• Results: “Altogether 941 responses were received. Overall, 29% of responders reported no change in respiratory symptoms, 5% reported worsening, and 66% reported an improvement (95% CI=62.9-69.0).”

2016: Respiratory infections and pneumonia: potential benefits of switching from smoking to Vaping

• Also, given that the propylene glycol in EC aerosols is a potent bactericidal agent, switching from smoking to regular vaping is likely to produce additional lung health benefits.
• In conclusion, smokers who quit by switching to regular ECs use can reduce risk and reverse harm from tobacco smoking.
• Innovation in the e-vapour category is likely not only to further minimise residual health risks, but also to maximise health benefits.

2015: What to Advise to Respiratory Patients Intending to Use Electronic Cigarettes

• The notion that under normal vaping conditions, EC toxicology is by far less problematic than tobacco cigarette toxicology and that there are beneficial effects associated with regular EC use, particularly in respiratory patients, will improve information exchange between physicians and their respiratory patients using or intending to use ECs.
• Therefore, smoking cessation should be strongly encouraged in respiratory patients who smoke, and they should be offered effective personalized strategies. Besides pharmacotherapy and behavioral support, other options should be made available to manage smokers who frequently relapse, and for those who are unable or unwilling to quit. A realistic alternative is to encourage these smokers to switch to ECs, a much less harmful source of nicotine

2014: Effect of Smoking Abstinence and Reduction in Asthmatic Smokers Switching to Electronic Cigarettes: Evidence for Harm Reversal

• The e-cig may help smokers with asthma to reduce their cigarette consumption or remain abstinent and hence reduce the burden of smoking-related asthma symptoms. The positive findings observed with e-cigs allows us to advance the hypothesis that these products may be valuable for smoking cessation and/or tobacco harm reduction also in asthma patients who smoke.
• By substantially reducing number of cigarettes smoked per day and exposure to their hazardous toxicants, e-cigs may not only improve asthma symptoms and pulmonary function but may also confer an overall health advantage in smokers with asthma [13]. Therefore, e-cig use in asthmatic smokers unable or unwilling to quit should be exploited as a safer alternative approach to harm-reversal (i.e., specific reversal of asthma-related outcomes) and, in general, to harm-reduction (i.e., overall reduction of smoke-related diseases).

Video

2021: Vaping Demystified

• Yorkshire Cancer Research - Through research and interviews with experts, we explore the truth about vaping and whether misconceptions are preventing us from reducing the largest preventable cause of cancer in Yorkshire.

2nd Hand Vapor

2022: Computational modeling method to estimate secondhand exposure potential from exhalations during e-vapor product use under various real-world scenarios

• Acetaldehyde and acrolein were not detectable after use of any of the test products.
• When these data were used as inputs to a computational room air level and non-user intake model, the ambient concentrations of exhaled nicotine and formaldehyde predicted that non-user intakes were substantially reduced for test product use compared to conventional cigarette use.
• Collectively, the results predict that room air levels and exposure of the selected analytes to non-users were relatively low and several-fold below regulatory PELs and AIHA limit under the modeled space and use conditions.
• ...room air levels of nicotine, formaldehyde, acrolein, and acetaldehyde levels were significantly below OSHA PELs or American Industrial Hygiene Association (AIHA) limit...

2020: Comparative Indoor Pollution from Glo, Iqos, and Juul, Using Traditional Combustion Cigarettes as Benchmark: Evidence from the Randomized SUR-VAPES AIR Trial

• Glo, Iqos, and Juul have significantly less intense and persistent effects on indoor pollution in comparison to combustible tobacco cigarettes.

2018: Characterization of the Spatial and Temporal Dispersion Differences Between Exhaled E-Cigarette Mist and Cigarette Smoke

• For both product categories, the particle concentrations registered following each puff were in the same order of magnitude. However, for e-cigarettes the particle concentration returned rapidly to background values within seconds; for conventional cigarettes it increased with successive puffs, returning to background levels after 30–45 minutes. Unlike for the e-cigarette devices tested, such temporal variation was dependent on the room ventilation rate. Particle size measurements showed that exhaled e-cigarette particles were smaller than those emitted during smoking conventional cigarettes and evaporated almost immediately after exhalation, thus affecting the removal of particles through evaporation rather than displacement by ventilation.

2017 Evaluation of Chemical Exposures at a Vape Shop

• We collected air samples for flavoring chemicals (diacetyl, 2,3-pentanedione, 2,3-hexanedione, acetaldehyde, and acetoin), nicotine, formaldehyde, and propylene glycol.
• Concentrations of vaping-related chemicals in our air samples were below occupational exposure limits.

2017 Dr. Michael Siegel - Vape Shop Air Sampling by California State Health Department Suggests that Second Hand Vape Exposure is Minimal

• This study, although conducted under very high exposure conditions in a small, non-ventilated vape shop with many employees and customers vaping and clouds of vapor visible, did not document any dangerous levels of exposure to any hazardous chemical. Nicotine exposure was essentially non-existent. *Formaldehyde exposure was no different than in many indoor and outdoor environments at baseline. Acetone, acetoin, other aldehydes, toluene, benzene, and xylene were not detected. Chemicals that have been associated with "popcorn lung" were also not detected by the standard method.
• This study adds to the evidence that under real-life conditions, "secondhand vaping" does not appear to pose any significant health risks.

2015: A rapid method for the chromatographic analysis of volatile organic compounds in exhaled breath of tobacco cigarette and electronic cigarette smokers

• Tobacco cigarette smoke provided the samples containing highest concentrations of all compounds analyzed. Besides nicotine it contained benzene, toluene, xylenes, ethylbenzene and naphthalene in high abundance as well as other compounds such as isoprene, pent-1-ene, n-pentane, n-hexane, n-heptane and others.
• This composition was in strong contrast with that of vapor from the e-cigarettes in which all these compounds were virtually absent except nicotine

2014: Peering through the mist: systematic review of what the chemistry of contaminants in electronic cigarettes tells us about health risks

• Threshold Limit Values (TLVs), were conducted under “worst case” assumptions about both chemical content of aerosol and liquids as well as behavior of vapers.
• There was no evidence of potential for exposures of e-cigarette users to contaminants that are associated with risk to health at a level that would warrant attention if it were an involuntary workplace exposures.
• Exposures of bystanders are likely to be orders of magnitude less, and thus pose no apparent concern.

2012: Comparison of the effects of e-cigarette vapor and cigarette smoke on indoor air quality

• Comparisons of pollutant concentrations were made between e-cigarette vapor and tobacco smoke samples. Pollutants included VOCs, carbonyls, PAHs, nicotine, TSNAs, and glycols.
• Non-cancer risk analysis revealed “No Significant Risk” of harm to human health for vapor samples from e-liquids.
• With regard to cancer risk analysis, no vapor sample from e-liquids exceeded the risk limit for either children or adults.

Misinformation About Nicotine and Lung Health

2023: Doctors’ Survey: China results

• Physicians Have Misperceptions About Nicotine. Participants were asked: “To what extent do you agree that nicotine by itself directly causes each of the smoking-related conditions below. The results include responses from “moderately agree” to “completely agree.” 92% - Nicotine causes COPD. 91% - Nicotine causes lung cancer

2023: Doctors' Survey: Germany results

• Physicians Have Misperceptions About Nicotine. Participants were asked: “To what extent do you agree that nicotine by itself directly causes each of the smoking-related conditions below. The results include responses from “moderately agree” to “completely agree.” 78% - Nicotine causes COPD. 77% - Nicotine causes lung cancer

2023: Doctors’ Survey: Greece results

• Physicians Have Misperceptions About Nicotine. Participants were asked: “To what extent do you agree that nicotine by itself directly causes each of the smoking-related conditions below. The results include responses from “moderately agree” to “completely agree.” 65% - Nicotine causes lung cancer. 64% - Nicotine causes COPD

2023: Doctors’ Survey: India results

• Physicians Have Misperceptions About Nicotine. Participants were asked: “To what extent do you agree that nicotine by itself directly causes each of the smoking-related conditions below. The results include responses from “moderately agree” to “completely agree.” 88% - Nicotine causes lung cancer. 86% - Nicotine causes COPD

2023: Doctors’ Survey: Indonesia results

• Physicians Have Misperceptions About Nicotine. Participants were asked: “To what extent do you agree that nicotine by itself directly causes each of the smoking-related conditions below. The results include responses from “moderately agree” to “completely agree.” 97% - Nicotine causes lung cancer. 92% - Nicotine causes COPD

2023: Doctors’ Survey: Israel results

• Physicians Have Misperceptions About Nicotine. Participants were asked: “To what extent do you agree that nicotine by itself directly causes each of the smoking-related conditions below. The results include responses from “moderately agree” to “completely agree.” 69% - Nicotine causes lung cancer. 66% - Nicotine causes COPD

2023: Doctors’ Survey: Italy results

• Physicians Have Misperceptions About Nicotine. Participants were asked: “To what extent do you agree that nicotine by itself directly causes each of the smoking-related conditions below. The results include responses from “moderately agree” to “completely agree.” 69% - Nicotine causes COPD. 67% - Nicotine causes lung cancer

2023: Doctors’ Survey: Japan results

• Physicians Have Misperceptions About Nicotine. Participants were asked: “To what extent do you agree that nicotine by itself directly causes each of the smoking-related conditions below. The results include responses from “moderately agree” to “completely agree.” 88% - Nicotine causes lung cancer. 88% - Nicotine causes COPD

2023: Doctors' Survey: South Africa results

• Physicians Have Misperceptions About Nicotine. Participants were asked: “To what extent do you agree that nicotine by itself directly causes each of the smoking-related conditions below. The results include responses from “moderately agree” to “completely agree.” 82% - Nicotine causes lung cancer. 81% - Nicotine causes COPD

2023: Doctors' Survey: UK results

• Physicians Have Misperceptions About Nicotine. Participants were asked: “To what extent do you agree that nicotine by itself directly causes each of the smoking-related conditions below. The results include responses from “moderately agree” to “completely agree.” 60% - Nicotine causes lung cancer. 59% - Nicotine causes COPD

2023: Doctors' Survey: USA results

• Physicians Have Misperceptions About Nicotine. Participants were asked: “To what extent do you agree that nicotine by itself directly causes each of the smoking-related conditions below. The results include responses from “moderately agree” to “completely agree.” 67% - Nicotine causes lung cancer. 66% - Nicotine causes COPD

2023: Electronic cigarette: what perceptions in France?

• Article: 80% of French people believe that vaping causes cancer

2022: TOBACCO HARM REDUCTION AND NICOTINE PERCEPTIONS

• People consume nicotine, but they die from smoking. Many consumers and doctors mistakenly believe that nicotine causes various illnesses, while it is proven that the many other toxins in smoking are the reason for them.
• 69% of smokers in France and 74% of smokers in Germany believe nicotine causes cancer.
• PDF of Report

2020: Nicotine Risk Misperception Among US Physicians

• Overall, the majority of physicians “strongly agreed” that nicotine directly contributes to the development of..., COPD (80.9%), and cancer (80.5%). ... and 30.2% did not answer this question—a potential indicator of “do not know.”
• While it is possible that some physicians may have misunderstood the question (e.g., considered harm caused by tobacco, rather than nicotine), results are consistent with other studies finding notable nicotine misperceptions.
• PDF Version
• Rutgers Article: Rutgers-Led National Survey Uncovers Doctors' Misconceptions About Nicotine Risks
• Rutgers Article: Researchers say physicians need to understand accurate nicotine risks better to assist patients addicted to the most harmful tobacco products
• Filter Article: Majority of Surveyed Doctors Misattribute Tobacco Harms to Nicotine

2020: Perceptions of nicotine in current and former users of tobacco and tobacco harm reduction products from seven countries

• PDF of full report
• ...Current consumers who agreed with the statement that nicotine is the primary cause of tobacco-related cancer ranged from 43.7% (men, UK) to 78.0% (men, SA).
• In six countries nicotine was rated nearly as harmful as cigarettes and alcohol...
• A reason why users of tobacco and THR products around the world find it hard to distinguish between the health risks of smoking and nicotine use may be due to conflicting messages from the media that deviate from the most recent scientific evidence base, overemphasize certain opinions or omit findings that do not align with their readers’ beliefs.
• We observed that the majority of current and previous product users estimated the harmfulness of nicotine and cigarettes alike. This has led to the misled conclusion that nicotine is responsible for the detrimental effects related to combustible tobacco consumption, even though science has found only very limited and often inconclusive evidence to date that nicotine is any more harmful than other legally consumed stimulants.
• Contradictory statements by leading researchers supported by renowned funding agencies and misreporting by the media may further public confusion as people have stated they use the media as a source of health information.

2013: Survey of GPs' understanding of tobacco and nicotine products

• However, when asked to rank components of cigarettes based on their health risks, GPs ranked nicotine as the third riskiest (74 percent England, 87 percent Sweden), after tar and carbon monoxide, but before smoke or tobacco.
• Article: ‘GPs falsley believe nicotine most harmful cigarette ingredient’
  • ...less than half believe that long-term nicotine replacement therapy (NRT) is preferable to smoking (31% UK, 48% Sweden).
  • Many (44% UK, 56% Sweden) also wrongly believe that nicotine in tobacco products is associated with cancer, while 15% in the UK and 22% in Sweden believe the same for pharmaceutical nicotine.

Stigma - Lung Diseases

2022: Society of Thoracic Radiology

• STR’S COMMITMENT TO NON-STIGMATIZING LANGUAGE IN LUNG CANCER CARE
• "Whether we as chest imagers realize it or not, our very language can have a negative impact on the care for the patients we serve. As published studies continue to demonstrate, smoking-related language bias often stigmatizes our patients with a smoking history and results in suboptimal care and less than desirable clinical outcomes... Instead of a report stigmatizing the patient as a “smoker,” consider describing the patient as a “person who smokes.” Rather than a “nicotine addict,” an expression such as a “person with a nicotine dependence” attenuates the common stigmatization of these patients. One will notice these alternative descriptors utilize a person-first approach rather than a habit-based one. This approach can and should be adopted in publications, society and conference presentations as well as in daily training with residents and fellows. Ultimately, this language shift more precisely aligns itself with a core underpinning of our approach to care – respect for our patients.

2022: Reducing stigma triggered by assessing smoking status among patients diagnosed with lung cancer: De-stigmatizing do and don't lessons learned from qualitative interviews

• Patients expressed clear preferences for CCPS to refrain from using judgmental labels when assessing smoking history, including a preference for questions such as “have you smoked cigarettes in the past 30 days” rather than “are you a smoker?” . This perspective is consistent with the broader clinical efforts and dissemination of resources to reduce illness-related stigma through the increased use of person-first language and other bias-free language in clinical care and research. [emphasis added]

2021: Great Britain: symptom awareness and attitudes to lung cancer Findings from a global study

• One in four (25%) people in the UK agreed that they have less sympathy for people with lung cancer than other forms of cancer. Globally, one in five (21%) people agreed that they have less sympathy for people with lung cancer than other forms of cancer.

2021: MNT investigates: How lung cancer stigma holds back research and treatment

• Drs. Carter-Harris and Williamson both encourage people to use person-first language when talking about smoking. One example of this is describing someone as “a person who formerly smoked” rather than “a former smoker.”
• “By labeling someone as a smoker, you’ve depersonalized them, and you’ve identified them by a behavior that’s stigmatized,” Dr. Carter-Harris said.
• The National Cancer Institute invested nearly $575 millionTrusted Source in breast cancer research in 2018. They invested only $350 million in lung cancer research that year. Research disparities exist in other countries as well. A global analysis found that lung cancer accounted for roughly 20% of cancer deaths but only 5.6% of cancer research output in 2013.

2019: ES13.05 Stigma and Impact of Tobacco Control Policy

• The stigma reduces the funding available for lung cancer research. In the US, federal funding for lung cancer research per lung cancer death is only 15% of the funding amount for breast cancer per breast cancer death.
• In a Global Lung Cancer Coalition survey, one in five people (21%) agreed with the statement that they have less sympathy for people with lung cancer than for people with other types of cancer.
• Stigmatization of smokers has the greatest impact on the socioeconomically deprived, the disadvantaged populations. These populations have the highest prevalence of smokers and encounter the stigma of their race or disadvantage (poverty, disability, sexual preference, behavioral health etc.) in addition to the stigma associated with smoking.
• This stigmatization leads people who smoke to be less likely to seek medical care when they have symptoms, more likely to lie about their smoking, more likely to be refused access to care including curative surgery for early stage lung cancer unless they quit smoking, less likely to be offered smoking cessation help if they are uncomfortable disclosing their smoking status due to stigma and bias from their healthcare professional.

2014: Lung Cancer Stigma, Anxiety, Depression and Quality of Life

• Regardless of smoking status, lung cancer patients have reported stigmatization from clinicians, family members and friends due to strong associations between smoking and lung disease.
• The results of this study confirm our previous findings that LCS [lung cancer stigma] is positively correlated with anxiety and depression and negatively correlated with QOL [quality of life].

2014: Let's Not Wage War on Smokers

• In 2004, a team of health scientists at Oxford interviewed 45 people with lung cancer and found that felt even more stigma than other cancer patients: Participants experienced stigma commonly felt by patients with other types of cancer, but, whether they smoked or not, they felt particularly stigmatized because the disease is so strongly associated with smoking… Some patients concealed their illness, which sometimes had adverse financial consequences or made it hard for them to gain support from other people.

Suggested studies to add to this page

2021: Lung function and respiratory symptoms in a randomized smoking cessation trial of electronic cigarettes

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More Information

• Click on the category link below for more studies by topic on ENDS and Nicotine.