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{{short description|Device that vaporizes a liquid nicotine solution for inhalation}}
{{pp-protected|small=yes}}
{{redirect|Vape|the Argentine reconnaissance vehicle|VAPE}}
{{Use dmy dates|date=April 2014}}
{{distinguish|Heated tobacco product|Vaporizer (inhalation device)}}
]
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<!-- Definition and Construction -->
{{Use dmy dates|date=November 2022}}
An '''electronic cigarette''' ('''e-cig''' or '''e-cigarette'''), '''personal vaporizer''' ('''PV''') or '''electronic nicotine delivery system''' ('''ENDS''') is a ]-powered ] which feels similar to ].<ref name=Caponnetto2012>{{cite journal|last1=Caponnetto|first1=Pasquale|last2=Campagna|first2=Davide|last3=Papale|first3=Gabriella|last4=Russo|first4=Cristina|last5=Polosa|first5=Riccardo|title=The emerging phenomenon of electronic cigarettes|journal=Expert Review of Respiratory Medicine|volume=6|issue=1|year=2012|pages=63–74|issn=1747-6348|doi=10.1586/ers.11.92|pmid=22283580}}</ref> Electronic cigarettes produce an ], commonly called ], rather than ].<ref name=Cheng2014/> This vapor is inhaled.<ref name=Cheng2014>{{cite journal|last1=Cheng|first1=T.|title=Chemical evaluation of electronic cigarettes|journal=Tobacco Control|volume=23|issue=Supplement 2|year=2014|pages=ii11–ii17|issn=0964-4563|doi=10.1136/tobaccocontrol-2013-051482|pmc=3995255|pmid=24732157}}</ref> In general, e-cigarettes have a ] that atomizes a ] known as e-liquid.<ref name=Weaver2014>{{cite journal|last1=Weaver|first1=Michael|last2=Breland|first2=Alison|last3=Spindle|first3=Tory|last4=Eissenberg|first4=Thomas|title=Electronic Cigarettes|journal=Journal of Addiction Medicine|volume=8|issue=4|year=2014|pages=234–240|issn=1932-0620|doi=10.1097/ADM.0000000000000043|pmid=25089953}}</ref> E-liquids are usually a mixture of ], ], ], and ].<ref name=Grana2014/> Others have similar ingredients but without nicotine.<ref name=Saitta2014/>
]
]
An '''electronic cigarette''' ('''e-cigarette'''), commonly called a '''vape''',{{#tag:ref|Also known as an '''e-cig''', '''vaporizer''', '''vape pen''', '''hookah pen''', '''e-pipe''', or, formally, '''electronic nicotine delivery system''' ('''ENDS''').<ref name=FDA2020/>|group=note}}<ref name=FDA2020>{{cite web|url=https://www.fda.gov/tobacco-products/products-ingredients-components/vaporizers-e-cigarettes-and-other-electronic-nicotine-delivery-systems-ends|title=Vaporizers, E-Cigarettes, and other Electronic Nicotine Delivery Systems (ENDS)|publisher=United States Food and Drug Administration|date=14 February 2020}}{{PD-notice}}</ref> is a device that simulates ]. It consists of an ], a power source such as a battery, and a container such as a cartridge or tank. Instead of ], the user inhales ].<ref name=Cheng2014>{{cite journal|last1=Cheng|first1=T.|title=Chemical evaluation of electronic cigarettes|journal=Tobacco Control |volume=23 |issue=Supplement 2|year=2014|pages=ii11–ii17|issn=0964-4563|doi=10.1136/tobaccocontrol-2013-051482|pmc=3995255|pmid=24732157}}</ref> As such, using an e-cigarette is often called "'''vaping'''".<ref name=Orellana-Barrios2015/> The atomizer is a ] that vaporizes a ] called ],<ref name=Weaver2014/> which quickly cools into an aerosol of tiny droplets, vapor and air.<ref>{{cite journal |last1=David |first1=Grégory |last2=Parmentier |first2=Evelyne A. |last3=Taurino |first3=Irene |last4=Signorell |first4=Ruth |title=Tracing the composition of single e-cigarette aerosol droplets in situ by laser-trapping and Raman scattering |journal=Scientific Reports |date=December 2020 |volume=10 |issue=1 |pages=7929 |doi=10.1038/s41598-020-64886-5 |pmid=32404884 |pmc=7220912 |bibcode=2020NatSR..10.7929D }}</ref> The vapor mainly comprises ] and/or ], usually with ] and ]. Its ], and depends on several things including user behavior.{{#tag:ref|A 2014 review found "In addition to the uniqueness of the liquid compositions in each brand, inconsistency of both the device performance properties and the data collection methodologies used by researchers contribute to the observed variation in constituent levels and to the range of particle size distributions among products."<ref name=Cheng2014/>|group=note}}


E-cigarettes are activated by taking a puff or pressing a button.<ref name=Orellana-Barrios2015/><ref name=Rahman2014/> Some look like ],<ref name=Orellana-Barrios2015/><ref name=Pepper2013>{{cite journal |last1=Pepper|first1=J. K.|last2=Brewer|first2=N. T.|title=Electronic nicotine delivery system (electronic cigarette) awareness, use, reactions and beliefs: a systematic review|journal=Tobacco Control |volume=23|issue=5|year=2013|pages=375–384|issn=0964-4563|doi=10.1136/tobaccocontrol-2013-051122 |pmc=4520227|pmid=24259045}}</ref> and most kinds are reusable.{{refn|group=note|"Most ENDS consist of a rechargeable, battery-operated heating element and a replaceable or refillable cartridge for the e-liquid. An atomizer heats the liquid in the cartridge to convert it into an aerosol, which is then inhaled by the user. Most of these products are rechargeable, but some are disposable."<ref name=DropeCahn2017>{{cite journal |last1=Drope |first1=Jeffrey |last2=Cahn |first2=Zachary |last3=Kennedy |first3=Rosemary |last4=Liber |first4=Alex C. |last5=Stoklosa |first5=Michal |last6=Henson |first6=Rosemarie |last7=Douglas |first7=Clifford E. |last8=Drope |first8=Jacqui |title=Key issues surrounding the health impacts of electronic nicotine delivery systems (ENDS) and other sources of nicotine |journal=CA: A Cancer Journal for Clinicians |volume=67 |issue=6 |pages=449–471 |date=November 2017 |issn=0007-9235 |doi=10.3322/caac.21413 |pmid=28961314 |s2cid=32928770 |doi-access=free}}</ref>}}
<!-- Health effects -->
The ] use are uncertain.<ref name=EbbertAgunwamba2015/><ref name=Harrell2014/> One review found limited evidence of a benefit as a ] aid.<ref name=Cochrane2014>{{cite journal|last1=McRobbie|first1=Hayden|last2=Bullen|first2=Chris|last3=Hartmann-Boyce|first3=Jamie|last4=Hajek|first4=Peter|last5=McRobbie|first5=Hayden|title=Electronic cigarettes for smoking cessation and reduction|journal=The Cochrane Library|year=2014|doi=10.1002/14651858.CD010216.pub2|pmid=25515689}}</ref> Their role in ] as a substitute for ] is unclear.<ref name=Drummond2014/> While they may be similar in safety to approved ] (NRT),<ref name=Caponnetto2013/> approved products are generally prefered due to greater safety data.<ref name=Drummond2014/>


Nicotine is highly addictive.<ref name="AAP_Policy_ENDS">{{cite journal |title=Policy on Electronic Nicotine Delivery Systems (ENDS) |journal=American Academy of Pediatrics |date=2020 |url=https://www.aapd.org/media/policies_guidelines/p_electroniccig.pdf |access-date=13 November 2022}}</ref><ref name="AAO_Statement">{{cite journal |title=Position Statements on e-cigarettes |journal=American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) |date=21 April 2021 |url=http://entnet.org/resource/position-statements-on-e-cigarettes/ |access-date=13 November 2022 |archive-date=13 November 2022 |archive-url=https://web.archive.org/web/20221113061837/https://www.entnet.org/resource/position-statements-on-e-cigarettes/ |url-status=dead }}</ref><ref name="FIRS_Statement">{{cite journal |last1=Schraufnagel |first1=Dean E. |last2=Blasi |first2=Francesco |last3=Drummond |first3=M. Bradley |last4=Lam |first4=David C. L. |last5=Latif |first5=Ehsan |last6=Rosen |first6=Mark J. |last7=Sansores |first7=Raul |last8=Van Zyl-Smit |first8=Richard |title=Electronic Cigarettes. A Position Statement of the Forum of International Respiratory Societies |journal=American Journal of Respiratory and Critical Care Medicine |date=15 September 2014 |volume=190 |issue=6 |pages=611–618 |doi=10.1164/rccm.201407-1198PP |pmid=25006874 |s2cid=43763340 |url=https://www.atsjournals.org/doi/full/10.1164/rccm.201407-1198PP |access-date=13 November 2022 |issn=1073-449X}}</ref> Users become physically and psychologically dependent.<ref>{{cite journal |last=Miyasato |first=K. |title= |journal=Nihon Rinsho. Japanese Journal of Clinical Medicine |volume=71 |issue=3 |pages=477–481 |date=March 2013 |pmid=23631239 |language=ja}}</ref> Scientists do not know how harmful e-cigarettes are over the long-term<ref name="Marques2021">{{cite journal |last1=Marques |first1=Patrice |last2=Piqueras |first2=Laura |last3=Sanz |first3=Maria-Jesus |title=An updated overview of e-cigarette impact on human health |journal=Respiratory Research |date=December 2021 |volume=22 |issue=1 |pages=151 |doi=10.1186/s12931-021-01737-5|pmid=34006276 |pmc=8129966 |s2cid=234753956 |quote="the safety of e-cigarette consumption and its potential as a smoking cessation method remain controversial due to limited evidence...the potential long-term effects of e-cigarette consumption have been scarcely investigated." |doi-access=free }}</ref><ref name="Walley2019">{{cite journal |last1=Walley |first1=Susan C. |last2=Wilson |first2=Karen M. |last3=Winickoff |first3=Jonathan P. |last4=Groner |first4=Judith |title=A Public Health Crisis: Electronic Cigarettes, Vape, and JUUL |journal=Pediatrics |date=1 June 2019 |volume=143 |issue=6 |pages=e20182741 |doi=10.1542/peds.2018-2741|pmid=31122947 |s2cid=163165584 |quote="Because e-cigarettes have only been marketed for ~10 years... scientific data are limited and will continue to emerge. Because e-cigarette solutions and emissions have been shown to contain nicotine and many of the same harmful toxicants and carcinogens as cigarettes, it is reasonable to assume that there is the potential for similar health effects for e-cigarette use, particularly with emerging data of tobacco toxicant exposure found among e-cigarette users."|doi-access=free }}</ref> because it is ] of vaping from the effects of smoking when so many people both vape and smoke.{{efn|group=note|"Once again, there is a strong potential for confounding, such that comparisons of dual users with smokers who do not use e-cigarettes will not yield meaningful causal estimates"<ref name=DropeCahn2017/>}}<ref name="Kim2020">{{cite journal |last1=Kim |first1=Sooyong |last2=Selya |first2=Arielle S |title=The Relationship Between Electronic Cigarette Use and Conventional Cigarette Smoking Is Largely Attributable to Shared Risk Factors |journal=Nicotine & Tobacco Research |date=12 June 2020 |volume=22 |issue=7 |pages=1123–1130 |doi=10.1093/ntr/ntz157|pmid=31680169 |pmc=7291806 |quote="past research remains inconclusive due to heavy confounding between cigarette and e-cigarette use"}}</ref> E-cigarettes have not been used widely enough or for long enough to be sure.<ref name="Gotts2019LongTerm">{{cite journal |last1=Gotts |first1=Jeffrey E |last2=Jordt |first2=Sven-Eric |last3=McConnell |first3=Rob |last4=Tarran |first4=Robert |title=What are the respiratory effects of e-cigarettes? |journal=BMJ |date=30 September 2019 |volume=366 |pages=l5275 |pmid=31570493 |pmc=7850161 |doi=10.1136/bmj.l5275 |quote="We reiterate that, to date, no long term vaping toxicological/safety studies have been done in humans; without these data, saying with certainty that e-cigarettes are safer than combustible cigarettes is impossible."}}</ref><ref name="Benowitz2016">{{cite journal |last1=Benowitz |first1=Neal L. |last2=Burbank |first2=Andrea D. |title=Cardiovascular toxicity of nicotine: Implications for electronic cigarette use |journal=Trends in Cardiovascular Medicine |date=August 2016 |volume=26 |issue=6 |pages=515–523 |doi=10.1016/j.tcm.2016.03.001|pmid=27079891 |pmc=4958544 |quote="It is difficult to distinguish the independent roles of nicotine vs tobacco combustion products in cigarette smokers because all smokers are exposed to both."}}</ref><ref name="BalsBoyd2019">{{cite journal |last1=Bals |first1=Robert |last2=Boyd |first2=Jeanette |last3=Esposito |first3=Susanna |last4=Foronjy |first4=Robert |last5=Hiemstra |first5=Pieter |last6=Jiménez-Ruiz |first6=Carlos A. |last7=Katsaounou |first7=Paraskevi |last8=Lindberg |first8=Anne |last9=Metz |first9=Carlos |last10=Schober |first10=Wolfgang |last11=Spira |first11=Avrum |last12=Blasi |first12=Francesco |title=Electronic cigarettes: a task force report from the European Respiratory Society |journal=European Respiratory Journal |date=February 2019 |volume=53 |issue=2 |pages=1801151 |doi=10.1183/13993003.01151-2018 |doi-access=free |pmid=30464018 |s2cid=53711734 |issn=0903-1936 |quote="The long-term effects of ECIG use are unknown, and there is therefore no evidence that ECIGs are safer than tobacco in the long term. Based on current knowledge, negative health effects cannot be ruled out."}}</ref>
<!-- Safety -->
The limited evidence suggests that e-cigarettes are safer than traditional ]s.<ref name=O2012/> Electronic cigarettes may carry a risk of addiction in those who do not already smoke,<ref name=WHOJuly2013/> but there is no evidence of ongoing use among those who have never smoked.<ref name=Hajek2014/> They may promote delaying of quitting smoking, or act as a deterrent to quitting.<ref name=Grana2014/> Emissions from e-cigarettes may contain tiny ]s of flavors, aroma transporters, glycerol, propylene glycol, nicotine, tiny amounts of ]s and ], and other chemicals.<ref name=Grana2014/><ref name=Hajek2014/> E-cigarette emissions have fewer ]s than cigarette smoke.<ref name=Grana2014/> They are likely to be less harmful to users and bystanders.<ref name=Grana2014/><ref name=Hajek2014/> No serious ]s from e-cigarettes have been reported in trials.<ref name=Cochrane2014/> Less serious adverse effects from e-cigarette use include throat and mouth inflammation, vomiting, nausea, and cough.<ref name=Grana2014/>


Vaping is likely far less harmful than smoking, but still harmful.<ref>{{harvp|National Academies of Sciences, Engineering, and Medicine|2018|p={{page needed|date=January 2023}}}}: "Laboratory tests of e-cigarette ingredients, in vitro toxicological tests, and short-term human studies suggest that e-cigarettes are likely to be far less harmful than combustible tobacco cigarettes."</ref><ref name="NICE_2021">{{cite web |first1=The National Institute for |last1=Health and Care Excellence|title=Recommendations on treating tobacco dependence Tobacco: preventing uptake, promoting quitting and treating dependence. Guidance NICE |url=https://www.nice.org.uk/guidance/ng209/chapter/recommendations-on-treating-tobacco-dependence |website=www.nice.org.uk |date=30 November 2021 |access-date=13 November 2022 |quote=use of e‑cigarettes is likely to be substantially less harmful than smoking}}</ref><ref name="ajph.aphapublications.org">{{Cite journal |title=Balancing Consideration of the Risks and Benefits of E-Cigarettes |date=September 2021 |doi=10.2105/AJPH.2021.306416 |last1=Balfour |first1=David J. K. |last2=Benowitz |first2=Neal L. |last3=Colby |first3=Suzanne M. |last4=Hatsukami |first4=Dorothy K. |last5=Lando |first5=Harry A. |last6=Leischow |first6=Scott J. |last7=Lerman |first7=Caryn |last8=Mermelstein |first8=Robin J. |last9=Niaura |first9=Raymond |last10=Perkins |first10=Kenneth A. |last11=Pomerleau |first11=Ovide F. |last12=Rigotti |first12=Nancy A. |last13=Swan |first13=Gary E. |last14=Warner |first14=Kenneth E. |last15=West |first15=Robert |journal=American Journal of Public Health |volume=111 |issue=9 |pages=1661–1672 |pmid=34410826 |pmc=8589069 |quote=Among potentially toxic substances common to both products, cigarette smoke generally contains substantially larger quantities than e-cigarette aerosol. However, e-cigarette aerosol contains some substances not found in cigarette smoke."}}</ref> E-cigarette vapor contains far fewer ]s than cigarette smoke, and at much lower concentrations. The vapor contains traces of harmful substances not found in cigarette smoke.<ref name="ajph.aphapublications.org"/> E-cigarettes containing nicotine are more effective than ] (NRT) for ].<ref name=":3">{{Cite journal |last1=Lindson |first1=Nicola |last2=Butler |first2=Ailsa R. |last3=McRobbie |first3=Hayden |last4=Bullen |first4=Chris |last5=Hajek |first5=Peter |last6=Begh |first6=Rachna |last7=Theodoulou |first7=Annika |last8=Notley |first8=Caitlin |last9=Rigotti |first9=Nancy A. |last10=Turner |first10=Tari |last11=Livingstone-Banks |first11=Jonathan |last12=Morris |first12=Tom |last13=Hartmann-Boyce |first13=Jamie |date=2024-01-08 |title=Electronic cigarettes for smoking cessation |journal=The Cochrane Database of Systematic Reviews |volume=1 |issue=1 |pages=CD010216 |doi=10.1002/14651858.CD010216.pub8 |issn=1469-493X |pmc=10772980 |pmid=38189560|pmc-embargo-date=January 8, 2025 }}</ref><ref>{{cite journal |last1=Lindson |first1=N |last2=Butler |first2=AR |last3=McRobbie |first3=H |last4=Bullen |first4=C |last5=Hajek |first5=P |last6=Begh |first6=R |last7=Theodoulou |first7=A |last8=Notley |first8=C |last9=Rigotti |first9=NA |last10=Turner |first10=T |last11=Livingstone-Banks |first11=J |last12=Morris |first12=T |last13=Hartmann-Boyce |first13=J |title=Electronic cigarettes for smoking cessation. |journal=The Cochrane Database of Systematic Reviews |date=8 January 2024 |volume=1 |issue=1 |pages=CD010216 |doi=10.1002/14651858.CD010216.pub8 |pmid=38189560 |pmc=10772980 |pmc-embargo-date=January 8, 2025 |url=https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD010216.pub8/full |access-date=17 April 2024 |ref=Jan'24Cochrane}}</ref> However, e-cigarettes have not been subject to the same rigorous testing that most nicotine replacement therapy products have,<ref name=":2">{{cite journal |last1=Carpenter |first1=Matthew J. |last2=Wahlquist |first2=Amy E. |last3=Dahne |first3=Jennifer |last4=Gray |first4=Kevin M. |last5=Cummings |first5=K. Michael |last6=Warren |first6=Graham |last7=Wagener |first7=Theodore L. |last8=Goniewicz |first8=Maciej L. |last9=Smith |first9=Tracy T. |title="Effect of unguided e-cigarette provision on uptake, use, and smoking cessation among adults who smoke in the USA: a naturalistic, randomised, controlled clinical trial."|journal=eClinicalMedicine |date=September 2023 |volume=63 |pages=102142 |doi=10.1016/j.eclinm.2023.102142|pmid=37753443 |pmc=10518503 }}</ref> and health warnings may encourage a smoker to quit vaping.<ref name="Al-HamdaniHopkins2019" />
<!-- Usage and History-->
The frequency of use has increased with up to 10% of American high school students having ever used them as of 2012 and around 3.4% of American adults as of 2011.<ref name=Car2014/> In the UK the number of e-cigarette users has increased from 700,000 in 2012 to 2.1 million in 2013.<!-- <ref name=ashuk2014/> --> About 60% are smokers and most of the rest are ex-smokers.<ref name=ashuk2014/> E-cigarette users most commonly continue to smoke traditional cigarettes.<ref name=Grana2014/> Current e-cigarettes arose from an invention made by ] in China in 2003,<ref name=Demick2009/> and devices are mostly manufactured in China.<ref name=Grana2014/> E-cigarette brands have increased advertising with similar marketing to that used to sell cigarettes in the 1950s and 1960s.<ref name=Grana2014/> Because of the possible relationship to tobacco laws and medical drug policies, ] is being debated in many countries.<ref name=Saitta2014/><ref name=Etter2011/> The ] passed regulations in February 2014 requiring standardization of liquids and personal vaporizers, listing of ingredients, and child-proofing of liquid containers.<ref name=EURegs2014/> The US ] (FDA) published proposed regulations in April 2014 with some similar measures.<ref>{{cite web|title=Electronic Cigarettes (e-Cigarettes)|url=http://www.fda.gov/NewsEvents/PublicHealthFocus/ucm172906.htm|website=FDA|accessdate=18 October 2014|date=11 August 2014}}</ref>


{{TOC limit|3}} {{TOC limit}}


==Usage== == Construction ==
{{Main|Construction of electronic cigarettes}}
].<ref name=Grana2014/>]]
Electronic cigarette sales increased from 50,000 in 2008 to 3.5 million in 2012.<ref name=Koch2012/> Electronic cigarette sales worldwide for 2014 were estimated at $7 billion.<ref>{{cite web|title=E-Cigarette Makers Face Rise of Counterfeits|url=http://www.nasdaq.com/article/ecigarette-makers-face-rise-of-counterfeits-20150220-00313|publisher=Dow Jones Business News}}</ref> Most people who use electronic cigarettes have a history of smoking cigarettes while some young people who have never smoked cigarettes have tried electronic cigarettes at least once.<ref name=Car2014/> Most studies found everyday use among e-cigarette users was common.<ref name=Pepper2013/> Among adults or children, the extent to which a dual use tendency exists using e-cigarettes and traditional cigarettes is unclear.<ref name=Grana2014/> E-cigarette users most commonly continue to smoke traditional cigarettes.<ref name=Grana2014/> Many users report that electronic cigarettes help them either quit smoking or reduce the number of cigarettes smoked.<ref name=Hajek2014/> Adults most frequently use electronic cigarettes as a replacement for tobacco, but not always to quit.<ref name=Car2014/> The majority of e-cigarette users are typically middle-aged males presently using traditional cigarettes to assist them to quit or for recreational use.<ref name=Rahman2014/> Although some people have a desire to quit smoking by using e-cigarettes, other common explanations for the use of these products are to circumvent ] and to cut back on traditional cigarettes.<ref name=Grana2014/> Some people used e-cigarettes to avoid smoking bans.<ref name=Pepper2013/> The extent to which traditional cigarette users use e-cigarettes to avoid smoking bans is unclear.<ref name=Pepper2013/> Some e-cigarette advocates have been worried that the device may be banned.<ref name=Pepper2013/> Dual use of e-cigarettes and traditional tobacco is still a definite concern.<ref name=EbbertAgunwamba2015/> Many have conveyed concern about the possibility that e-cigarettes may function as a "gateway" to using traditional cigarettes.<ref name=Franck2014/> Ethical concerns exist from e-cigarettes use among minors and their possibility to weaken efforts to reduce traditional cigarette use.<ref name=Franck2014/>


]
<!-- United States -->
In the United States, as of 2011, one in five adults who smoke have tried electronic cigarettes and 3.3% are currently using them.<ref name=Car2014/><ref>{{cite news|url=http://www.cdc.gov/media/releases/2013/p0228_electronic_cigarettes.html|accessdate=4 March 2013|newspaper=CDC Newsroom|date=28 February 2013|title=CDC Electronic Cigarette Statistics}}</ref> Among grade 6 to 12 students in the United States, those who have at least once used the product increased from 3.3% in 2011 to 6.8% in 2012.<ref name=Car2014>{{cite journal|last=Carroll Chapman|first=SL|author2=Wu, LT|title=E-cigarette prevalence and correlates of use among adolescents versus adults: A review and comparison.|journal=Journal of Psychiatric Research|date=18 Mar 2014|pmid=24680203|doi=10.1016/j.jpsychires.2014.03.005|volume=54|pages=43–54}}</ref> and those currently using electronic cigarettes increased from 0.6% to 1.1%. Over the same period the percentage of grade 6 to 12 students who regularly smoke tobacco cigarettes fell from 7.5% to 6.7%.<ref name=MMWR-2013>{{cite journal |title=Tobacco product use among middle and high school students--United States, 2011 and 2012 |journal=MMWR Morb. Mortal. Wkly. Rep. |volume=62 |issue=45 |pages=893-7 |date=November 2013 |pmid=24226625 |url=http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6245a2.htm?s_cid=mm6245a2_e |author1=Centers for Disease Control and Prevention (CDC)}}</ref> The frequency of use has increased with up to 10% of American high school students having ever used them as of 2012.<ref name=Car2014/> In 2013 the CDC found a threefold increase from 2011 in the number of youth who have used electronic cigarettes who have never smoked.<ref name=CDC2014>{{cite web|title=More than a quarter-million youth have used e-cigarettes who have never smoked.|url=http://www.cdc.gov/media/releases/2014/p0825-e-cigarettes.html|accessdate=30 August 2014|date=25 August 2014}}</ref> The limited data suggests that e-cigarette use is rapidly growing among adolescents.<ref name=Lauterstein2014>{{cite journal|last1=Lauterstein|first1=Dana|last2=Hoshino|first2=Risa|last3=Gordon|first3=Terry|last4=Watkins|first4=Beverly-Xaviera|last5=Weitzman|first5=Michael|last6=Zelikoff|first6=Judith|title=The Changing Face of Tobacco Use Among United States Youth|journal=Current Drug Abuse Reviews|volume=7|issue=1|year=2014|pages=29–43|issn=18744737|doi=10.2174/1874473707666141015220110|pmid=25323124}}</ref> The majority of youth who use e-cigarettes also smoke combustible cigarettes.<ref name=CDCNYTS2013>{{cite journal |title=Tobacco Use Among Middle and High School Students — United States, 2013|journal=MMWR Morb. Mortal. Wkly. Rep.|volume=63 |issue=45 |pages=1021–1026 |date=14 November 2014 |pmid=24699766 |url=http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6345a2.htm?s_cid=mm6345a2_w |author=Arrazola, RA; Neff, LJ; Kennedy, SM; Holder-Hayes, E; Jones, CD}}</ref> E-cigarette use among never-smoking youth in the U.S is correlated with an elevated desire to use traditional cigarettes.<ref name=EbbertAgunwamba2015/>


An electronic cigarette consists of an atomizer, a power source such as a battery,<ref>{{cite web|title=What's in an E-Cigarette?|url=https://www.lung.org/quit-smoking/e-cigarettes-vaping/whats-in-an-e-cigarette|publisher=American Lung Association|year=2023}}</ref> and a container for e-liquid such as a cartridge or tank.
<!-- UK -->
In the UK in 2014, 18% of regular smokers identified themselves as using electronic cigarettes and 51% stated that they had used them in the past.<ref name=ASH2014>{{cite web|title=Use of electronic cigarettes in Great Britain|url=http://www.ash.org.uk/files/documents/ASH_891.pdf|website=ASH|publisher=ASH|accessdate=18 September 2014|date=July 2014}}</ref> Among those who had never smoked, 1.1% said they had tried them and 0.2% continue to use them.<ref name=ASH2014/> In 2013, among those under 18, 7% have used e-cigarettes at least once.<ref name=ASH2014/> Among non-smokers' children, 1% reported having tried e-cigarettes "once or twice", and there was no evidence of continued use.<ref name=ASH2014/> Sustained use was mostly confined to children who smoke or have smoked.<ref name=ASH2014/> In 2014 child regular users was at 1.8%, children who have ever used e-cigarettes was at 10%, and occasional or greater use among never smoking children was at 0.18%.<ref>{{cite web|title=New survey finds regular use by children still rare|url=http://www.ash.org.uk/:new-survey-finds-regular-use-of-electronic-cigarettes-by-children-still-rare|work=ASH-UK|accessdate=17 September 2014}}</ref> About 60% are smokers and most of the rest are ex-smokers.<ref name=ashuk2014>{{cite web | url=http://www.ash.org.uk/media-room/press-releases/:over-2-million-britons-now-regularly-use-electronic-cigarettes | title=Over 2 million Britons now regularly use electronic cigarettes | date=28 April 2014 | accessdate=30 May 2014 | author=ASH UK}}</ref>


E-cigarettes have evolved over time, and the different designs are classified in generations. First-generation e-cigarettes tend to look like traditional cigarettes and are called "cigalikes".<ref name=Farsalinos2014>{{cite journal|author1=Farsalinos KE|author2=Spyrou A|author3=Tsimopoulou K|author4=Stefopoulos C|author5=Romagna G|author6=Voudris V|title=Nicotine absorption from electronic cigarette use: Comparison between first and new-generation devices|journal=Scientific Reports|volume=4|pages=4133|year=2014|bibcode=2014NatSR...4E4133F|doi=10.1038/srep04133|pmc=3935206|pmid=24569565}}</ref><ref name=Bhatnagar2014/> Second-generation devices are larger and look less like traditional cigarettes.<ref name=McRobbie2014>{{cite web|url=http://www.ncsct.co.uk/usr/pub/e-cigarette_briefing.pdf|title=Electronic cigarettes|author=Hayden McRobbie|pages=1–16|publisher=National Centre for Smoking Cessation and Training|year=2014|access-date=4 June 2014|archive-date=23 April 2022|archive-url=https://web.archive.org/web/20220423185420/https://www.ncsct.co.uk/usr/pub/e-cigarette_briefing.pdf|url-status=dead}}</ref> Third-generation devices include mechanical mods and variable ] devices.<ref name=Farsalinos2014/> The fourth-generation includes sub-ohm tanks (meaning they have electrical resistance of less than 1 ]) and ].<ref name=Farsalinos2015>{{cite web|url=https://gfn.net.co/downloads/2015/Plenary%203/Konstantinos%20Farsalinos.pdf|title=Electronic cigarette evolution from the first to fourth generation and beyond|page=23|author=Konstantinos Farsalinos|publisher=Global Forum on Nicotine|year=2015|archive-url=https://web.archive.org/web/20150708172614/http://gfn.net.co/downloads/2015/Plenary%203/Konstantinos%20Farsalinos.pdf|archive-date=8 July 2015|url-status=dead}}</ref> There are also ] devices that use ], rather than ] nicotine found in earlier generations,<ref name=JenssenBoykan2019/> providing higher nicotine yields.<ref name=Weedston2019>{{cite news|url=https://www.thefix.com/fda-investigate-whether-vaping-causes-seizures|title=FDA To Investigate Whether Vaping Causes Seizures|last1=Weedston|first1=Lindsey|work=The Fix|date=8 April 2019}}</ref><ref name=Barrington-TrimisLeventhal2018>{{cite journal|last1=Barrington-Trimis|first1=Jessica L.|last2=Leventhal|first2=Adam M.|title=Adolescents' Use of "Pod Mod" E-Cigarettes — Urgent Concerns|journal=New England Journal of Medicine|volume=379|issue=12|year=2018|pages=1099–1102|issn=0028-4793|doi=10.1056/NEJMp1805758|pmid=30134127|pmc=7489756|doi-access=free}}</ref>
<!-- France -->
A February 2014 survey in France estimated that between 7.7 and 9.2 million individuals have experimented with using electronic cigarettes, with between 1.1 and 1.9 million using on a daily basis. 67% of tobacco smokers in the survey used electronic cigarettes to reduce or quit tobacco smoking. 9% of those who experimented with electronic cigarettes had never smoked tobacco. Of the 1.2% that had recently stopped tobacco smoking at the time of the survey, 84% (or 1% of the population surveyed) credited electronic cigarettes for stopping tobacco use.<ref>{{cite web|title=Prévalence, comportements d'achat et d'usage, motivations des utilisateurs de la cigarette électronique|url=http://www.ofdt.fr/BDD/publications/docs/eisxalu2.pdf|publisher=Observatoire Français des Drogues et des Toxicomanies|accessdate=28 March 2014}}</ref>


===E-liquid===
<!-- Youth -->
The mixture used in ] such as e-cigarettes is called e-liquid.<ref name="JankowskiBrożek2017">{{cite journal|last1=Jankowski|first1=Mateusz|last2=Brożek |first2=Grzegorz |last3=Lawson|first3=Joshua|last4=Skoczyński|first4=Szymon|last5=Zejda|first5=Jan |title=E-smoking: Emerging public health problem?|journal=International Journal of Occupational Medicine and Environmental Health|volume=30 |issue=3|pages=329–344|year=2017|issn=1232-1087|doi=10.13075/ijomeh.1896.01046|pmid=28481369|doi-access=free}}</ref> E-liquid formulations vary widely.<ref name=Bhatnagar2014/><ref name=Bertholon2013/> A typical e-liquid is composed of ] and ] (95%) and a combination of ], ], and other additives (5%).<ref name=England2015>{{cite journal |last1=England|first1=Lucinda J.|last2=Bunnell|first2=Rebecca E.|last3=Pechacek|first3=Terry F.|last4=Tong|first4=Van T.|last5=McAfee|first5=Tim A.|title=Nicotine and the Developing Human|journal=American Journal of Preventive Medicine|year=2015|volume=49|issue=2|pages=286–93|issn=0749-3797|doi=10.1016/j.amepre.2015.01.015|pmc=4594223|pmid=25794473}}</ref><ref name=JimenezRuiz2014>{{cite journal|last1=Jimenez Ruiz|first1=CA|last2=Solano Reina|first2=S|last3=de Granda Orive|first3=JI|last4=Signes-Costa Minaya|first4=J|last5=de Higes Martinez|first5=E|last6=Riesco Miranda|first6=JA|last7=Altet Gómez|first7=N|last8=Lorza Blasco|first8=JJ|last9=Barrueco Ferrero|first9=M|last10=de Lucas Ramos|first10=P|title=The electronic cigarette. Official statement of the Spanish Society of Pneumology and Thoracic Surgery (SEPAR) on the efficacy, safety and regulation of electronic cigarettes|journal=Archivos de Bronconeumologia|date=August 2014|volume=50|issue=8|pages=362–7|doi=10.1016/j.arbres.2014.02.006|pmid=24684764}}</ref> The flavorings may be natural, artificial,<ref name=Bertholon2013>{{cite journal|last1=Bertholon|first1=J.F.|last2=Becquemin|first2=M.H.|last3=Annesi-Maesano|first3=I.|last4=Dautzenberg|first4=B.|title=Electronic Cigarettes: A Short Review|journal=Respiration|year=2013|issn=1423-0356 |volume=86|issue=5|pages=433–8|doi=10.1159/000353253|pmid=24080743|doi-access=free}}</ref> or ].<ref name=Nosowitz2015>{{cite news|author1=Dan Nosowitz|title=America's First Certified Organic E-Cigarette Vaping Liquid Is Here|url=http://modernfarmer.com/2015/06/americas-first-certified-organic-e-cigarette-vaping-liquid-is-here/|publisher=Modern Farmer|date=5 June 2015}}</ref> Over 80 harmful chemicals such as formaldehyde and metallic nanoparticles have been found in e-liquids at trace quantities.<ref name="Thirión-RomeroPérez-Padilla2019">{{cite journal|last1=Thirión-Romero|first1=Ireri|last2=Pérez-Padilla|first2=Rogelio |last3=Zabert|first3=Gustavo|last4=Barrientos-Gutiérrez|first4=Inti |title=Respiratory Impact of Electronic Cigarettes and Low-Risk Tobacco|journal=Revista de investigación Clínica|volume=71|issue=1|pages=17–27|year=2019 |issn=0034-8376|doi=10.24875/RIC.18002616|pmid=30810544 |doi-access=free|s2cid=73511138}}</ref> There are many e-liquid manufacturers,<ref name=Blackwell2015>{{cite web |url=http://www.richmond.com/business/local/article_9f65201a-94c0-51b1-9663-f9fbb5c522af.html |title=Avail Vapor offers glimpse into the 'art and science' of e-liquids|author=John Reid Blackwell|publisher=Richmond Times-Dispatch|date=7 June 2015}}</ref> and more than 15,000 flavors.<ref name=HenryKligerman2019>{{cite journal|last1=Henry|first1=Travis S.|last2=Kligerman|first2=Seth J.|last3=Raptis|first3=Constantine A.|last4=Mann |first4=Howard|last5=Sechrist|first5=Jacob W.|last6=Kanne|first6=Jeffrey P. |title=Imaging Findings of Vaping-Associated Lung Injury|journal=American Journal of Roentgenology|volume=214|issue=3|year=2020|pages=498–505 |issn=0361-803X|doi=10.2214/AJR.19.22251|pmid=31593518|s2cid=203985885}}</ref>
Larger numbers of young people are starting to use e-cigarettes.<!-- <ref name=Grana2014/> --> A high number of youths who use e-cigarettes also smoking traditional cigarettes.<!-- <ref name=Grana2014/> --> Some youths who have tried an e-cigarette have never smoked a traditional cigarette; this indicates that they can be a starting point for nicotine use for some youths.<!-- <ref name=Grana2014/> --> There are high levels of dual use with e-cigarettes and traditional cigarettes.<ref name=Grana2014/>


Many countries regulate what e-liquids can contain. In the US, there are ] (FDA) compulsory manufacturing standards<ref name=FDA-Manufacturing-2016>{{cite web |url=https://www.fda.gov/TobaccoProducts/GuidanceComplianceRegulatoryInformation/Manufacturing/default.htm|title=Manufacturing|publisher=United States Food and Drug Administration|date=12 August 2016}}</ref> and American E-liquid Manufacturing Standards Association (AEMSA) recommended manufacturing standards.<ref name=AEMSA2015>{{Cite book|title=E-Liquid Manufacturing Standards|url=http://www.aemsa.org/wp-content/uploads/2015/09/AEMSA-Standards-v2.3.pdf|location=US|publisher=American E-Liquid Manufacturing Standards Association (AEMSA)|date=4 September 2015|pages=1–13}}</ref> European Union standards are published in the EU ].<ref name=FameleFerranti2014>{{cite journal|last1=Famele|first1=M.|last2=Ferranti|first2=C.|last3=Abenavoli|first3=C.|last4=Palleschi|first4=L.|last5=Mancinelli|first5=R.|last6=Draisci|first6=R.|title=The Chemical Components of Electronic Cigarette Cartridges and Refill Fluids: Review of Analytical Methods|journal=Nicotine & Tobacco Research|volume=17|issue=3|year=2014|pages=271–279|issn=1462-2203|doi=10.1093/ntr/ntu197|pmc=5479507 |pmid=25257980}}</ref>
===Motivation for use===


===Coils===
The users' motivation for using e-cigarettes are related to quitting.<ref name=Rahman2014/> There is a concern that a considerable proportion of their use is recreational.<ref name=Rahman2014/> Some traditional cigarette users and e-cigarette users liked that e-cigarettes resembled traditional cigarettes, whereas others thought this was a drawback.<ref name=Pepper2013/> Some vapers use e-cigarettes for the enjoyment.<ref name=Pepper2013/> Traditional cigarette users who have not used e-cigarettes had mixed ideas about their possible satisfaction.<ref name=Pepper2013/> Around one third thought that e-cigarettes might taste bad.<ref name=Pepper2013/> The users of e-cigarettes disagree whether it was a benefit or a drawback regarding the way they look, feel or taste similar to traditional cigarettes, or resemble traditional cigarettes.<ref name=Pepper2013/> E-cigarettes users' views about saving money from using e-cigarettes compared to traditional cigarettes are inconsistent.<ref name=Pepper2013/> Some users stopped using e-cigarettes due to issues with the devices.<ref name=Pepper2013>{{cite journal|last1=Pepper|first1=J. K.|last2=Brewer|first2=N. T.|title=Electronic nicotine delivery system (electronic cigarette) awareness, use, reactions and beliefs: a systematic review|journal=Tobacco Control|volume=23|issue=5|year=2013|pages=375–384|issn=0964-4563|doi=10.1136/tobaccocontrol-2013-051122|pmid=24259045}}</ref> E-cigarette users often begin with using an e-cigarette device resembling a cigarette and eventually most of them switched to a later-generation device.<ref name=Yingst2015/> Most users of later-generation e-cigarettes shifted to their present model with the intent of getting a "more satisfying hit".<ref name=Yingst2015>{{cite journal|last1=Yingst|first1=J. M.|last2=Veldheer|first2=S.|last3=Hrabovsky|first3=S.|last4=Nichols|first4=T. T.|last5=Wilson|first5=S. J.|last6=Foulds|first6=J.|title=Factors associated with electronic cigarette users' device preferences and transition from first generation to advanced generation devices.|year=2015|issn=1462-2203|doi=10.1093/ntr/ntv052|pmid=25744966}}</ref>


In 2019 a study found that the metal coils of e-cigarettes can leach metal into the e-liquid leading to permanent lung damage in some cases. Research has shown that higher voltages generate more heat and release more toxic substances into the e-liquid. Vaping cannabis usually involves higher temperatures than nicotine.<ref>{{cite news |title=Toxic metal, leached from e-cigarette coil, permanently scars woman's lung |website=NBC News |url=https://www.nbcnews.com/health/vaping/toxic-metal-leached-e-cigarette-coil-permanently-scars-woman-s-n1095156}}</ref>
== Construction ==
] light cover<br />B. ] (also houses circuitry)<br />C. atomizer (heating element)<br />D. cartridge (mouthpiece)]]


== Use ==
Most electronic cigarettes take an overall cylindrical shape although a wide array of shapes can be found: box, pipe styles etc.<ref>{{cite web|last1=WHO|title=Electronic cigarettes (e-cigarettes) or electronic nicotine delivery systems|url=http://www.who.int/tobacco/communications/statements/eletronic_cigarettes/en/}}</ref> There are 3 main categories of e-cigarette products: cigalikes, looks similar cigarettes; eGos, bigger than cigalikes with refillable liquid tanks; and mods, assembled from basic parts or by altering existing products.<ref name=EbbertAgunwamba2015>{{cite journal|last1=Ebbert|first1=Jon O.|last2=Agunwamba|first2=Amenah A.|last3=Rutten|first3=Lila J.|title=Counseling Patients on the Use of Electronic Cigarettes|journal=Mayo Clinic Proceedings|volume=90|issue=1|year=2015|pages=128–134|issn=00256196|doi=10.1016/j.mayocp.2014.11.004|pmid=25572196}}</ref> First generation electronic cigarettes were usually designed to simulate smoking implements, such as cigarettes or cigars, in their use and appearance.<ref name=Farsalinos2014>{{cite journal | author=Farsalinos KE, Spyrou A, Tsimopoulou K, Stefopoulos C, Romagna G, Voudris V | title=Nicotine absorption from electronic cigarette use: Comparison between first and new-generation devices | journal=Scientific Reports | volume=4 | pages=4133 | year=2014 | doi=10.1038/srep04133 | pmc=3935206 | pmid=24569565}}</ref> Later-generation electronic cigarettes often called mods, PVs (personal vaporizer) or APVs (advanced personal vaporizer) have an increased nicotine-dispersal performance,<ref name=Farsalinos2014/> housing higher capacity batteries,<ref name=mcqueen2011/> and come in various form factors, including metal tubes and boxes.<ref name=mcqueen2011>{{Cite journal|pmid=21571692|doi=10.1093/ntr/ntr088|journal=Nicotine & Tobacco Research|year=2011|volume=13|issue=9|title=Interviews with "vapers": implications for future research with electronic cigarettes|url=http://www.stop-tabac.ch/fra/images/stories/documents_stop_tabac/interview%20with%20vapers.pdf|last2=Tower|author3-last=Sumner|first=Amy|last=McQueen|first2=Stephanie|first3=Walton|pages=860–7}}</ref><ref>{{cite web|url=http://www.lasvegassun.com/news/2013/oct/18/faqs-about-electronic-cigarettes/ |title=FAQs about electronic cigarettes – Las Vegas Sun News |publisher=] |accessdate=20 November 2013}}</ref><ref>{{cite web|url=http://www.stgeorgeutah.com/news/archive/2013/10/07/da-vaping-nicotine-gadget-craze-reaches-southern-utah/ |title=Vaping; nicotine gadget craze reaches Southern Utah |publisher=St George News |accessdate=20 November 2013}}</ref> Many electronic cigarettes are composed of standardized replaceable parts that are interchangeable from one brand to the other.<ref>{{cite news | url=http://www.clubic.com/materiel-informatique/article-704447-1-cigarette-electronique.html%7C | title=A la découverte de la cigarette électronique | author=Jérôme Cartegini | publisher=Clubic | date=27 May 2014}}</ref> Common components include a liquid delivery and container system like tanks or cartomizers, an atomizer, and a power source.<ref name=howstuffworks>{{cite web|last=Cassidy |first=Susan |url=http://science.howstuffworks.com/innovation/everyday-innovations/electronic-cigarette1.htm |title=HowStuffWorks "How Electronic Cigarettes Work" |publisher=Science.howstuffworks.com |date=26 October 2011 |accessdate=27 August 2013}}</ref> A wide array of component combinations exist.<ref name=digitaltrends.com>{{cite web|last=Couts |first=Andrew |url=http://www.digitaltrends.com/features/inside-the-world-of-vapers-the-subculture-that-might-save-smokers-lives/ |title=Inside the world of vapers, the subculture that might save smokers' lives |publisher=] |date=13 May 2013 |accessdate=20 November 2013}}</ref> The main parts for majority of e-cigarettes include an aerosol generator, flow sensor, battery, and a liquid storage chamber.<ref name=Meo2014/> An e-cigarette may be made with the materials silver, steel, metals, ceramics, plastics, fibers, aluminum, rubber and spume, and lithium batteries.<ref name=Meo2014>{{cite journal|last1=SA|first1=Meo|last2=SA|first2=Al Asiri|title=Effects of electronic cigarette smoking on human health|url=http://www.europeanreview.org/wp/wp-content/uploads/3315-3319.pdf|journal=Eur Rev Med Pharmacol Sci|volume=18|issue=21|year=2014|pages=3315-9|pmid=25487945}}</ref> Some e-cigarettes have a light-emitting diode at the tip to resemble the glow of burning tobacco.<ref name=Brandon2015/> E-cigarettes are available as one-time use products or as reusable products.<ref name=EbbertAgunwamba2015/> A traditional cigarette is smooth and light, while an e-cigarette can be rigid and a bit bulky.<ref name=Caponnetto2012/> In comparison to traditional cigarettes, the general e-cigarette puff time was much longer, and e-cigarette use needed a more forceful suction.<ref name=Evans2014>{{cite journal|last1=Evans|first1=S. E.|last2=Hoffman|first2=A. C.|title=Electronic cigarettes: abuse liability, topography and subjective effects|journal=Tobacco Control|volume=23|issue=Supplement 2|year=2014|pages=ii23–ii29|issn=0964-4563|doi=10.1136/tobaccocontrol-2013-051489|pmid=24732159}}</ref>
<!-- Usage, History, Regulation, Marketing, and Economics -->


===Device generations=== === Popularity ===
]
Since entering the market around 2003, e-cigarette use has risen rapidly.<ref name="Rom2014" /><ref name="BourkeBauld2017">{{cite journal|last1=Bourke|first1=Liam|last2=Bauld|first2=Linda|last3=Bullen |first3=Christopher |last4=Cumberbatch|first4=Marcus|last5=Giovannucci|first5=Edward|last6=Islami |first6=Farhad|last7=McRobbie|first7=Hayden|last8=Silverman|first8=Debra T.|last9=Catto|first9=James W.F. |title=E-cigarettes and Urologic Health: A Collaborative Review of Toxicology, Epidemiology, and Potential Risks|journal=European Urology|volume=71|issue=6|pages=915–923|year=2017|issn=0302-2838|doi=10.1016/j.eururo.2016.12.022|pmid=28073600|hdl=1893/24937 |hdl-access=free |url=http://dspace.stir.ac.uk/bitstream/1893/24937/1/E-cigarettes_review%20091216.pdf}}</ref><ref name="Schraufnage2014">{{cite journal|last1=Schraufnagel|first1=Dean E.|last2=Blasi|first2=Francesco |last3=Drummond|first3=M. Bradley|last4=Lam|first4=David C. L.|last5=Latif|first5=Ehsan|last6=Rosen |first6=Mark J.|last7=Sansores|first7=Raul|last8=Van Zyl-Smit|first8=Richard|title=Electronic Cigarettes. A Position Statement of the Forum of International Respiratory Societies|journal=American Journal of Respiratory and Critical Care Medicine|volume=190|issue=6|year=2014|pages=611–618|issn=1073-449X|doi=10.1164/rccm.201407-1198PP |pmid=25006874 |s2cid=43763340 |url=https://figshare.com/articles/journal_contribution/10758143}}</ref> In 2011 there were about 7 million adult e-cigarette users globally, increasing to 68 million in 2020 compared with 1.1 billion cigarette smokers.<ref>{{Cite web|last=Shapiro|first=Harry|date=2020|title=Burning Issues: The Global State of Tobacco Harm Reduction |url=https://gsthr.org/resources/item/burning-issues-global-state-tobacco-harm-reduction-2020}}</ref> There was a further rise to 82 million e-cigarette users in 2021.<ref name="GSTHR_Report">{{cite web |title=82 million vapers worldwide in 2021: the GSTHR estimate |url=https://gsthr.org/briefing-papers/82-million-vapers-worldwide-in-2021-the-gsthr-estimate/ |website=Global State of Tobacco Harm Reduction |access-date=13 November 2022}}</ref> This increase has been attributed to targeted marketing, lower cost compared to conventional cigarettes, and the better safety profile of e-cigarettes compared to tobacco.<ref name="CamengaKlein2016">{{cite journal |last1=Camenga|first1=Deepa R.|last2=Klein|first2=Jonathan D.|title=Tobacco Use Disorders|journal=Child and Adolescent Psychiatric Clinics of North America|volume=25|issue=3|year=2016|pages=445–460|issn=1056-4993 |doi=10.1016/j.chc.2016.02.003|pmc=4920978|pmid=27338966}}</ref> E-cigarette use is highest in China, the US, and Europe, with China having the most users.<ref name="Rahman2014" /><ref name="CaiWang2017">{{cite journal |last1=Cai|first1=Hua|last2=Wang|first2=Chen|title=Graphical review: The redox dark side of e-cigarettes; exposure to oxidants and public health concerns|journal=Redox Biology|volume=13|year=2017|pages=402–406|issn=2213-2317 |doi=10.1016/j.redox.2017.05.013|pmc=5493817|pmid=28667909}}</ref>


=== Motivation ===
{{Asof|2014}} there have been four generations of devices.<ref name=Brandon2015/> The different generations look different from each other. They all have distinct batteries and atomizers. The atomizer and battery are connected. Common connection types are 510, 901, 808 and 801 with the 510 being the most common.
], in a 2018 ] poll<ref>{{cite news |url=https://www.europeandatajournalism.eu/index.php/eng/News/Data-news/Lung-cancer-deaths-on-the-rise-in-two-thirds-of-European-countries|title=Lung cancer deaths on the rise in two thirds of European countries |last1=Aguilar|first1=Carmen|publisher=VoxEurop/The European Data Journalism Network (EDJNet)|date=11 June 2018}}</ref>]]


There are varied reasons for e-cigarette use.<ref name=Rahman2014>{{cite journal|last1=Rahman|first1=Muhammad|last2=Hann|first2=Nicholas|last3=Wilson|first3=Andrew|last4=Worrall-Carter|first4=Linda|title=Electronic cigarettes: patterns of use, health effects, use in smoking cessation and regulatory issues|journal=Tobacco Induced Diseases|volume=12|issue=1|year=2014|pages=21|doi=10.1186/1617-9625-12-21|pmc=4350653|pmid=25745382 |doi-access=free }}</ref> Most users are trying to quit smoking,<ref name=Siu2015/> but a large proportion of use is recreational or as an attempt to get around ].<ref name=Rahman2014/><ref name=Pepper2013/><ref name=GlantzBareham2018/><ref name=Siu2015/> Many people vape because they believe vaping is safer than smoking.<ref name=Tomashefski2016>{{cite journal|last1=Tomashefski|first1=A|title=The perceived effects of electronic cigarettes on health by adult users: A state of the science systematic literature review.|journal=Journal of the American Association of Nurse Practitioners|volume=28|issue=9|pages=510–515|date=21 March 2016|doi=10.1002/2327-6924.12358|pmid=26997487|s2cid=42900184}}</ref><ref name=Wang2016>{{cite journal|last1=Wang|first1=Meng|last2=Wang|first2=Jian-Wei|last3=Cao|first3=Shuang-Shuang|last4=Wang|first4=Hui-Qin|last5=Hu|first5=Ru-Ying |title=Cigarette Smoking and Electronic Cigarettes Use: A Meta-Analysis|journal=International Journal of Environmental Research and Public Health|volume=13|issue=1|year=2016|pages=120|issn=1660-4601|doi=10.3390/ijerph13010120 |pmc=4730511|pmid=26771624|doi-access=free}}</ref>{{sfn|McNeill|2018|p=178}} The wide choice of flavors and lower price compared to cigarettes are also important factors.<ref name=HefnerValentine2017>{{cite journal |last1=Hefner|first1=Kathryn|last2=Valentine|first2=Gerald|last3=Sofuoglu|first3=Mehmet|title=Electronic cigarettes and mental illness: Reviewing the evidence for help and harm among those with psychiatric and substance use disorders|journal=The American Journal on Addictions|volume=26|issue=4|pages=306–315|year=2017|issn=1055-0496|doi=10.1111/ajad.12504|pmid=28152247|s2cid=24298173}}{{PD-notice}}</ref>
====First generation====
] (vapor) exhaled by a first generation e-cigarette user.]]
First generation e-cigarettes commonly look like tobacco cigarettes and are thus called "cigalikes".<ref name=Farsalinos2014/> They may be designed as a single unit that contains a battery, coil and filling saturated with e-juice in a single tube to be used and disposed of after either the battery is no longer charged or the e-liquid is depleted.<ref name=Farsalinos2014/> They may also be designed as a reusable device with a battery and cartridge called a cartomizer.<ref name=McRobbie2014>{{cite web | url=http://www.ncsct.co.uk/usr/pub/e-cigarette_briefing.pdf Electronic cigarettes | title=Electronic cigarettes | author=Hayden McRobbie | publisher=National Centre for Smoking Cessation and Training | date=2014}}</ref> This is so the battery and cartridge can be separated to allow the battery to be charged when drained or the cartomizer replaced when the e-juice is used up.<ref name=Farsalinos2014/> The battery may contain an electronic airflow sensor whereby activation is triggered simply by drawing breath through the device, while other models employ a power button that must be held during operation.<ref name=McRobbie2014/> An LED in the button or on the end may also be employed to indicate activation.<ref name=EcigGuide2012>{{cite news|title=The skyrocketing popularity of e-cigarettes: A guide|url=http://theweek.com/article/index/232221/the-skyrocketing-popularity-of-e-cigarettes-a-guide|accessdate=21 November 2014|publisher=The Week|date=August 20, 2012}}</ref> Charging is commonly done with a USB charger that the battery attaches to.<ref name=USB-powered>{{cite news |url = http://www.engadget.com/2009/03/31/thankos-usb-powered-health-e-cigarettes-sound-healthy/ |title = Thanko's USB-powered Health E-Cigarettes sound healthy| publisher=Engagdet| author=Tim Stevens |accessdate = 18 November 2014}}</ref> Some manufacturers also have a cigarette pack-shaped portable charging case (PCC), which contains a larger battery capable of recharging e-cigarettes batteries.<ref name=box-charger>{{cite web |url=http://www.engadget.com/2011/07/15/e-lite-electronic-cigarette-review-no-one-ever-said-healthy-was/ |title=E-Lites electronic cigarette review | publisher=Engagdet| author=Terrence O'Brien |accessdate=18 November 2014}}</ref> Reusable devices can come in a kit that contains a battery, a charger, and at least one cartridge.<ref name=box-charger/> Varying nicotine concentrations are delivered to users because of cartomizer, e-juice mixtures, and battery manufacturing differences.<!-- <ref name=Grana2014/> --> These hardware differences cause differences in the ingredients and their concentrations delivered to users and the surrounding air from the exhaled ], even when the same liquid is used.<ref name=Grana2014/>


Other motivations include reduced odor and fewer stains.<ref name=GibsonCreamer2017>{{cite journal|last1=Gibson|first1=Laura A.|last2=Creamer|first2=MeLisa R.|last3=Breland|first3=Alison B.|last4=Giachello|first4=Aida Luz |last5=Kaufman|first5=Annette|last6=Kong|first6=Grace|last7=Pechacek|first7=Terry F.|last8=Pepper|first8=Jessica K.|last9=Soule|first9=Eric K.|last10=Halpern-Felsher|first10=Bonnie|title=Measuring perceptions related to e-cigarettes: Important principles and next steps to enhance study validity|journal=Addictive Behaviors|volume=79|pages=219–225|year=2018|issn=0306-4603|doi=10.1016/j.addbeh.2017.11.017|pmc=5807230|pmid=29175027}}</ref> E-cigarettes also appeal to technophiles who enjoy customizing their devices.<ref name="GibsonCreamer2017"/>
====Second generation====
]
Second generation devices tend to be used by more experienced users.<ref name=McRobbie2014/> These devices are larger overall and look less like tobacco cigarettes.<ref name=McRobbie2014/> They have larger non removable batteries with higher capacity.<ref name=Farsalinos2014/> They are charged with a USB charger that the battery attaches to. Some battery sections have a USB port for recharging and can be used while they are charging or a "passthrough".<ref name=SpinfuelGlossaryP2/> They are usually two part devices meant to be reused and so reduce the cost of operation.<ref name=Farsalinos2014/> Second generation e-cigarettes commonly use a tank or a "clearomizer".<ref name=McRobbie2014/> The tanks are meant to be refilled with bottles of e-juice.<ref name=Farsalinos2014/> They can also be used with cartomizers.<ref name=Farsalinos2014/> Some cheaper batteries use a microphone to activate them.<ref name=HowWork>{{cite web |url=http://www.howtovape.com/page1/page1.html|title = How does the battery work?|accessdate=3 October 2014}}</ref> Other batteries, like Ego type batteries, can use a custom ] to indicate ] status on the included LED and a button for activation.<ref name=HowWork/> The power button can also used to turn the battery off and on.<ref>{{cite web|title=Joyetech eCom|url=http://www.pcmag.com/article2/0,2817,2430142,00.asp|website=PC|publisher=Ziff Davis|accessdate=24 November 2014}}</ref> These batteries may also have adjustable power adjustments.<ref name=McRobbie2014/>


====Third generation==== === Gateway theory ===
The ] is the idea that using less harmful drugs can lead to more harmful ones.<ref name=Lee2015>{{cite journal|last1=Lee|first1=Peter N|title=Appropriate and inappropriate methods for investigating the "gateway" hypothesis, with a review of the evidence linking prior snus use to later cigarette smoking|journal=Harm Reduction Journal|volume=12|issue=1|year=2015|pages=8|issn=1477-7517|doi=10.1186/s12954-015-0040-7|pmc=4369866|pmid=25889396 |doi-access=free }}{{CC-notice|cc=by4|url=https://harmreductionjournal.biomedcentral.com/articles/10.1186/s12954-015-0040-7?optIn=false|author=Peter N Lee}}</ref> Evidence shows that many users who begin by vaping will go on to also smoke traditional cigarettes.<ref name="Baenziger2021">{{cite journal|last1=Baenziger|first1=Olivia|last2=Ford|first2=Laura|last3=Yazidjoglou|first3=Amelia|last4=Joshy|first4=Grace|last5=Banks |first5=Emily|title=E-cigarette use and combustible tobacco cigarette smoking uptake among non-smokers, including relapse in former smokers: umbrella review, systematic review and meta-analysis|journal=BMJ Open|volume=11 |issue=3|year=2021|pages=e045603|issn=2044-6055|doi=10.1136/bmjopen-2020-045603|pmid=33785493|pmc=8011717|url=https://bmjopen.bmj.com/content/11/3/e045603}}</ref>{{sfn|WHO|2014|p=6}}<ref name=Franck2014>{{cite journal |last1=Franck|first1=C.|last2=Budlovsky|first2=T.|last3=Windle|first3=S. B.|last4=Filion|first4=K. B.|last5=Eisenberg|first5=M. J.|title=Electronic Cigarettes in North America: History, Use, and Implications for Smoking Cessation|journal=Circulation|volume=129|issue=19|year=2014|pages=1945–1952|issn=0009-7322|doi=10.1161/CIRCULATIONAHA.113.006416|pmid=24821825|doi-access=free}}</ref><ref name="Yoong2021">{{cite journal|last1=Yoong|first1=Sze Lin|last2=Hall|first2=Alix|last3=Turon|first3=Heidi|last4=Stockings|first4=Emily|last5=Leonard|first5=Alecia|last6=Grady|first6=Alice|last7=Tzelepis|first7=Flora|last8=Wiggers|first8=John |last9=Gouda|first9=Hebe|last10=Fayokun|first10=Ranti|last11=Commar|first11=Alison|last12=Prasad|first12=Vinayak M|last13=Wolfenden|first13=Luke |title=Association between electronic nicotine delivery systems and electronic non-nicotine delivery systems with initiation of tobacco use in individuals aged < 20 years. A systematic review and meta-analysis|journal=PLOS ONE|volume=16|issue=9|year=2021|at=e0256044|pmid=34495974|pmc=8425526 |doi=10.1371/journal.pone.0256044|bibcode=2021PLoSO..1656044Y|eissn=1932-6203|doi-access=free}}</ref>{{overcite|date=December 2024}} People with mental illnesses, who as a group are more susceptible to nicotine addiction, are at particularly high risk of dual use.<ref name="DautzenbergAdler2017">{{cite journal|last1=Dautzenberg|first1=B.|last2=Adler|first2=M.|last3=Garelik|first3=D.|last4=Loubrieu|first4=J.F.|last5=Mathern|first5=G.|last6=Peiffer|first6=G. |last7=Perriot|first7=J.|last8=Rouquet|first8=R.M.|last9=Schmitt|first9=A.|last10=Underner|first10=M.|last11=Urban|first11=T.|title=Practical guidelines on e-cigarettes for practitioners and others health professionals. A French 2016 expert's statement|journal=Revue des Maladies Respiratoires|volume=34|issue=2|pages=155–164|year=2017|issn=0761-8425|doi=10.1016/j.rmr.2017.01.001|pmid=28189437}}</ref><ref name="NansseuBigna2016">{{cite journal |last1=Nansseu|first1=Jobert Richie N.|last2=Bigna|first2=Jean Joel R.|title=Electronic Cigarettes for Curbing the Tobacco-Induced Burden of Noncommunicable Diseases: Evidence Revisited with Emphasis on Challenges in Sub-Saharan Africa|journal=Pulmonary Medicine|volume=2016|year=2016|pages=1–9|issn=2090-1836|doi=10.1155/2016/4894352|pmc=5220510|pmid=28116156|doi-access=free}}{{CC-notice|cc=by4|url=https://www.hindawi.com/journals/pm/2016/4894352/|author(s)=Jobert Richie N. Nansseu and Jean Joel R. Bigna}}</ref>
]
Third generation devices includes mechanical mods and variable voltage devices though both are commonly called "mods" are the battery section of the device.<ref name=Farsalinos2014/> Mechanical and variable devices are commonly either cylindrical or a box.<ref name=trading-addictions/> They can be made of wood, aluminium, stainless steel, or brass.<ref name=trading-addictions/> A box can hold larger and sometimes multiple batteries.<ref name=trading-addictions/> Mechanical mods and variable devices use larger batteries.<ref name=vaporizers-explainer/> The battery is installed in the mod and can be removed. This allows the user to change the battery when it is depleted. Variable devices often have a USB connector for recharging and can be used while they are charging as a "passthrough".<ref name=SpinfuelGlossaryP2/><ref name=Vapologist>{{cite news|title=The Vapologist will see you now: Inside New York's first e-cigarette bar|url=http://theweek.com/article/index/251049/the-vapologist-will-see-you-now-inside-new-yorks-first-e-cigarette-bar|accessdate=21 November 2014|publisher=The Week|date=October 11, 2013}}</ref> Mechanical mods do not because they do not contain circuitry. The battery must be removed and charged with an external charger. Common battery sizes used in mechanical mods and variable wattage devices are 18350, 18490, 18500 and 18650.<ref name=MilliAmpHours>{{cite web|title=Understanding MilliAmp Hours|url=http://spinfuel.com/understanding-milliamp-hours/|publisher=Spinfuel Magazine|accessdate=20 November 2014|date=2 January 2014}}</ref> The power section may include additional options, such as displays and support of a wide range of internal batteries and allow different atomizers to be connected.<ref name=McRobbie2014/> Third generation devices commonly use rebuildable atomizers allowing users to choose the wicking material.<ref name=Farsalinos2014/><ref name=McRobbie2014/> Handmade coils can be installed in the atomizer to increase vapor production.<ref name=vaporizers-explainer/> Hardware in this generation is sometimes modified to increase flavor.<ref name=pimpvape>{{cite news|author1=Eric Larson|title=Pimp My Vape: The Rise of E-Cigarette Hackers|url=http://mashable.com/2014/01/25/vaping-subculture/|accessdate=22 November 2014|publisher=Mashable|date=25 January 2014}}</ref> This generation can also use clearomizers.<ref name=Farsalinos2014/> The size of the battery section allows the use of larger tanks that hold more e-liquid.<ref name=trading-addictions/> A fourth generation digital e-cigarette became available in the U.S. in 2014.<ref name=Brandon2015>{{cite journal|last1=Brandon|first1=T. H.|last2=Goniewicz|first2=M. L.|last3=Hanna|first3=N. H.|last4=Hatsukami|first4=D. K.|last5=Herbst|first5=R. S.|last6=Hobin|first6=J. A.|last7=Ostroff|first7=J. S.|last8=Shields|first8=P. G.|last9=Toll|first9=B. A.|last10=Tyne|first10=C. A.|last11=Viswanath|first11=K.|last12=Warren|first12=G. W.|title=Electronic Nicotine Delivery Systems: A Policy Statement from the American Association for Cancer Research and the American Society of Clinical Oncology|journal=Clinical Cancer Research|url=http://clincancerres.aacrjournals.org/content/early/2015/01/08/1078-0432.CCR-14-2544.full.pdf+html|year=2015|issn=1078-0432|doi=10.1158/1078-0432.CCR-14-2544|pmid=25557889}}</ref>


However, an association between vaping and subsequent smoking does not necessarily imply a causal gateway effect.<ref>{{Cite journal |last=Etter |first=Jean-François |date=2017-06-19 |title=Gateway effects and electronic cigarettes: Gateway effects and e-cigarettes |url=https://onlinelibrary.wiley.com/doi/10.1111/add.13924 |journal=Addiction |language=en |volume=113 |issue=10 |pages=1776–1783 |doi=10.1111/add.13924|pmid=28786147 }}</ref> Instead, people may have ] that predispose them to both activities.<ref name="HallChan2021">{{Cite journal |last1=Hall |first1=Wayne |last2=Chan |first2=Gary |date=2021-03-18 |title=The "gateway" effect of e-cigarettes may be explained by a genetic liability to risk-taking |journal=PLOS Medicine |language=en |volume=18 |issue=3 |pages=e1003554 |doi=10.1371/journal.pmed.1003554 |issn=1549-1676 |pmc=7971461 |pmid=33735167 |doi-access=free }}</ref><ref name="KozlowskiWarner2017">{{Cite journal |last1=Kozlowski |first1=Lynn T. |last2=Warner |first2=Kenneth E. |date=2017-05-01 |title=Adolescents and e-cigarettes: Objects of concern may appear larger than they are |url=https://www.sciencedirect.com/science/article/pii/S0376871617300236 |journal=Drug and Alcohol Dependence |language=en |volume=174 |pages=209–214 |doi=10.1016/j.drugalcdep.2017.01.001 |pmid=29350617 |issn=0376-8716}}</ref> There is a genetic association between smoking, vaping, gambling, promiscuity and other risk-taking behaviors.<ref>{{Cite journal |last1=Khouja |first1=Jasmine N. |last2=Wootton |first2=Robyn E. |last3=Taylor |first3=Amy E. |last4=Smith |first4=George Davey |last5=Munafò |first5=Marcus R. |date=2021-03-18 |title=Association of genetic liability to smoking initiation with e-cigarette use in young adults: A cohort study |journal=PLOS Medicine |language=en |volume=18 |issue=3 |pages=e1003555 |doi=10.1371/journal.pmed.1003555 |issn=1549-1676 |pmc=7971530 |pmid=33735204 |doi-access=free }}</ref> Young people with poor ] use e-cigarettes, cigarettes, and alcohol at higher rates than their peers.<ref>{{Cite journal |last1=Pentz |first1=Mary Ann |last2=Shin |first2=HeeSung |last3=Riggs |first3=Nathaniel |last4=Unger |first4=Jennifer B. |last5=Collison |first5=Katherine L. |last6=Chou |first6=Chih-Ping |date=2015-03-01 |title=Parent, peer, and executive function relationships to early adolescent e-cigarette use: A substance use pathway? |journal=Addictive Behaviors |language=en |volume=42 |pages=73–78 |doi=10.1016/j.addbeh.2014.10.040 |pmid=25462657 |pmc=4292878 |issn=0306-4603}}</ref> E-cigarette users are also more likely to use both cannabis and unprescribed ] or ].<ref>{{Cite journal |last1=Bentivegna |first1=Kathryn |last2=Atuegwu |first2=Nkiruka C. |last3=Oncken |first3=Cheryl |last4=DiFranza |first4=Joseph R. |last5=Mortensen |first5=Eric M. |date=2021-01-01 |title=Electronic Cigarettes Associated With Incident and Polysubstance Use Among Youth |url=https://www.jahonline.org/article/S1054-139X(20)30278-0/abstract |journal=Journal of Adolescent Health |language=English |volume=68 |issue=1 |pages=123–129 |doi=10.1016/j.jadohealth.2020.05.026 |issn=1054-139X |pmid=32641242|s2cid=220435106 }}</ref> ] of e-cigarettes and smoking have been criticized for failing to adequately ] for these and other ].<ref>{{Cite journal |last1=Chan |first1=Gary C. K. |last2=Stjepanović |first2=Daniel |last3=Lim |first3=Carmen |last4=Sun |first4=Tianze |last5=Shanmuga Anandan |first5=Aathavan |last6=Connor |first6=Jason P. |last7=Gartner |first7=Coral |last8=Hall |first8=Wayne D. |last9=Leung |first9=Janni |date=2020-09-04 |title=Gateway or common liability? A systematic review and meta-analysis of studies of adolescent e-cigarette use and future smoking initiation |url=https://onlinelibrary.wiley.com/doi/10.1111/add.15246 |journal=Addiction |language=en |volume=116 |issue=4 |pages=743–756 |doi=10.1111/add.15246 |pmid=32888234 |s2cid=221503932 |issn=0965-2140 |quote=Only two studies comprehensively adjusted for confounding. The median E‐value was 2.90, indicating that the estimates were not robust against unmeasured confounding.}}</ref><ref>{{Cite journal |last=Phillips |first=Carl V. |date=2015-05-21 |title=Gateway Effects: Why the Cited Evidence Does Not Support Their Existence for Low-Risk Tobacco Products (and What Evidence Would) |journal=International Journal of Environmental Research and Public Health |language=en |volume=12 |issue=5 |pages=5439–5464 |doi=10.3390/ijerph120505439 |issn=1660-4601 |pmc=4454978 |pmid=26006122|doi-access=free }}</ref><ref>{{Cite journal |last1=Khouja |first1=Jasmine N. |last2=Suddell |first2=Steph F. |last3=Peters |first3=Sarah E. |last4=Taylor |first4=Amy E. |last5=Munafò |first5=Marcus R. |date=2021-01-01 |title=Is e-cigarette use in non-smoking young adults associated with later smoking? A systematic review and meta-analysis |url=https://tobaccocontrol.bmj.com/content/30/1/8 |journal=Tobacco Control |language=en |volume=30 |issue=1 |pages=8–15 |doi=10.1136/tobaccocontrol-2019-055433 |issn=0964-4563 |pmc=7803902 |pmid=32156694 |quote=None of the studies included negative controls which would provide stronger evidence for whether the association may be causal.}}</ref>
=== Atomizer ===
]) in view.]]
An atomizer generally consists of a small ] responsible for vaporizing e-liquid, as well as a ] material that draws liquid in.<ref name=SpinfuelGlossaryP1>{{cite news |url=http://spinfuel.com/vapers-glossary/ | title=Vaper Talk – The Vaper's Glossary | work=Spinfuel Magizine | date=5 July 2013 | accessdate=18 November 2014}}</ref> Along with a battery, the atomizer is the central component of every personal vaporizer.


Smoking rates have continually declined as e-cigarettes have grown in popularity, especially among young people, suggesting that there is little evidence for a gateway effect at the population level.<ref name="HallChan2021"/><ref name="KozlowskiWarner2017"/> This observation has been criticized, however, for ignoring the effect of ] interventions.<ref>{{Cite journal |last1=Chapman |first1=Simon |last2=Bareham |first2=David |last3=Maziak |first3=Wasim |date=2019-04-17 |title=The Gateway Effect of E-cigarettes: Reflections on Main Criticisms |url=https://academic.oup.com/ntr/article/21/5/695/4962533 |journal=Nicotine & Tobacco Research |language=en |volume=21 |issue=5 |pages=695–698 |doi=10.1093/ntr/nty067 |issn=1469-994X |pmc=6468127 |pmid=29660054}}</ref>
A small length of ] is coiled around the wicking material and then connected to the positive and negative poles of the device. When activated the resistance wire (or coil) quickly heats up thus creating a vapor from the liquid, which is then inhaled by the user.<ref>{{Cite patent |country=EP |number=2614731|status=application |pubdate=17 July 2013|fdate=12 January 2012|inventor= Yonghai Li, Zhongli Xu |title=An atomizer for electronic cigarette}}</ref>


=== Young adult and teen use ===
The ] of the coil, the ] output of the device, the ] of the atomizer and the efficiency of the wick play important roles in the perceived quality of the vapor coming from the atomizer. They also greatly affect the vapor quantity or ] that will be produced by the atomizer.


Worldwide, increasing numbers of young people are vaping.<ref>{{Cite journal|title=The Vaping Epidemic in Adolescents|last1=Jones|first1=Kristen|last2=Salzman|first2=Gary A.|date=2020|journal=]|issue=1|volume=117|pages=56–58|pmc=7023954 |pmid=32158051}}</ref><ref name=SchneiderDiehl2016>{{cite journal |last1=Schneider|first1=Sven|last2=Diehl|first2=Katharina|title=Vaping as a Catalyst for Smoking? An Initial Model on the Initiation of Electronic Cigarette Use and the Transition to Tobacco Smoking Among Adolescents|journal=Nicotine & Tobacco Research|volume=18|issue=5|year=2016|pages=647–653|issn=1462-2203 |doi=10.1093/ntr/ntv193 |pmid=26386472|doi-access=free}}</ref><ref name=YoongStockings2018>{{cite journal|last1=Yoong |first1=Sze Lin|last2=Stockings|first2=Emily|last3=Chai|first3=Li Kheng|last4=Tzelepis|first4=Flora |last5=Wiggers|first5=John|last6=Oldmeadow |first6=Christopher|last7=Paul|first7=Christine|last8=Peruga |first8=Armando|last9=Kingsland|first9=Melanie|last10=Attia|first10=John|last11=Wolfenden|first11=Luke |title=Prevalence of electronic nicotine delivery systems (ENDS) use among youth globally: a systematic review and meta-analysis of country level data|journal=Australian and New Zealand Journal of Public Health|volume=42|issue=3|pages=303–308|year=2018|issn=1326-0200|pmid=29528527 |doi=10.1111/1753-6405.12777|doi-access=free}}</ref> With access to e-cigarettes, young people's tobacco use has dropped by about 75%.<ref name="realitycheck">{{cite journal |last1=Levy |first1=David T. |last2=Warner |first2=Kenneth E. |last3=Cummings |first3=K. Michael |last4=Hammond |first4=David |last5=Kuo |first5=Charlene |last6=Fong |first6=Geoffrey T. |last7=Thrasher |first7=James F. |last8=Goniewicz |first8=Maciej Lukasz |last9=Borland |first9=Ron |title=Examining the relationship of vaping to smoking initiation among US youth and young adults: a reality check |journal=Tobacco Control |date=1 November 2019 |volume=28 |issue=6 |pages=629–635 |doi=10.1136/tobaccocontrol-2018-054446 |pmid=30459182 |pmc=6860409 |language=en |issn=0964-4563}}</ref><ref>{{cite journal |last1=West |first1=Robert |last2=Brown |first2=Jamie |last3=Jarvis |first3=Martin |title=Epidemic of youth nicotine addiction? What does the National Youth Tobacco Survey reveal about high school e-cigarette use in the USA? (Preprint) |journal=Qeios |date=7 October 2019 |doi=10.32388/745076.3 |doi-access=free |issn=2632-3834 |url=https://www.qeios.com/read/article/391 |access-date=24 February 2020}}</ref><ref>{{cite journal |last1=Hallingberg |first1=Britt |last2=Maynard |first2=Olivia M. |last3=Bauld |first3=Linda |last4=Brown |first4=Rachel |last5=Gray |first5=Linsay |last6=Lowthian |first6=Emily |last7=MacKintosh |first7=Anne-Marie |last8=Moore |first8=Laurence |last9=Munafo |first9=Marcus R. |last10=Moore |first10=Graham |title=Have e-cigarettes renormalised or displaced youth smoking? Results of a segmented regression analysis of repeated cross sectional survey data in England, Scotland and Wales |journal=Tobacco Control |date=1 March 2020 |volume=29 |issue=2 |pages=207–216 |pmid=30936390 |pmc=7036293 |doi=10.1136/tobaccocontrol-2018-054584 |issn=0964-4563}}</ref><ref>{{cite web |title=Historical NYTS Data and Documentation |publisher=Centers for Disease Control and Prevention |date=17 December 2019 |url=https://www.cdc.gov/tobacco/data_statistics/surveys/nyts/data/index.html |website=www.cdc.gov |access-date=24 February 2020}}</ref>{{overcite|date=December 2024}}
Atomizer resistances usually vary from 1.5Ω (]s) to 3.0Ω from one atomizer to the next but can go as low as 0.1Ω in the most extreme cases of ] coil building. Coils of lower ohms have increased vapor production but could present a fire hazard and other dangerous ] if the user is not knowledgeable enough about basic ] and how they relate to battery safety.<ref>{{cite web | url=http://www.hardingenergy.com/pdfs/5%20Lithium%20Ion.pdf | title=Harding Battery Handbook For | publisher=Harding Energy, Inc.}}</ref>


Most young e-cigarette users have never smoked,<ref name=ZhongCao2016>{{cite journal|last1=Zhong |first1=Jieming|last2=Cao|first2=Shuangshuang|last3=Gong|first3=Weiwei|last4=Fei|first4=Fangrong |last5=Wang|first5=Meng |title=Electronic Cigarettes Use and Intention to Cigarette Smoking among Never-Smoking Adolescents and Young Adults: A Meta-Analysis|journal=International Journal of Environmental Research and Public Health|volume=13|issue=5 |year=2016|pages=465|issn=1660-4601|pmc=4881090 |pmid=27153077|doi=10.3390/ijerph13050465|doi-access=free}}</ref> but there is a substantial minority who both vape and smoke.<ref name=Grana2014>{{cite journal|last1=Grana |first1=R|author2=Benowitz, N|author3=Glantz, SA|title=E-cigarettes: a scientific review.|journal=Circulation|date=13 May 2014 |volume=129|issue=19|pages=1972–86|doi=10.1161/circulationaha.114.007667|pmc=4018182 |pmid=24821826}}</ref> Many young people who would not smoke are vaping.<ref name=Modesto-LoweAlvarado2017>{{cite journal |last1=Modesto-Lowe|first1=Vania|last2=Alvarado|first2=Camille|title=E-cigs ... Are They Cool? Talking to Teens About E-Cigarettes|journal=Clinical Pediatrics|volume=56|issue=10|year=2017|pages=947–952 |issn=0009-9228|doi=10.1177/0009922817705188|pmid=28443340|s2cid=44423931}}</ref><ref name=GlantzBareham2018>{{cite journal |last1=Glantz|first1=Stanton A.|last2=Bareham|first2=David W. |title=E-Cigarettes: Use, Effects on Smoking, Risks, and Policy Implications|journal=Annual Review of Public Health|volume=39|issue=1|pages=215–235|date=January 2018|issn=0163-7525|doi=10.1146/annurev-publhealth-040617-013757|doi-access=free |pmc=6251310|pmid=29323609}}{{CC-notice|cc=by4 |url=http://www.annualreviews.org/doi/pdf/10.1146/annurev-publhealth-040617-013757 |author(s)=Stanton A. Glantz and David W. Bareham}}</ref> Young people who smoke tobacco or marijuana, or who drink alcohol, are much more likely to vape.<ref name=SGUSReport2016/><ref name=ChadiSchroeder2019>{{cite journal |last1=Chadi|first1=Nicholas|last2=Schroeder|first2=Rachel|last3=Jensen|first3=Jens Winther|last4=Levy |first4=Sharon|title=Association Between Electronic Cigarette Use and Marijuana Use Among Adolescents and Young Adults |journal=JAMA Pediatrics|volume=173|issue=10|year=2019|pages=e192574|issn=2168-6203 |doi=10.1001/jamapediatrics.2019.2574|pmc=6692686|pmid=31403684}}</ref> Among young people who have tried vaping, most used a flavored product the first time.<ref name=SGUSReport2016>{{cite report |url=https://e-cigarettes.surgeongeneral.gov/documents/2016_SGR_Full_Report_non-508.pdf |author=U.S. Department of Health and Human Services |title=E-Cigarette Use Among Youth and Young Adults. A Report of the Surgeon General |place=Atlanta, GA |publisher=U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health |pages=1–298 |year=2016}}{{PD-notice}}</ref><ref name=Cormet-BoyakaZare2018>{{cite journal|last1=Cormet-Boyaka|first1=Estelle|last2=Zare|first2=Samane|last3=Nemati |first3=Mehdi |last4=Zheng|first4=Yuqing|title=A systematic review of consumer preference for e-cigarette attributes: Flavor, nicotine strength, and type|journal=PLOS ONE|volume=13|issue=3|year=2018|at=e0194145|issn=1932-6203|doi=10.1371/journal.pone.0194145|pmc=5854347|pmid=29543907|bibcode=2018PLoSO..1394145Z|doi-access=free}}{{CC-notice|cc=by4|url=http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0194145|author(s)=Samane Zare, Mehdi Nemati, and Yuqing Zheng}}</ref>
Wicking materials vary greatly from one atomizer to another but ] fibers are the most commonly used in manufactured atomizers. "Rebuildable" or "do it yourself" atomizers can use silica, cotton, rayon, ], ], ], ] and even ] cables as wicking materials.<ref>{{cite web|last=Ngonngo |first=Nancy |url=http://www.twincities.com/health/ci_24192074/e-cigarette-stores-pop-up-twin-cities-so |title=As e-cigarette stores pop up in Twin Cities, so do the questions |publisher=] |accessdate=20 November 2013}}</ref>


Vaping correlates with smoking among young people, even in those who would otherwise be unlikely to smoke.<ref name=ChatterjeeAlzghoul2016>{{cite journal|last1=Chatterjee|first1=Kshitij|last2=Alzghoul|first2=Bashar|last3=Innabi|first3=Ayoub|last4=Meena|first4=Nikhil|title=Is vaping a gateway to smoking: a review of the longitudinal studies|journal=International Journal of Adolescent Medicine and Health|issue=3|year=2018|volume=30|issn=2191-0278|doi=10.1515/ijamh-2016-0033|pmid=27505084|s2cid=23977146}}</ref> Experimenting with vaping encourages young people to continue smoking.<ref name=KnorstBenedetto2014/> A 2015 study found minors had little resistance to buying e-cigarettes online.<ref name=Hildick-SmithPesko2015/> Teenagers may not admit to using e-cigarettes, but use, for instance, a hookah pen.<ref name=Schraufnagel2015>{{cite journal|last1=Schraufnagel|first1=Dean E.|title=Electronic Cigarettes: Vulnerability of Youth|journal=Pediatric Allergy, Immunology, and Pulmonology|volume=28|issue=1|year=2015|pages=2–6|issn=2151-321X|doi=10.1089/ped.2015.0490|pmc=4359356|pmid=25830075}}</ref> As a result, self-reporting may be lower in surveys.<ref name=Schraufnagel2015/>
====Cartomizers====
]
A "cartomizer" (a ] of cartridge and atomizer) or "carto" consists of an atomizer surrounded by a liquid-soaked poly-foam that acts as an e-liquid holder.<ref name=SpinfuelGlossaryP1/> They can have up to 3 coils and each coil will increase vapor production.<ref name=SpinfuelGlossaryP1/> It is usually disposed of once the e-liquid acquires a burnt taste, which is usually due to an activation when the coil is dry or when the cartomizer gets consistently flooded (gurgling) because of ] of the wick.<ref name=SpinfuelGlossaryP1/> Most cartomizers are refillable even if not advertised as such.<ref name=SpinfuelGlossaryP1/><ref>{{cite web|title=E-Cig Basics: What Is a Cartomizer?|url=http://vaperanks.com/e-cig-basics-what-is-a-cartomizer/|publisher=VapeRanks|accessdate=19 November 2013}}</ref>


More recent studies show a trend of an increasing proportion of young people who use e-cigarettes. In 2018, 20% of high school students were using e-cigarettes. In 2020, however, this number increased to 50% of high school students reported to have used e-cigarettes.<ref name=":04">{{Cite journal |last1=Virgili |first1=Fabrizio |last2=Nenna |first2=Raffaella |last3=Ben David |first3=Shira |last4=Mancino |first4=Enrica |last5=Di Mattia |first5=Greta |last6=Matera |first6=Luigi |last7=Petrarca |first7=Laura |last8=Midulla |first8=Fabio |date=December 2022 |title=E-cigarettes and youth: an unresolved Public Health concern |journal=Italian Journal of Pediatrics |language=en |volume=48 |issue=1 |pages=97 |doi=10.1186/s13052-022-01286-7 |issn=1824-7288 |pmc=9194784 |pmid=35701844 |doi-access=free }}</ref> Similarly, in Canada, there has been trend showing 29% of young people reporting to have used e-cigarettes in 2017, increasing to 37% in 2018.<ref name="Jiahong, Xi - American Journal of Public Health">{{Cite journal |last1=Sun |first1=Jiahong |last2=Xi |first2=Bo |last3=Ma |first3=Chuanwei |last4=Zhao |first4=Min |last5=Bovet |first5=Pascal |date=April 2022 |title=Prevalence of E-Cigarette Use and Its Associated Factors Among Youths Aged 12 to 16 Years in 68 Countries and Territories: Global Youth Tobacco Survey, 2012‒2019 |journal=American Journal of Public Health |language=en |volume=112 |issue=4 |pages=650–661 |doi=10.2105/AJPH.2021.306686 |issn=0090-0036 |pmc=8961851 |pmid=35319939}}</ref>
Cartomizers can be used on their own or in conjunction with a tank that allows more e-liquid capacity.<ref name=SpinfuelGlossaryP1/> In this case the portmanteau word of "cartotank" has been coined. When used in a tank, the cartomizer is inserted in a plastic, glass or metal tube and holes or slots have to be punched on the sides of the cartomizer to allow liquid to reach the coil.<ref name=SpinfuelGlossaryP1/>


== Health effects ==
====Clearomizers====
{{main|Health effects of electronic cigarettes}}
] to the coil that is located directly under the mouthpiece.]]
<!-- Health effects, Safety, and Addiction and dependence -->
Clearomizers or "clearos", not unlike cartotanks, use a clear tank in which an atomizer is inserted.<ref>{{cite news | url=http://www.thetelegraph.com/news/community-home_top-news/717182/Smoking-going-electronic | title=Smoking going electronic | work=Thetelegraph.com | date=29 January 2014 | accessdate=6 February 2014 | author=Greg Olson}}</ref> Unlike cartotanks, however, no poly-foam material can be found in them. There are a lot of different wicking systems employed inside of clearomizers to ensure good moistening of the wick without flooding the coil. Some rely on ] to bring the e-liquid to the wick and coil assembly (bottom coil clearomizers for example) whereas others rely on capillary action and to some degree the user agitating the e-liquid while handling the clearomizer (top coil clearomizers).<ref name=SpinfuelGlossaryP1/><ref>{{cite web | url=http://www.dxtechinc.com/whats-the-choice-between-a-clearomizer-vs-atomizer/ | title=WHAT'S THE CHOICE BETWEEN A CLEAROMIZER VS ATOMIZER? | accessdate=6 February 2014}}</ref> The coil and wicks are typically inside a prefabricated assembly or "head" that is replaceable by the user and can contain either single or dual coils.
The health risks of e-cigarettes are not known for certain, but the risk of ]s is thought to be low,<ref name=PaleyEchalier2016>{{cite journal|last1=Paley|first1=Grace L.|last2=Echalier |first2=Elizabeth|last3=Eck|first3=Thomas W.|last4=Hong|first4=Augustine R.|last5=Farooq|first5=Asim V.|last6=Gregory|first6=Darren G.|last7=Lubniewski|first7=Anthony J.|title=Corneoscleral Laceration and Ocular Burns Caused by Electronic Cigarette Explosions|journal=Cornea|volume=35|issue=7|year=2016|pages=1015–1018|issn=0277-3740|doi=10.1097/ICO.0000000000000881|pmc=4900417|pmid=27191672}}</ref><ref name=BalsBoyd2019/> and e-cigarettes are likely safer than combusted ].{{#tag:ref|A 2019 review concluded that, "no long term vaping toxicological/safety studies have been done in humans; without these data, saying with certainty that e-cigarettes are safer than combustible cigarettes is impossible."<ref name=GottsJordt2019>{{cite journal|last1=Gotts|first1=Jeffrey E|last2=Jordt|first2=Sven-Eric|last3=McConnell|first3=Rob|last4=Tarran|first4=Robert|title=What are the respiratory effects of e-cigarettes?|journal=BMJ|volume=366|year=2019|pages=l5275|issn=0959-8138|doi=10.1136/bmj.l5275|pmid=31570493|pmc=7850161|doi-access=free}}</ref>|group=note}}<ref name=KnorstBenedetto2014/><ref name=Burstyn2014/> However, this does not mean that e-cigarettes are harmless. E-cigarette use is associated with increased risk of ], ],<ref name=Wills2020/> ], and ]. Those who use e-cigarettes daily have higher risk than those who use them occasionally.<ref>{{cite journal |title=Association Between E-Cigarette Use and Chronic Obstructive Pulmonary Disease by Smoking Status: Behavioral Risk Factor Surveillance System 2016 and 2017 |journal=American Journal of Preventive Medicine |author1=Albert D. Osei |author2=Mohammadhassan Mirbolouk |author3=Olusola A. Orimoloye |author4=Omar Dzaye |author5=S.M. Iftekhar Uddin |author6=Emelia J. Benjamin |author7=Michael E. Hall |author8=Andrew P. DeFilippis |author9=Aruni Bhatnagar |author10=Shyam S. Biswal |author11=Michael J. Blaha |date=January 1, 2020 |volume=58 |issue=3 |pages=336–332 |doi=10.1016/j.amepre.2019.10.014|pmid=31902685 |pmc=9843649 }}</ref> According to the ], "Laboratory tests of e-cigarette ingredients, in vitro toxicological tests, and short-term human studies suggest that e-cigarettes are likely to be far less harmful than combustible tobacco cigarettes."<ref name="ajph.aphapublications.org"/> ] provide "high-certainty" evidence that e-cigarettes containing nicotine are more effective than ] for discontinuing tobacco smoking, and moderate‐certainty evidence that they are more effective than e-cigarettes free of nicotine.<ref name=":3" />{{#tag:ref|Two of the authors of this study received funding from ], which manufactures ] products.|group=note}}
Present day clearomizers commonly have adjustable air flow control. They also hold up to 5ml of e-liquid. Tanks can be either plastic or glass. Some flavors of e-juice have been known to crack plastic clearomizer tanks.<ref name=crackedtank>{{cite web | url=http://ecigarettereviewed.com/e-liquid-and-tank-safety | title=ecigarettereviewed.com | accessdate=6 November 2014}}</ref>


Some of the most common but less serious ]s include abdominal pain, headache, blurry vision,<ref name=BrelandSpindle2014>{{cite journal|last1=Breland|first1=Alison B.|last2=Spindle|first2=Tory|last3=Weaver|first3=Michael|last4=Eissenberg|first4=Thomas |title=Science and Electronic Cigarettes|journal=Journal of Addiction Medicine|volume=8|issue=4|year=2014|pages=223–233|issn=1932-0620|doi=10.1097/ADM.0000000000000049|pmc=4122311|pmid=25089952}}</ref> throat and mouth irritation, vomiting, nausea, and coughing.<ref name=Grana2014/> Nicotine is addictive and harmful to fetuses, children, and young people.<ref name=Edgar2013>{{cite web|url=https://www.webmd.com/smoking-cessation/news/20131112/e-cigarettes-cdc#1|title=E-Cigarettes: Expert Q&A With the CDC|last1=Edgar|first1=Julie|publisher=]|date=12 November 2013}}</ref>{{Better source needed|date=November 2024}} In 2019 and 2020, an ] was strongly linked to ] by the ]. While it is still widely debated which particular component of vape liquid is the cause of illness, vitamin E acetate, specifically, has been identified as a potential culprit in vape-related illnesses.<ref name=BoudiPatel2019>{{cite journal|last1=Boudi|first1=F Brian|last2=Patel|first2=Sonia|last3=Boudi|first3=Ava|last4=Chan|first4=Connie|title=Vitamin E Acetate as a Plausible Cause of Acute Vaping-related Illness|journal=Cureus|volume=11|issue=12|pages=e6350|year=2019|issn=2168-8184|doi=10.7759/cureus.6350|doi-access=free |pmc=6952050|pmid=31938636}}{{CC-notice|cc=by3|url=https://www.cureus.com/articles/25498-vitamin-e-acetate-as-a-plausible-cause-of-acute-vaping-related-illness|author(s)=F Brian Boudi, Sonia Patel, Ava Boudi, Connie Chan}}</ref> There was likely more than one cause of the outbreak.<ref name=KingJones2020>{{cite journal|last1=King|first1=Brian A.|last2=Jones|first2=Christopher M.|last3=Baldwin|first3=Grant T.|last4=Briss |first4=Peter A.|title=The EVALI and Youth Vaping Epidemics — Implications for Public Health|journal=New England Journal of Medicine|volume=382|issue=8|pages=689–691|year=2020|issn=0028-4793|doi=10.1056/NEJMp1916171 |pmid=31951683|pmc=7122126|doi-access=free}}</ref><ref name="CDC2020">{{cite web |date=17 January 2020 |title=Outbreak of Lung Injury Associated with the Use of E-Cigarette, or Vaping, Products |url=https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html |publisher=Centers for Disease Control and Prevention}}</ref>
====Rebuildable atomizers====
A rebuildable atomizer or an RBA is an atomizer that allows the user to assemble or "build" the wick and coil themselves instead of replacing them by an ] atomizer "head".<ref name=Farsalinos2014/> They are generally considered advanced devices. They also allow the user to build atomizers at any desired electrical resistance.<ref name=Farsalinos2014/> The materials needed to "rebuild" the atomizers are usually much cheaper than the usual prefabricated replaceable wick and coil assemblies used in clearomizers.


E-cigarettes produce similar levels of ]s to tobacco cigarettes.<ref name=":1">{{Cite journal|last1=Li|first1=Liqiao|last2=Lin|first2=Yan|last3=Xia|first3=Tian|last4=Zhu|first4=Yifang|date=7 January 2020|title=Effects of Electronic Cigarettes on Indoor Air Quality and Health |journal=Annual Review of Public Health|volume=41|pages=363–380|doi=10.1146/annurev-publhealth-040119-094043|pmid=31910714|pmc=7346849|issn=0163-7525|doi-access=free}}</ref> There is "only limited evidence showing adverse respiratory and cardiovascular effects in humans", with the authors of a 2020 review calling for more long-term studies on the subject.<ref name=":1" /> E-cigarettes increase the risk of ] by 40% and ] by 50% compared to not using nicotine at all.<ref name=Wills2020>{{Cite journal|last1=Wills|first1=Thomas A.|last2=Soneji|first2=Samir S.|last3=Choi|first3=Kelvin|last4=Jaspers|first4=Ilona |last5=Tam|first5=Elizabeth K.|date=10 October 2020|title=E-cigarette Use and Respiratory Disorder: An Integrative Review of Converging Evidence from Epidemiological and Laboratory Studies|journal=European Respiratory Journal|volume=56|issue=5|pages=363–380|doi=10.1183/13993003.01815-2019|pmid=33154031|pmc=7817920|issn=1399-3003|doi-access=free}}</ref>
These atomizers are divided into three main categories; rebuildable tank atomizers (RTAs), rebuildable dripping atomizers (RDAs),<ref name=3StepsRebuild>{{cite web|title=3 steps to rebuilding atomizers|url=http://vapenewsmagazine.com/november-2013/3-steps-to-rebuilding-atomizers|website=Vapenews Magazine|publisher=Vapenews Magazine|accessdate=21 November 2014}}</ref> and rebuildable dripping tank atomizers (RDTAs).


=== Pregnancy ===
Rebuildable tank atomizers (RTAs) are similar to clearomizers in that they use a tank or container to hold and bring liquid to the coil. They usually hold significantly more e-liquid than other atomizers or clearomizers. The tank can be either plastic, glass, or metal. An early form of tank atomizers was the Genesis style atomizers. They commonly use stainless steel mesh or rope for wicking material. The steel wick must be oxidized to prevent arcing of the coil. The drawbacks of Genesis style atomizers include leaking if they are not not kept upright.


The British ] states: "While vaping devices such as electronic cigarettes (e-cigs) do contain some toxins, they are at far lower levels than found in tobacco smoke. If a pregnant woman who has been smoking chooses to use an e-cig and it helps her to quit smoking and stay smokefree, she should be supported to do so." Based on the available evidence on e-cigarette safety, there was also "no reason to believe that use of an e-cig has any adverse effect on breastfeeding." The statement went on to say, "vaping should continue, if it is helpful to quitting smoking and staying smokefree". The UK ] says: "If using an e-cigarette helps you to stop smoking, it is much safer for you and your baby than continuing to smoke." Many women who vape continue to do so during pregnancy because of the perceived safety of e-cigarettes compared to tobacco.<ref name=QasimKarim2017>{{cite journal|last1=Qasim|first1=Hanan|last2=Karim|first2=Zubair A.|last3=Rivera|first3=Jose O.|last4=Khasawneh|first4=Fadi T.|last5=Alshbool|first5=Fatima Z.|title=Impact of Electronic Cigarettes on the Cardiovascular System|journal=Journal of the American Heart Association|volume=6|issue=9|year=2017|pages=e006353|issn=2047-9980|doi=10.1161/JAHA.117.006353|pmc=5634286|pmid=28855171}}</ref>
Rebuildable dripping atomizers (RDAs) are atomizers where the ejuice is dripped directly onto the coil and wick. They typically consist only of an atomizer "building deck", commonly with three posts with holes drilled in them, which can accept one or more coils.<ref name=pimpvape/> A "top cap" to cover the coils with airflow holes and a hole at the top where a mouth piece can be attached. The wick is generally larger than in tank atomizers. The user needs to manually keep the atomizer wet by dripping liquid on the bare wick and coil assembly, hence their name. Modern dripping atomizers can have raised edges forming a cup or "juice well". This allows more wick to be used and helps stop leaking. Some atomizers have heat sink fins to help dissipate the heat from the coil before it reaches the mouth piece or "drip tip".


====United States====
Rebuildable dripping tank atomizers (RDTAs) are a combination of both RTAs and RDAs. They usually consist of a RDA build deck with a tank over the deck held up by a spring. The user pushes down on the mouth piece and liquid is then dripped onto the coils and wick.This is unlike a RTA that continuously feeds liquid to the wicks.


In one of the few studies identified, a 2015 survey of 316 pregnant women in a Maryland clinic found that the majority had heard of e-cigarettes, 13% had used them, and 0.6% were current daily users.<ref name=SGUSReport2016/> These findings are of concern because the dose of nicotine delivered by e-cigarettes can be as high or higher than that delivered by traditional cigarettes.<ref name=SGUSReport2016/>
=== Power ===
Most portable devices contain a ], which tends to be the largest component of an electronic cigarette.


Data from two states in the Pregnancy Risk Assessment System (PRAMS) show that in 2015—roughly the mid-point of the study period—10.8% of the sample used e-cigarettes in the three months prior to the pregnancy while 7.0%, 5.8%, and 1.4% used these products at the time of the pregnancy, in the first trimester, and at birth respectively.<ref>{{cite journal |last1=Kapaya |first1=Martha |title=Use of Electronic Vapor Products Before, During, and After Pregnancy Among Women with a Recent Live Birth — Oklahoma and Texas, 2015 |journal=MMWR. Morbidity and Mortality Weekly Report |language=en-us |doi=10.15585/mmwr.mm6808a1 |date=2019|volume=68 |issue=8 |pages=189–194 |pmid=30817748 |pmc=6394383 }}</ref> According to National Health Interview Survey (NHIS) data from 2014 to 2017, 38.9% of pregnant smokers used e-cigarettes compared to only 13.5% of non-pregnant, reproductive age women smokers.<ref>{{cite journal |last1=Liu |first1=Buyun |last2=Xu |first2=Guifeng |last3=Rong |first3=Shuang |last4=Santillan |first4=Donna A. |last5=Santillan |first5=Mark K. |last6=Snetselaar |first6=Linda G. |last7=Bao |first7=Wei |title=National Estimates of e-Cigarette Use Among Pregnant and Nonpregnant Women of Reproductive Age in the United States, 2014-2017 |journal=JAMA Pediatrics |date=2019 |volume=173 |issue=6 |pages=600–602 |doi=10.1001/jamapediatrics.2019.0658 |pmid=31034001 |pmc=6547070 |issn=2168-6211}}</ref> A health economic study found that passing an e-cigarette minimum legal sale age law in the United States increased teenage prenatal smoking by 0.6 percentage points and had no effect on birth outcomes.<ref>{{cite journal |last1=Pesko |first1=Michael F. |last2=Currie |first2=Janet M. |title=E-cigarette minimum legal sale age laws and traditional cigarette use among rural pregnant teenagers |journal=Journal of Health Economics |date=1 July 2019 |volume=66 |pages=71–90 |pmid=31121389 |pmc=7051858 |doi=10.1016/j.jhealeco.2019.05.003 |issn=0167-6296}}</ref> Nevertheless, additional research needs to be done on the health effects of electronic cigarette use during pregnancy.<ref>{{harvnb|National Academies of Sciences, Engineering, and Medicine|2018|loc=}}</ref>
==== Variable power and voltage devices ====
]
Variable ] and or voltage are personal vaporizer devices that contain a built-in ] allowing the user to adjust the power that goes through the heating element.<ref name=McRobbie2014/> They are often rectangular in shape but can also be cylindrical.<ref name=trading-addictions/> They usually incorporate an LED screen to display information.<ref>{{cite news | url=http://online.wsj.com/article/PR-CO-20140129-910446.html | title=Vapor Corp. Launches New Store-in-Store VaporX(R) Retail Concept at Tobacco Plus Convenience Expo in Las Vegas | work=The Wall Street Journal | date=29 January 2014 | accessdate=6 February 2014}}</ref> Variable wattage lets you adjust the voltage to the coil. Variable wattage devices check the ohms of the coil and automatically adjust the voltage to get the desired power to the coil.<ref>{{cite news | url=http://spinfuel.com/taking-the-mystery-out-of-variable-wattage/ | title=Taking The Mystery Out Of Variable Wattage | work=Spinfuel Magizine | date=28 February 2013 | accessdate=18 November 2014}}</ref> Vairable devices are either variable wattage, variable voltage or both.<ref name=SpinfuelGlossaryP2>{{cite news |url=http://spinfuel.com/vapers-glossary/2/ | title=Vaper Talk – The Vaper's Glossary page 2 | work=Spinfuel Magizine | date=5 July 2013 | accessdate=18 November 2014}}</ref> To adjust the settings the user presses buttons or rotates a dial to make adjustments in power either up or down.<ref name=digitaltrends.com/> The amount of power has a direct relationship to the heat produced by the coil, thus changing the vapor output.<ref name=McRobbie2014/><ref name=digitaltrends.com/> Greater heat generated by the coil increases vapor production.<ref name=digitaltrends.com/> Some of these devices include additional settings through their menu system such as: atomizer resistance checker, remaining battery voltage, puff counter, activation cut-off etc.<ref>{{cite web|url=http://realelectriccigarettereviews.com/joyetech-evic-review/ | title=JoyeTech eVic Review | publisher=Real Electric Cigarettes Reviews}}</ref>


According to the CDC, E-cigarettes are not safe during pregnancy. "Although the aerosol of e-cigarettes generally has fewer harmful substances than cigarette smoke, e-cigarettes and other products containing nicotine are not safe to use during pregnancy. Nicotine is a health danger for pregnant women and developing babies and can damage a developing baby's brain and lungs. Also, some of the flavorings used in e-cigarettes may be harmful to a developing baby."<ref>{{Cite web |url= https://www.cdc.gov/reproductivehealth/maternalinfanthealth/substance-abuse/e-cigarettes-pregnancy.htm |title=E-Cigarettes and Pregnancy |website=Centers for Disease Control |date=March 2019}}</ref>
==== Mechanical personal vaporizers ====
]
Mechanical PVs or mechanical "mods", often called "mechs", are devices without electronic components and battery protection (apart from vent holes drilled in some mechanical devices) or voltage regulation. Because there is neither protection nor regulation, they will work either way the battery is inserted. They are activated by spring loaded or opposing ] mechanical ], hence their name. They rely on the natural voltage output of a battery and the material that the mod is made of.<ref name=Amann2014>{{cite web | url=http://onvaping.com/battery-safety-and-ohms-law/ | title=Battery Safety and Ohm's Law | publisher=onvaping.com | author=Dale Amann | date=10 February 2014 | accessdate=1 October 2014}}</ref>


A popular vaporizer named ] was widely used by American young people until 2022, when the FDA banned its products from sale.<ref name="ReutersSampathJul2022">{{cite news |last1=Sampath |first1=Uday |last2=Tanna |first2=Shivani |last3=Sharma |first3=Akriti |title=Juul ban put on hold as FDA starts additional review |url=https://www.reuters.com/business/healthcare-pharmaceuticals/juul-gets-temporary-reprieve-us-fda-ban-2022-07-06/ |access-date=15 January 2023 |work=Reuters |date=6 July 2022}}</ref><ref name=Kelly2018>{{cite news|url=https://www.washingtontimes.com/news/2018/apr/25/juul-maker-popular-e-cigarettes-invests-30m-youth-/|title=JUUL, maker of popular e-cigarettes, invests $30M in youth awareness|author=Laura Kelly and Tom Howell Jr.|work=]|date=25 April 2018}}</ref> Close to 80% of respondents in a 2017 ] study aged 15–24 reported using Juul also used the device in the last 30 days.<ref name=Willett2018>{{cite journal|last1=Willett|first1=Jeffrey G|last2=Bennett|first2=Morgane|last3=Hair|first3=Elizabeth C|last4=Xiao|first4=Haijuan |last5=Greenberg |first5=Marisa S|last6=Harvey|first6=Emily|last7=Cantrell|first7=Jennifer|last8=Vallone|first8=Donna |title=Recognition, use and perceptions of JUUL among youth and young adults|journal=Tobacco Control |volume=28|issue=1|pages=tobaccocontrol–2018–054273|date=18 April 2018|doi=10.1136/tobaccocontrol-2018-054273|pmid=29669749|s2cid=4953543|url=https://truthinitiative.org/sites/default/files/Recognition-use-and-perceptions-of-JUUL-among-youth-and-young-adults.pdf|archive-date=7 December 2018|archive-url=https://web.archive.org/web/20181207152101/https://truthinitiative.org/sites/default/files/Recognition-use-and-perceptions-of-JUUL-among-youth-and-young-adults.pdf|url-status=dead}}</ref> In the 2010s, US teenagers used the verb "Juuling" to describe vaping,<ref name=Suiters2018/> and Juuling was the subject of widespread ] on social media.<ref name=Barshad>{{cite news |url=https://www.nytimes.com/2018/04/07/style/the-juul-is-too-cool.html|title=The Juul Is Too Cool |last1=Barshad|first1=Amos|work=The New York Times|date=7 April 2018}}</ref>
The term "mod" was originally used instead of "modification".<ref name=Farsalinos2014/> Users would modify existing hardware to get better performance, and as an alternative to the e-cigarettes that looked like traditional cigarettes.<ref name=digitaltrends.com/> Users would also modify other items like flashlights as battery compartments to power atomizers.<ref name="trading-addictions"/><ref name=digitaltrends.com/> Today the word mod is used to describe most personal vaporizers either bought in a store or created by the user.


=== Harm reduction ===
They are commonly used with "low resistance" (1.0Ω ~ 0.2Ω) rebuildable atomizers.<ref name=SpinfuelFirstMod>{{cite web | url=http://spinfuel.com/first-mechanical-mod/ | title=Time For Your First Mechanical Mod? | publisher=Spinfuel Magizine | author=Team Spinfuel | date=11 January 2014 | accessdate=18 November 2014}}</ref> Seeing that most e-cigarettes containing electronic battery protection will interpret sub ohm resistance coils as a ], thus prohibiting the device from being activated, mechanical mods are among the only devices that will accept such atomizer resistances although more recent (2013) electronic devices have this possibility as well.{{citation needed|date=November 2013}}
]<ref>Detailed reference list is located at a ].</ref>|alt=Switching from tobacco to vaping may reduce weight gain after smoking cessation, increase exercise tolerance, reduce exposure to toxic chemicals, and reduce risk of death. Vaping may reduce shortness of breath, reduce coughing, reduce spitting, and reduce sore throat compared to tobacco.]]
<!-- What is Harm reduction -->
] refers to any reduction in harm from a prior level.<ref name=AbramsGlasser2018/> Harm minimization strives to reduce harms to the lowest achievable level.<ref name=AbramsGlasser2018/> When a person does not want to quit nicotine, harm minimization means striving to eliminate tobacco exposure by replacing it with vaping.<ref name=AbramsGlasser2018>{{cite journal|last1=Abrams|first1=David B.|last2=Glasser|first2=Allison M. |last3=Pearson|first3=Jennifer L.|last4=Villanti|first4=Andrea C.|last5=Collins|first5=Lauren K.|last6=Niaura|first6=Raymond S.|title=Harm Minimization and Tobacco Control: Reframing Societal Views of Nicotine Use to Rapidly Save Lives|journal=Annual Review of Public Health|volume=39|issue=1|year=2018|pages=193–213|issn=0163-7525|doi=10.1146/annurev-publhealth-040617-013849|pmid=29323611|pmc=6942997}}{{CC-notice|cc=by4 |url=https://www.annualreviews.org/doi/pdf/10.1146/annurev-publhealth-040617-013849|author(s)=David B. Abrams, Allison M. Glasser, Jennifer L. Pearson, Andrea C. Villanti, Lauren K. Collins, and Raymond S. Niaura}}</ref> E-cigarettes can reduce smokers' exposure to carcinogens and other toxic chemicals found in tobacco.<ref name=Weaver2014>{{cite journal|last1=Weaver|first1=Michael|last2=Breland|first2=Alison |last3=Spindle|first3=Tory |last4=Eissenberg|first4=Thomas|title=Electronic Cigarettes|journal=Journal of Addiction Medicine|volume=8|issue=4|year=2014|pages=234–240|issn=1932-0620|pmc=4123220|pmid=25089953 |doi=10.1097/ADM.0000000000000043}}</ref>


] has been a controversial area of ].<ref name=Cahn2011/> Health advocates have been slow to support a harm reduction method out of concern that ] cannot be trusted to sell products that will lower the risks associated with tobacco use.<ref name=Cahn2011/> A large number of smokers want to reduce harm from smoking by using e-cigarettes.<ref name=Britton2014/> The argument for harm reduction does not take into account the adverse effects of nicotine.<ref name=Schraufnage2014/> There cannot be a defensible reason for harm reduction in children who are vaping with a base of nicotine.<ref name="FerkolFarber2018">{{cite journal|last1=Ferkol|first1=Thomas W.|last2=Farber|first2=Harold J.|last3=La Grutta|first3=Stefania|last4=Leone|first4=Frank T.|last5=Marshall|first5=Henry M.|last6=Neptune|first6=Enid |last7=Pisinger|first7=Charlotta|last8=Vanker|first8=Aneesa|last9=Wisotzky|first9=Myra|last10=Zabert|first10=Gustavo E.|last11=Schraufnagel|first11=Dean E.|title=Electronic cigarette use in youths: a position statement of the Forum of International Respiratory Societies|journal=European Respiratory Journal|volume=51|issue=5|year=2018|pages=1800278|issn=0903-1936|doi=10.1183/13993003.00278-2018|pmid=29848575|doi-access=free}}</ref> Quitting smoking is the most effective strategy to tobacco harm reduction.<ref name=Scherer2018>{{cite journal|last1=Scherer|first1=Gerhard|title=Suitability of biomarkers of biological effects (BOBEs) for assessing the likelihood of reducing the tobacco related disease risk by new and innovative tobacco products: A literature review|journal=Regulatory Toxicology and Pharmacology|volume=94|year=2018|pages=203–233|issn=0273-2300|doi=10.1016/j.yrtph.2018.02.002 |pmid=29428304}}</ref>
Since mechanical PVs have no power regulation and are unprotected, they require special attention on the user's part that other regulated and protected PVs do not need. Making sure that the battery does not over-discharge and that the atomizer will not require more ] than what the battery can safely allow are the user's responsibilities.<ref name=Amann2014/>


Tobacco smoke contains 100 known carcinogens and 900 potentially cancer-causing chemicals, but e-cigarette vapor contains less of the potential carcinogens than found in tobacco smoke.<ref name="Kacker2014">{{cite journal |last1=Oh|first1=Anne Y.|last2=Kacker|first2=Ashutosh|title=Do electronic cigarettes impart a lower potential disease burden than conventional tobacco cigarettes?: Review on e-cigarette vapor versus tobacco smoke|journal=The Laryngoscope|date=December 2014|volume=124|issue=12|pages=2702–2706|doi=10.1002/lary.24750|pmid=25302452|s2cid=10560264|doi-access=free}}</ref> A study in 2015 using a third-generation device found levels of formaldehyde were greater than with cigarette smoke when adjusted to a maximum power setting.{{sfn|Wilder|2016|p=82}} E-cigarettes cannot be considered safe because there is no safe level for carcinogens.<ref name=Cahn2011>{{cite journal|first2=M. |last1=Cahn|first1=Z.|last2=Siegel|title=Electronic cigarettes as a harm reduction strategy for tobacco control: a step forward or a repeat of past mistakes?|journal=Journal of Public Health Policy|date=February 2011 |volume=32|issue=1|pages=16–31|doi=10.1057/jphp.2010.41|pmid=21150942|doi-access=free}}</ref> Due to their similarity to traditional cigarettes, e-cigarettes could play a valuable role in tobacco harm reduction.<ref name=FranckFilion2016/> The public health community remains divided concerning the appropriateness of endorsing a device whose safety and efficacy for smoking cessation remain unclear.<ref name=FranckFilion2016/> Overall, the available evidence supports the cautionary implementation of harm reduction interventions aimed at promoting e-cigarettes as attractive and competitive alternatives to cigarette smoking, while taking measures to protect vulnerable groups and individuals.<ref name=FranckFilion2016/>
===E-liquid===
E-liquid, e-juice or simply "juice", refers to a liquid solution that when heated by an atomizer produces vapor. The main ingredients of e-liquids are usually a mix of propylene glycol (PG), ] (G), and/or ] (PEG400), sometimes with differing levels of alcohol mixed with concentrated or extracted flavorings; and optionally, a variable concentration of tobacco-derived nicotine.<ref name=Caponnetto2013/><ref name=Koch2012>{{cite web|url=http://usatoday30.usatoday.com/news/health/story/2012-08-18/electronic-cigarettes-smokeless-vaping-risks/57121894/1|publisher=]|title=E-cigarettes: No smoke, but fiery debate over safety|accessdate=20 July 2013}}</ref> The nicotine may be obtained from tobacco plants or tobacco dust.<ref name=Chang2014>{{cite journal|last1=Chang|first1=H.|title=Research gaps related to the environmental impacts of electronic cigarettes|journal=Tobacco Control|volume=23|issue=Supplement 2|year=2014|pages=ii54–ii58|issn=0964-4563|doi=10.1136/tobaccocontrol-2013-051480|pmc=3995274|pmid=24732165}}</ref> The nicotine in e-liquid may be prepared using a ]-grade nicotine, a tobacco extract, or a synthetic nicotine.<ref name=Chang2014/> Most e-cigarette liquids contain nicotine, but the level of nicotine is chosen by the consumer.<ref name=Bur2014/> E-liquid that does not contain nicotine is also available.<ref name=Bur2014>{{cite journal|last1=Burstyn|first1=I|title=Peering through the mist: systematic review of what the chemistry of contaminants in electronic cigarettes tells us about health risks.|journal=BMC Public Health|date=9 January 2014|volume=14|pages=18|pmid=24406205|doi=10.1186/1471-2458-14-18|pmc=3937158}}</ref> Although some e-cigarettes are nicotine free, surveys demonstrate that 97% of e-cigarette users use products that contain nicotine.<ref name=Brandon2015/>


<!-- Concerns -->
The solution is often sold in bottles or pre-filled disposable cartridges, or as a kit for consumers to make their own eJuices. Components are also available to modify or boost their flavor, nicotine strength, or concentration of e-liquid.<ref name=DiyLiquid>{{cite web|url=http://www.ecigarettemag.com/e-liquid-mixing/|publisher=ecigarettemag.com|title=E-liquid Mixing Guide – a Guide to DIY Mixing|accessdate=10 November 2014}}</ref> Pre-made e-liquids are manufactured with various tobacco, fruit, and other flavors,<ref name=Grana2014/> as well as variable nicotine concentrations (including nicotine-free versions). The standard notation "mg/ml" is often used in labelling for denoting nicotine concentration, and is sometimes shortened to a simple "mg".<ref name=Laugesen2007>{{cite web|url=http://www.healthnz.co.nz/Ruyan_ecigarette.htm |author=Murray Laugesen|title=The Ruyan e-cigarette; Technical Information Sheet|publisher=Health New Zealand|date=17 October 2007|accessdate=31 March 2008}}</ref> In surveys of regular e-cigarette users the most liked e-liquids had a nicotine content of 18&nbsp;mg/ml, and largely the favorite flavors were tobacco, mint and fruit.<ref name=Hajek2014/> A cartridge may contain 0 to 20 mg of nicotine.<ref name=Cervellin2013/> A refill bottle can contain up to 1 g of nicotine.<ref name=Cervellin2013>{{cite journal|last1=Cervellin|first1=Gianfranco|last2=Borghi|first2=Loris|last3=Mattiuzzi|first3=Camilla|last4=Meschi|first4=Tiziana|last5=Favaloro|first5=Emmanuel|last6=Lippi|first6=Giuseppe|title=E-Cigarettes and Cardiovascular Risk: Beyond Science and Mysticism|journal=Seminars in Thrombosis and Hemostasis|volume=40|issue=01|year=2013|pages=060–065|issn=0094-6176|doi=10.1055/s-0033-1363468|pmid=24343348}}</ref> The flavorings may be natural or artificial.<ref name=Bertholon2013>{{cite journal|last1=Bertholon|first1=J.F.|last2=Becquemin|first2=M.H.|last3=Annesi-Maesano|first3=I.|last4=Dautzenberg|first4=B.|title=Electronic Cigarettes: A Short Review|journal=Respiration|year=2013|issn=1423-0356|doi=10.1159/000353253|pmid=24080743}}</ref> A person does not normally use an entire cartridge of one e-cigarette in a single session.<ref name=Pepper2013/>
The core concern is that smokers who could have quit entirely will develop an alternative nicotine addiction.<ref name=Cahn2011/> Dual use may be an increased risk to a smoker who continues to use even a minimal amount of traditional cigarettes, rather than quitting.<ref name=Grana2014/> Because of the convenience of e-cigarettes, it may further increase the risk of addiction.<ref>{{Cite journal |last1=Warner |first1=Kenneth E. |last2=Kiessling |first2=Karalyn A. |last3=Douglas |first3=Clifford E. |last4=Liber |first4=Alex C. |date=2022-09-01 |title=A Proposed Policy Agenda For Electronic Cigarettes In The US: Product, Price, Place, And Promotion: Policy Insight offers a proposed agenda for electronic cigarettes in the United States: product, price, place, and promotion. |url=http://www.healthaffairs.org/doi/10.1377/hlthaff.2022.00187 |journal=Health Affairs |language=en |volume=41 |issue=9 |pages=1299–1306 |doi=10.1377/hlthaff.2022.00187 |pmid=36067433 |s2cid=252110211 |issn=0278-2715}}</ref> The promotion of vaping as a harm reduction aid is premature,<ref name=Drummond2014>{{cite journal|last1=Drummond|first1=MB|last2=Upson|first2=D|title=Electronic cigarettes. Potential harms and benefits.|journal=Annals of the American Thoracic Society|date=February 2014|volume=11|issue=2|pages=236–242 |doi=10.1513/annalsats.201311-391fr|pmc=5469426|pmid=24575993}}</ref> while a 2011 review found they appear to have the potential to lower tobacco-related death and disease.<ref name=Cahn2011/> Evidence to substantiate the potential of vaping to lower tobacco-related death and disease is unknown.<ref name=FranksSando2018/> The health benefits of reducing cigarette use while vaping is unclear.<ref name=BroaddusMason2015>{{cite book|author1=V.Courtney Broaddus|author2=Robert C Mason|author3=Joel D Ernst|author4=Talmadge E King Jr.|author5=Stephen C Lazarus|author6=John F. Murray|author7=Jay A. Nadel|author8=Arthur Slutsky|author9=Michael Gotway|title=Murray & Nadel's Textbook of Respiratory Medicine|url=https://books.google.com/books?id=Hux1BwAAQBAJ&pg=PR20|date=17 March 2015|publisher=Elsevier Health Sciences|isbn=978-0-323-26193-7|page=820}}</ref> E-cigarettes could have an influential role in tobacco harm reduction.<ref name=FranckFilion2016/> The authors warned against the potential harm of excessive regulation and advised health professionals to consider advising smokers who are reluctant to quit by other methods to switch to e-cigarettes as a safer alternative to smoking.<ref name=Hajek2014/>


A 2014 review recommended that regulations for e-cigarettes could be similar to those for dietary supplements or cosmetic products to not limit their potential for harm reduction.<ref name=Saitta2014>{{cite journal|last1=Saitta|first1=D|author2=Ferro, GA|author3=Polosa, R|title=Achieving appropriate regulations for electronic cigarettes.|journal=Therapeutic Advances in Chronic Disease|date=March 2014|volume=5|issue=2|pages=50–61|doi=10.1177/2040622314521271|pmc=3926346|pmid=24587890}}</ref> A 2012 review found e-cigarettes could considerably reduce traditional cigarettes use and they likely could be used as a lower risk replacement for traditional cigarettes, but there is not enough data on their safety and efficacy to draw definite conclusions.<ref name=Caponnetto2012>{{cite journal|last1=Caponnetto|first1=Pasquale|last2=Campagna|first2=Davide|last3=Papale|first3=Gabriella|last4=Russo|first4=Cristina|last5=Polosa|first5=Riccardo|title=The emerging phenomenon of electronic cigarettes|journal=Expert Review of Respiratory Medicine|volume=6|issue=1|year=2012|pages=63–74|issn=1747-6348|doi=10.1586/ers.11.92|pmid=22283580|s2cid=207223131}}</ref> There is no research available on vaping for reducing harm in high-risk groups such as people with ]s.<ref name=Nowak2014>{{cite journal|author1=Nowak D |author2=Jörres RA |author3=Rüther T|title=E-cigarettes—prevention, pulmonary health, and addiction|journal=Dtsch Ärztebl Int|volume=111|issue=20|pages=349–55|year=2014|doi=10.3238/arztebl.2014.0349|pmc=4047602|pmid=24882626}}</ref>
==Health effects==
===Position of medical organizations===
{{Main|Positions of medical organizations regarding electronic cigarettes}}
{{Asof|2014}} electronic cigarettes have not been approved for helping people quit smoking by any government.<ref name=WHOPosition2014/> In July 2014, a report produced by the ] (WHO) for the Conference of the Parties to the ], found there was not enough evidence to determine if electronic cigarettes can help people quit smoking.<!-- <ref name=WHOPosition2014/> --> It suggested that smokers should be encouraged to use approved methods for help with quitting.<ref name=WHOPosition2014/> But the same report also mentioned expert opinions in scientific papers that suggested e-cigarettes may have a role helping people quit who have failed using other methods.<ref name=WHOPosition2014>{{cite web|last1=WHO|title=Electronic nicotine delivery systems|url=http://apps.who.int/gb/fctc/PDF/cop6/FCTC_COP6_10-en.pdf|accessdate=28 August 2014}}</ref> A previous WHO statement from July 2013 stated that e-cigarettes have not been shown to be effective helping people quit smoking.<ref name=WHOJuly2013>{{cite web|title=Tobacco Free Initiative (TFI)|url=https://web.archive.org/web/20130721131331/http://www.who.int/tobacco/communications/statements/eletronic_cigarettes/en|website=World Health Organization|date=9 July 2013}}</ref> It also recommended that "consumers should be strongly advised not to use" e-cigarettes unless a reputable national regulatory body has found them safe and effective.<ref name=WHOJuly2013/> The ] applauded the 2014 WHO report's recommendation for tighter regulation of e-cigarettes due to concerns about the safety of e-cigarettes and the possible increased nicotine or tobacco addiction among youth.<ref>{{cite web|title=WHO Right to Call for E-Cigarette Regulation|url=http://www.worldlungfoundation.org/ht/d/ReleaseDetails/i/32757|publisher=World Lung Federation|accessdate=6 November 2014}}</ref>


A 2014 PHE report concluded that hazards associated with products currently on the market are probably low, and apparently much lower than smoking.<ref name=Britton2014/> However, harms could be reduced further through reasonable product standards.<ref name=Britton2014>{{cite web|url=https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/311887/Ecigarettes_report.pdf|title=Electronic cigarettes – A report commissioned by Public Health England|publisher=Public Health England|date=15 May 2014|author1-first=John|author1-last=Britton|author2-first=Ilze|author2-last=Bogdanovica}}</ref> The British Medical Association encourages health professionals to recommend conventional nicotine replacement therapies, but for patients unwilling to use or continue using such methods, health professionals may present e-cigarettes as a lower-risk option than tobacco smoking.<ref name=BMAhandout2013>{{cite web|url=http://bma.org.uk/-/media/Files/PDFs/Working%20for%20change/Improving%20health/tobaccoecigarettespublicplaces_jan2013.pdf|title=BMA calls for stronger regulation of e-cigarettes|publisher=British Medical Association|date=January 2013|access-date=11 August 2013|archive-date=7 November 2013|archive-url=https://web.archive.org/web/20131107014659/http://bma.org.uk/-/media/Files/PDFs/Working%20for%20change/Improving%20health/tobaccoecigarettespublicplaces_jan2013.pdf|url-status=dead}}</ref>
The UK ] has concluded, "While e-cigarettes may be safer than conventional cigarettes, we don't yet know the long-term effects of vaping on the body. There are clinical trials in progress to test the quality, safety and effectiveness of e-cigarettes, but until these are complete, the government can't give any advice on them or recommend their use."<ref>{{cite web|title=Stop smoking treatments|url=http://www.nhs.uk/Conditions/Smoking-%28quitting%29/Pages/Treatment.aspx|publisher=UK National Health Service|accessdate=6 November 2014}}</ref>


The ] (AAPHP) suggests those who are unwilling to quit tobacco smoking or unable to quit with medical advice and pharmaceutical methods should consider other nicotine-containing products such as e-cigarettes and ] for long-term use instead of smoking.<ref>{{cite web|url=http://www.aaphp.org/tobacco|title=Principles to Guide AAPHP Tobacco Policy|publisher=American Association of Public Health Physicians|date=June 2013}}</ref> A 2014 WHO report concluded that some smokers will switch completely to e-cigarettes from traditional tobacco but a "sizeable" number will use both.{{sfn|WHO|2014|p=6}} This report found that such "dual-use" of e-cigarettes and tobacco "will have much smaller beneficial effects on overall survival compared with quitting smoking completely."{{sfn|WHO|2014|p=6}}
In 2014, the US ] (FDA) concluded, "E-cigarettes have not been fully studied, so consumers currently don't know: the potential risks of e-cigarettes when used as intended, how much nicotine or other potentially harmful chemicals are being inhaled during use, or whether there are any benefits associated with using these products. Additionally, it is not known whether e-cigarettes may lead young people to try other tobacco products, including conventional cigarettes, which are known to cause disease and lead to premature death."<ref>{{cite web|title=Electronic Cigarettes (e-Cigarettes)|url=http://www.fda.gov/NewsEvents/PublicHealthFocus/ucm172906.htm|publisher=US Food and Drug Administration|accessdate=6 November 2014}}</ref>


===Smoking cessation=== === Smoking cessation ===
Whether e-cigarettes help people quit smoking is debated.<ref name="Orellana-Barrios2016">{{cite journal|author1=Orellana-Barrios MA|author2=Payne D|author3=Medrano-Juarez RM|author4=Yang S|author5=Nugent K|year=2016 |title=Electronic Cigarettes for Smoking Cessation.|journal=The American Journal of the Medical Sciences|volume=52|issue=4|pages=420–426|doi=10.1016/j.amjms.2016.07.013 |pmid=27776725|s2cid=23548705}}</ref> Limited evidence suggests that e-cigarettes likely do help people to ] when used in clinical settings.<ref name=":0">{{Cite journal|last1=Hartmann-Boyce|first1=Jamie|last2=McRobbie|first2=Hayden|last3=Butler|first3=Ailsa R. |last4=Lindson|first4=Nicola|last5=Bullen|first5=Chris|last6=Begh|first6=Rachna|last7=Theodoulou |first7=Annika|last8=Notley|first8=Caitlin|last9=Rigotti|first9=Nancy A.|last10=Turner|first10=Tari |last11=Fanshawe|first11=Thomas R.|date=14 September 2021|title=Electronic cigarettes for smoking cessation|journal=The Cochrane Database of Systematic Reviews|volume=9|issue=11|pages=CD010216 |doi=10.1002/14651858.CD010216.pub6|issn=1469-493X|pmc=8438601|pmid=34519354}}</ref> However, more smokers become dual users than succeed in complete abstinence.<ref>{{cite journal |last1=Traboulsi |first1=Hussein |last2=Cherian |first2=Mathew |last3=Abou Rjeili |first3=Mira |last4=Preteroti |first4=Matthew |last5=Bourbeau |first5=Jean |last6=Smith |first6=Benjamin M. |last7=Eidelman |first7=David H. |last8=Baglole |first8=Carolyn J. |title=Inhalation Toxicology of Vaping Products and Implications for Pulmonary Health |journal=International Journal of Molecular Sciences |date=15 May 2020 |volume=21 |issue=10 |pages=3495 |doi=10.3390/ijms21103495 |pmid=32429092 |pmc=7278963 |doi-access=free }}</ref> Outside clinical settings, vaping does not greatly change the odds of quitting smoking.<ref name=PatilArakeri2019>{{cite journal|last1=Patil|first1=Shankargouda |last2=Arakeri|first2=Gururaj|last3=Patil|first3=Shekar|last4=Ali Baeshen|first4=Hosam|last5=Raj |first5=Thirumal|last6=Sarode|first6=Sachin C.|last7=Sarode|first7=Gargi S.|last8=Awan|first8=Kamran H.|last9=Gomez |first9=Ricardo|last10=Brennan|first10=Peter A|title=Are electronic nicotine delivery systems (ENDs) helping cigarette smokers quit? – A current evidence|journal=Journal of Oral Pathology & Medicine|year=2019|volume=49 |issue=3|pages=181–189|issn=0904-2512|doi=10.1111/jop.12966|pmid=31642553 |s2cid=204850725}}</ref>


<!-- Smoking reduction (without cessation) -->
{{Asof|2014}}, research on the safety and efficacy of e-cigarette use for ] is limited.<ref name=Franck2014>{{cite journal|last1=Franck|first1=C.|last2=Budlovsky|first2=T.|last3=Windle|first3=S. B.|last4=Filion|first4=K. B.|last5=Eisenberg|first5=M. J.|title=Electronic Cigarettes in North America: History, Use, and Implications for Smoking Cessation|journal=Circulation|volume=129|issue=19|year=2014|pages=1945–1952|issn=0009-7322|doi=10.1161/CIRCULATIONAHA.113.006416|pmid=24821825}}</ref> Their benefit in helping people quit smoking is uncertain.<ref name=Harrell2014>{{cite journal |last1=Harrell |first1=PT|last2=Simmons|first2=VN|last3=Correa|first3=JB|last4=Padhya|first4=TA|last5=Brandon|first5=TH|title=Electronic Nicotine Delivery Systems ("E-cigarettes"): Review of Safety and Smoking Cessation Efficacy.|journal=Otolaryngology—head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery|date= 4 June 2014|pmid=24898072|quote=These devices are unregulated, of unknown safety, and of uncertain benefit in quitting smoking.|doi=10.1177/0194599814536847}}</ref> A 2014 ] found limited evidence of a benefit as a smoking cessation aid from a small number of studies.<ref name=Cochrane2014/> The evidence suggests that e-cigarettes can at least partially supply nicotine at concentrations that are enough to substitute for traditional cigarettes.<ref name=Schroeder2014/> A 2015 review found that e-cigarettes were associated with smoking cessation and reduction.<ref>{{cite journal|last1=Rahman|first1=Muhammad Aziz|title=E-Cigarettes and Smoking Cessation: Evidence from a Systematic Review and Meta-Analysis.|journal=PLoS One|date=30 March 2015|doi=10.1371/journal.pone.0122544|pmid=25822251|url=http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0122544}}</ref> A 2014 review found e-cigarettes may have some potential for reducing smoking.<ref name=Rahman2014>{{cite journal |authors=Rahman MA, Hann N, Wilson A, Worrall-Carter L |title=Electronic cigarettes: patterns of use, health effects, use in smoking cessation and regulatory issues |journal=Tob Induc Dis |volume=12 |issue=1 |pages=21 |year=2014 |doi=10.1186/1617-9625-12-21 |pmc=4350653 |pmid=25745382}}</ref>
A small number of studies have looked at whether using e-cigarettes reduces the number of cigarettes smokers consume.<ref name=ElDibSuzumura2017/> E-cigarette use may decrease the number of cigarettes smoked,<ref name=Orr2014>{{cite journal|last1=Orr|first1=KK|last2=Asal|first2=NJ|title=Efficacy of electronic cigarettes for smoking cessation.|journal=The Annals of Pharmacotherapy|date=November 2014|volume=48|issue=11|pages=1502–1506 |doi=10.1177/1060028014547076|pmid=25136064|s2cid=29307238}}</ref> but smoking just one to four cigarettes daily greatly increases the risk of cardiovascular disease compared to not smoking.<ref name=Grana2014/> The extent to which decreasing cigarette smoking with vaping leads to quitting is unknown.<ref name=Bullen2014>{{cite journal|last1=Bullen|first1=Christopher|year=2014|title=Electronic Cigarettes for Smoking Cessation |url=http://qmro.qmul.ac.uk/xmlui/handle/123456789/16169|journal=Current Cardiology Reports|volume=16|issue=11|pages=538|doi=10.1007/s11886-014-0538-8|issn=1523-3782|pmid=25303892|s2cid=2550483}}</ref>


<!-- Target population -->
Two 2014 reviews found no evidence that e-cigarettes are more effective than existing nicotine replacement treatments for smoking cessation.<ref name=Drummond2014/><ref name=Cochrane2014/> One of these reviews stated that to encourage e-cigarette use as a cessation aid in cigarette users is premature.<ref name=Drummond2014/> A 2013 ] found higher smoking cessation rates associated with e-cigarettes with nicotine than e-cigarettes without nicotine or traditional NRT patches, but the study was too small to make these results statistically significant.<ref name=Polosa2013>{{citation|first=Riccardo |last=Polosa|first2=Brad|last2=Rodu|author3-first=Pasquale|author3-last=Caponnetto|author4-first=Marilena |author4-last=Maglia|author5-first=Cirino |author5-last=Raciti|journal=Harm Reduction Journal| volume=10|issue=10|title=A fresh look at tobacco harm reduction: the case for the electronic cigarette |year=2013|url=http://www.biomedcentral.com/content/pdf/1477-7517-10-19.pdf|pmid=24090432|doi=10.1186/1477-7517-10-19}}</ref> There are some ] which have reported possible benefit.<ref name=Caponnetto2013>{{cite journal|title=Electronic cigarette: a possible substitute for cigarette dependence.|journal=Monaldi archives for chest disease|date=Mar 2013|author1=Caponnetto P|author2=Russo C|author3=Bruno CM|author4=Alamo A|author5=Amaradio MD|author6=Polosa R.|volume=79|issue=1|pages=12–19|pmid=23741941}}</ref> Electronic cigarettes were not regularly associated with trying to quit tobacco among young people.<ref name=Car2014/> A 2014 review concluded that the adverse public health effects resulting from the widespread use of e-cigarettes could be significant, in part due to the possibility that they could undermine smoking cessation.<ref name=Pisinger2014/> This review therefore called for their use to be limited to smokers who are unwilling or unable to quit.<ref name=Pisinger2014>{{cite journal|last1=Pisinger|first1=Charlotta|last2=Døssing|first2=Martin|title=A systematic review of health effects of electronic cigarettes|journal=Preventive Medicine|date=December 2014|volume=69|pages=248–260|doi=10.1016/j.ypmed.2014.10.009|pmid=25456810}}</ref> A 2014 review found four experimental studies and six cohort studies that indicated that electronic cigarettes reduced the desire to smoke and withdrawal symptoms.<ref name=Gualano2014/> This review also noted that two cohort studies found that electronic cigarettes led to a reduction in the number of cigarettes smoked per day.<ref name=Gualano2014>{{cite journal|last1=Gualano|first1=M. R.|last2=Passi|first2=S.|last3=Bert|first3=F.|last4=La Torre|first4=G.|last5=Scaioli|first5=G.|last6=Siliquini|first6=R.|title=Electronic cigarettes: assessing the efficacy and the adverse effects through a systematic review of published studies|journal=Journal of Public Health|date=9 August 2014|doi=10.1093/pubmed/fdu055|pmid=25108741}}</ref> A 2014 review found that the research suggested that personal e-cigarette use may reduce overall health risk in comparison to traditional cigarettes.<ref name=Rom2014/> However, e-cigarettes could have a broad adverse effect for a population by expanding initiation and lowering cessation of smoking.<ref name=Rom2014/> A 2014 review found that the evidence suggests that "e-cigarettes are not associated with successful quitting in general population-based samples of smokers."<ref name=Grana2014/>
It is unclear whether e-cigarettes are only helpful for particular types of smokers.<ref name=Malasvan-der-Tempel2016>{{cite journal|last1=Malas|first1=Muhannad|last2=van der Tempel|first2=Jan|last3=Schwartz|first3=Robert |last4=Minichiello|first4=Alexa|last5=Lightfoot|first5=Clayton|last6=Noormohamed|first6=Aliya|last7=Andrews|first7=Jaklyn|last8=Zawertailo|first8=Laurie|last9=Ferrence|first9=Roberta|title=Electronic Cigarettes for Smoking Cessation: A Systematic Review|journal=Nicotine & Tobacco Research|date=25 April 2016|volume=18|issue=10|pages=1926–1936|issn=1462-2203|doi=10.1093/ntr/ntw119|pmid=27113014|doi-access=free}}</ref> Vaping with nicotine may reduce tobacco use among daily smokers.<ref name=VanderkamBoussageon2016>{{cite journal|last1=Vanderkam|first1=Paul|last2=Boussageon|first2=Rémy|last3=Underner|first3=Michel|last4=Langbourg|first4=Nicolas |last5=Brabant|first5=Yann|last6=Binder|first6=Philippe|last7=Freche|first7=Bernard|last8=Jaafari|first8=Nematollah|title=Efficacité et sécurité de la cigarette électronique pour la réduction du tabagisme : revue systématique et méta-analyse|journal=La Presse Médicale|volume=45|issue=11|pages=971–985|year=2016|issn=0755-4982|doi=10.1016/j.lpm.2016.05.026|pmid=27597300}}</ref> Whether vaping is effective for quitting smoking may depend on whether it was used as part of an effort to quit.<ref name=ElDibSuzumura2017>{{cite journal|last1=El Dib|first1=Regina|last2=Suzumura|first2=Erica A|last3=Akl|first3=Elie A|last4=Gomaa|first4=Huda|last5=Agarwal|first5=Arnav |last6=Chang|first6=Yaping|last7=Prasad|first7=Manya|last8=Ashoorion|first8=Vahid|last9=Heels-Ansdell|first9=Diane|last10=Maziak|first10=Wasim|last11=Guyatt|first11=Gordon|title=Electronic nicotine delivery systems and/or electronic non-nicotine delivery systems for tobacco smoking cessation or reduction: a systematic review and meta-analysis|journal=BMJ Open|volume=7|issue=2|year=2017|pages=e012680|issn=2044-6055|doi=10.1136/bmjopen-2016-012680|pmc=5337697|pmid=28235965}}</ref>


<!-- Other considerations (effect of tanks, flavors, social pressure, etc.) -->
=== Harm reduction ===
One of the challenges in studying e-cigarettes is that there are hundreds of brands and models of e-cigarettes sold that vary in the design and operation of the devices and composition of the liquid, and the technology continues to change.<ref name=McRobbieBullen2014>{{cite journal|last1=McRobbie|first1=Hayden|last2=Bullen|first2=Chris|last3=Hartmann-Boyce|first3=Jamie|last4=Hajek|first4=Peter|last5=McRobbie|first5=Hayden|title=Electronic cigarettes for smoking cessation and reduction|journal=The Cochrane Database of Systematic Reviews|year=2014|volume=12|issue=12|pages=CD010216|doi=10.1002/14651858.CD010216.pub2|pmid=25515689|hdl=2292/27824|hdl-access=free}}</ref> E-cigarettes have not been subjected to the same type of efficacy testing as ].<ref name=Jerry2015/> There are also social concerns - use of e-cigarettes may normalize tobacco use and prolong cigarette use for people who could have quit instead, or it could put extra pressure on smokers to stop cigarette smoking because e-cigarettes are a more socially acceptable alternative.<ref name=FranckFilion2016/> The evidence indicates smokers are more frequently able to completely quit smoking using tank devices compared to cigalikes, which may be due to their more efficient nicotine delivery.<ref name=Hartmann-BoyceMcRobbie2016/> One study supports the claim that smokers are more likely to use e-cigarettes as a nicotine replacement product to aid in smoking cessation than other pharmaceutical products.<ref name=":2" />
] has been a controversial area of tobacco control.<ref name=Cahn2011>{{cite journal |last1= M. |first1=Z. |last2=Siegel |title=Electronic cigarettes as a harm reduction strategy for tobacco control: a step forward or a repeat of past mistakes? |journal=Journal of public health policy |date=February 2011 |volume=32 |issue=1 |pages=16–31 |pmid=21150942 |doi= 10.1057/jphp.2010.41 |first2= M}}</ref> The health community have been cautious to support the ] to bring safer products to market that will lessen the risks related with tobacco use.<ref name=Cahn2011/> A 2011 review found in the fight to decrease tobacco related death and disease, e-cigarettes show great promise.<ref name=Cahn2011/> A 2014 review found no long-term evidence on the safety or efficacy of e-cigarettes, including whether they reduce harm for tobacco related disease or will improve the health of the population as a whole.<!-- <ref name=Drummond2014/> --> Therefore, promotion of e-cigarettes as a harm reduction product is premature.<ref name=Drummond2014>{{cite journal|last1=Drummond|first1=MB|last2=Upson|first2=D|title=Electronic cigarettes. Potential harms and benefits.|journal=Annals of the American Thoracic Society|date=February 2014|volume=11|issue=2|pages=236–42|pmid=24575993|doi=10.1513/annalsats.201311-391fr}}</ref> A 2014 review found e-cigarettes may be less harmful than tobacco cigarettes to users and bystanders.<ref name=Hajek2014/> The same review concluded that health professionals may consider advising smokers who are reluctant to quit by way of other methods to switch to e-cigarettes as a safer alternative to smoking.<ref name=Hajek2014/> A 2014 review argued that regulations for electronic cigarettes should be similar to those for dietary supplements or cosmetic products to not limit the potential for harm reduction with electronic cigarettes replacing tobacco.<ref name=Saitta2014>{{cite journal|last=Saitta|first=D|author2=Ferro, GA |author3=Polosa, R |title=Achieving appropriate regulations for electronic cigarettes.|journal=Therapeutic advances in chronic disease|date=Mar 2014|volume=5|issue=2|pages=50–61|doi=10.1177/2040622314521271|pmc=3926346|pmid=24587890}}</ref> A 2012 review found electronic systems appear to generally deliver less nicotine than smoking, raising the question of whether they can effectively substitute for tobacco smoking over a long-term period.<ref name=O2012/> A 2012 review found e-cigarettes could considerably reduce traditional cigarettes use and they likely could be used as a lower risk replacement for traditional cigarettes, but there is not enough data on the safety and efficacy to draw definite conclusions.<ref name=Caponnetto2012/> E-cigarette use for risk reduction in high-risk groups such as people with ]s is unavailable.<ref name=Nowak2014>{{cite journal |authors=Nowak D, Jörres RA, Rüther T |title=E-cigarettes--prevention, pulmonary health, and addiction |journal=Dtsch Arztebl Int |volume=111 |issue=20 |pages=349–55 |year=2014 |pmid=24882626 |pmc=4047602 |doi=10.3238/arztebl.2014.0349 |url=http://www.aerzteblatt.de/int/archive/article?id=159697}}</ref>

There is low quality evidence that vaping assists smokers to quit smoking in the long-term compared with nicotine-free vaping.<ref name=Hartmann-BoyceMcRobbie2016/> Nicotine-containing e-cigarettes were associated with greater effectiveness for quitting smoking than e-cigarettes without nicotine.<ref name=Rahman2015/> A 2013 study in smokers who were not trying to quit, found that vaping, with or without nicotine decreased the number of cigarettes consumed.<ref name=Lindson-HawleyHartmann-Boyce2016>{{cite journal|last1=Lindson-Hawley|first1=Nicola|last2=Hartmann-Boyce|first2=Jamie |last3=Fanshawe|first3=Thomas R|last4=Begh|first4=Rachna|last5=Farley|first5=Amanda|last6=Lancaster|first6=Tim|last7=Lindson-Hawley|first7=Nicola|title=Interventions to reduce harm from continued tobacco use|journal=The Cochrane Database of Systematic Reviews|volume=10|pages=CD005231|year=2016|issue=12|doi=10.1002/14651858.CD005231.pub3|pmc=6463938|pmid=27734465}}</ref> E-cigarettes without nicotine may reduce tobacco cravings because of the smoking-related physical stimuli.<ref name=Cahn2011/>


Smoke from traditional tobacco products has 40 known carcinogens among the 10,000 chemicals it contains, none of which has been found in more than trace quantities in the cartridges or aerosol of e-cigarettes.<ref name=Cahn2011/> A 2011 review stated that while e-cigarettes can not be considered "safe" because there is no safe level for carcinogens, they are doubtless safer compared to tobacco cigarettes.<ref name=Cahn2011/> Any residual risk of e-cigarette use should be weighed relative to the risk of continuing or returning to smoking, taking account of the low success rate of currently-approved smoking cessation medications.<ref name=FarsalinosPolosa2014>{{cite journal|last1=Farsalinos|first1=K. E.|last2=Polosa|first2=R.|title=Safety evaluation and risk assessment of electronic cigarettes as tobacco cigarette substitutes: a systematic review|journal=Therapeutic Advances in Drug Safety|volume=5|issue=2|year=2014|pages=67–86|issn=2042-0986|doi=10.1177/2042098614524430|pmc=4110871|pmid=25083263}}</ref> Adults most frequently use electronic cigarettes as a replacement for tobacco, but not always to quit.<ref name=Car2014/> Although some people have a desire to quit smoking by using e-cigarettes, another common explanation for the use of these products is to cut back on traditional cigarettes.<ref name=Grana2014>{{cite journal|last=Grana|first=R|author2=Benowitz, N |author3=Glantz, SA |title=E-cigarettes: a scientific review.|journal=Circulation|date=13 May 2014|volume=129|issue=19|pages=1972–86|doi=10.1161/circulationaha.114.007667|pmc=4018182|pmid=24821826}}</ref> A 2015 meta-analysis on ]s found that e-cigarettes containing nicotine are more effective than nicotine-free ones for quitting smoking.<ref name=Rahman2015/> They compared their finding that nicotine-containing e-cigarettes helped 20% of people quit with the results from other studies that found nicotine replacement products helps 10% of people quit.<ref name=Rahman2015>{{cite journal|last1=Rahman|first1=Muhammad Aziz|title=E-Cigarettes and Smoking Cessation: Evidence from a Systematic Review and Meta-Analysis.|journal=PLOS ONE|date=30 March 2015|volume=10|issue=3 |pages=e0122544|bibcode=2015PLoSO..1022544R|doi=10.1371/journal.pone.0122544|pmc=4378973|pmid=25822251|doi-access=free}}</ref> A 2016 review found low quality evidence of a trend towards benefit of e-cigarettes with nicotine for smoking cessation.<ref name=KhoudigianDevji2016>{{cite journal|last1=Khoudigian|first1=S.|last2=Devji|first2=T.|last3=Lytvyn|first3=L.|last4=Campbell|first4=K.|last5=Hopkins|first5=R.|last6=O'Reilly|first6=D.|title=The efficacy and short-term effects of electronic cigarettes as a method for smoking cessation: a systematic review and a meta-analysis|journal=International Journal of Public Health|volume=61|issue=2|date=29 January 2016 |pages=257–267|issn=1661-8556|doi=10.1007/s00038-016-0786-z|pmid=26825455|s2cid=22227035}}</ref> In terms of whether flavored e-cigarettes assisted quitting smoking, the evidence is inconclusive.<ref name=Cormet-BoyakaZare2018/> Tentative evidence indicates that health warnings on vaping products may influence users to give up vaping.<ref name="Al-HamdaniHopkins2019">{{cite journal|last1=Al-Hamdani|first1=Mohammed|last2=Hopkins |first2=D. Brett|last3=Park|first3=Tristan|year=2020|title=Vaping among youth and young adults: a "red alert" state|journal=Journal of Public Health Policy|volume=41|issue=1|pages=63–69|doi=10.1057/s41271-019-00193-2 |issn=0197-5897|pmid=31664162|s2cid=204966830}}</ref>


<!-- Other populations than non-pregnant adults (pregnancy, adolescents, others) -->
In 2014 a report commissioned by ] concluded that there is large potential for health benefits when switching from tobacco use to other nicotine delivery devices such as electronic cigarettes, but realizing their full potential requires regulation and monitoring to minimize possible risks.<ref name=NHE2014>{{cite web|url=https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/311887/Ecigarettes_report.pdf|title=Electronic cigarettes – A report commissioned by Public Health England |publisher=]|date=15 May 2014|author1-first=John |author1-last=Britton|author2-first=Ilze|author2-last=Bogdanovica}}</ref> They found that the evidence suggests that a considerable number of smokers want to reduce harm from smoking by using these products.<ref name=NHE2014/> The British Medical Association encourages health professionals to recommend conventional nicotine replacement therapies, but for patients unwilling to use or continue using such methods, health professionals may present e-cigarettes as a lower-risk option than tobacco smoking.<ref name=BMAhandout2013>{{cite web|title=BMA calls for stronger regulation of e-cigarettes|url=http://bma.org.uk/-/media/Files/PDFs/Working%20for%20change/Improving%20health/tobaccoecigarettespublicplaces_jan2013.pdf|publisher=British Medical Association|accessdate=18 November 2013}}</ref> The ] (AAPHP) suggests those who are unwilling to quit tobacco smoking or unable to quit with medical advice and pharmaceutical methods should consider other nicotine containing products such as electronic cigarettes and ] for long term use instead of smoking.<ref>{{cite web |title=Principles to Guide AAPHP Tobacco Policy |url=http://www.aaphp.org/tobacco|work=American Association of Public Health Physicians |accessdate=31 July 2013}}</ref> In an interview, the director of the Office on Smoking and Health for the U.S. federal agency ] (CDC) believes that there is enough evidence to say that using e-cigarettes is likely less harmful than smoking a pack of conventional cigarettes.<!-- <ref name=CDCQ&A/> --> However, due to the lack of regulation of the contents of the numerous different brands of electronic cigarettes and the presence of nicotine, which is not a benign substance, the CDC has issued warnings.<ref name=CDCQ&A>{{cite web |author=Edgar, Julie |title=E-Cigarettes: Expert Q&A With the CDC |url=http://www.webmd.com/smoking-cessation/news/20131112/e-cigarettes-cdc |publisher=WebMD |accessdate=17 November 2013}}</ref> A 2014 WHO report concluded that some smokers will switch completely to e-cigarettes from traditional tobacco but a "sizeable" number will use both tobacco cigarettes and electronic cigarettes.<!-- <ref name=WHOPosition2014/> --> This report found that such "dual use" of e-cigarettes and tobacco "will have much smaller beneficial effects on overall survival compared with quitting smoking completely."<ref name=WHOPosition2014/>
As of 2020, the efficacy and safety of vaping for quitting smoking during pregnancy was unknown.<ref>{{Cite journal|last1=Claire|first1=Ravinder|last2=Chamberlain|first2=Catherine|last3=Davey|first3=Mary-Ann|last4=Cooper |first4=Sue E.|last5=Berlin|first5=Ivan|last6=Leonardi-Bee|first6=Jo|last7=Coleman|first7=Tim|date=4 March 2020|title=Pharmacological interventions for promoting smoking cessation during pregnancy|journal=The Cochrane Database of Systematic Reviews|volume=2020|issue=3|pages=CD010078|doi=10.1002/14651858.CD010078.pub3|issn=1469-493X|pmc=7059898|pmid=32129504}}</ref> No research is available to provide details on the efficacy of vaping for quitting smoking during pregnancy.<ref name=FranksSando2018>{{cite journal|last1=Franks|first1=Andrea S|last2=Sando|first2=Karen|last3=McBane|first3=Sarah|title=Do Electronic Cigarettes Have a Role in Tobacco Cessation?|journal=Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy|volume=38|issue=5|pages=555–568|year=2018|issn=0277-0008|doi=10.1002/phar.2103|pmid=29573440|s2cid=4365503}}</ref> There is robust evidence that vaping is not effective for quitting smoking among adolescents.<ref name=ChatterjeeAlzghoul2016/> In view of the shortage of evidence, vaping is not recommend for cancer patients, although for all patients vaping is likely less dangerous than smoking cigarettes.<ref name=LucchiariMasiero2016>{{cite journal|last1=Lucchiari|first1=Claudio|last2=Masiero|first2=Marianna|last3=Botturi|first3=Andrea|last4=Pravettoni|first4=Gabriella|title=Helping patients to reduce tobacco consumption in oncology: a narrative review|journal=SpringerPlus|volume=5|issue=1|pages=1136|year=2016|issn=2193-1801|doi=10.1186/s40064-016-2798-9 |pmc=4954805|pmid=27504234 |doi-access=free }}</ref> The effectiveness of vaping for quitting smoking among vulnerable groups is uncertain.<ref name=GentryForouhi2018>{{cite journal|last1=Gentry|first1=Sarah|last2=Forouhi|first2=Nita|last3=Notley|first3=Caitlin|title=Are Electronic Cigarettes an Effective Aid to Smoking Cessation or Reduction Among Vulnerable Groups? A Systematic Review of Quantitative and Qualitative Evidence|journal=Nicotine & Tobacco Research|volume=21|issue=5|pages=602–616 |year=2018|issn=1462-2203|doi=10.1093/ntr/nty054|pmc=6697178|pmid=29608714}}</ref>


=== Safety === === Safety ===
{{Main|Safety of electronic cigarettes}} {{Main|Health effects of electronic cigarettes}}
{{further|Composition of electronic cigarette aerosol}}
The risks of electronic cigarette use are uncertain,<ref name=EbbertAgunwamba2015/><ref name=Harrell2014/> as there is little data regarding ]s,<ref name=Palazzolo>{{Citation | title=Electronic cigarettes and vaping: a new challenge in clinical medicine and public health. A literature review. | url=http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3859972/ | author1-first=Dominic L. |author1-last=Palazzolo | journal=Frontiers in Public Health | volume=1 |issue=56 | date=Nov 2013| doi=10.3389/fpubh.2013.00056 | pmid=24350225 | pmc=3859972}}</ref> and considerable variability between vaporizers and in the composition, concentration and quality of their liquid ingredients and thus the contents of the aerosol delivered to the user.<ref name=Grana2014/><ref name=O2012>{{cite journal|last=O'Connor|first=RJ|title=Non-cigarette tobacco products: what have we learnt and where are we headed?|journal=Tobacco control|date=March 2012|volume=21|issue=2|pages=181–90|doi=10.1136/tobaccocontrol-2011-050281|pmid=22345243|pmc=3716250}}</ref><ref name=Odum2012>{{cite journal|last1=Odum|first1=L. E.|last2=O'Dell|first2=K. A.|last3=Schepers|first3=J. S.|title=Electronic cigarettes: do they have a role in smoking cessation?|journal=Journal of pharmacy practice|date=December 2012|volume=25|issue=6|pages=611–4|doi=10.1177/0897190012451909|pmid=22797832}}</ref> The limited evidence suggests that e-cigarettes are probably safer than traditional ]s.<ref name=O2012/> A 2014 review recommended that e-cigarettes should be regulated for ].<ref name=Saitta2014/> Various methodological issues, conflicts of interest, and often inconsistent research has been identified in the research regarding e-cigarettes.<ref name=Pisinger2014/> However, e-cigarettes cannot be regarded as simply harmless.<ref name=Pisinger2014/>
There is no consensus on the risks of e-cigarette use.<ref name=Siu2015>{{cite journal|last1=Siu|first1=AL|title=Behavioral and Pharmacotherapy Interventions for Tobacco Smoking Cessation in Adults, Including Pregnant Women: U.S. Preventive Services Task Force Recommendation Statement.|journal=Annals of Internal Medicine|date=22 September 2015|volume=163|issue=8|pages=622–634 |doi=10.7326/M15-2023|pmid=26389730|doi-access=free}}</ref><ref name=Harrell2014>{{cite journal|last1=Harrell|first1=PT|last2=Simmons|first2=VN|last3=Correa |first3=JB|last4=Padhya|first4=TA|last5=Brandon|first5=TH |title=Electronic Nicotine Delivery Systems ("E-cigarettes"): Review of Safety and Smoking Cessation Efficacy.|journal=Otolaryngology–Head and Neck Surgery|date=4 June 2014|volume=151|issue=3|pages=381–393 |doi=10.1177/0194599814536847|pmc=4376316 |pmid=24898072}}</ref> There is little data about their safety, and a considerable variety of liquids are used as carriers,<ref name=PatnodeHenderson2015>{{cite journal |last1=Patnode|first1=Carrie D. |last2=Henderson|first2=Jillian T.|last3=Thompson|first3=Jamie H.|last4=Senger|first4=Caitlyn A. |last5=Fortmann|first5=Stephen P.|last6=Whitlock|first6=Evelyn P.|title=Behavioral Counseling and Pharmacotherapy Interventions for Tobacco Cessation in Adults, Including Pregnant Women: A Review of Reviews for the U.S. Preventive Services Task Force|journal=Annals of Internal Medicine|volume=163 |issue=8|date=September 2015|pages=608|issn=0003-4819|doi=10.7326/M15-0171|pmid=26491759|s2cid=207538340 |url=http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0079361/pdf/PubMedHealth_PMH0079361.pdf}}</ref> and thus are present in the ] delivered to the user.<ref name=Grana2014/> Reviews of the safety of e-cigarettes have reached quite different conclusions.<ref name=FarsalinosLeHouezec2015>{{cite journal|last1=Farsalinos|first1=Konstantinos |last2=LeHouezec |first2=Jacques|title=Regulation in the face of uncertainty: the evidence on electronic nicotine delivery systems (e-cigarettes)|journal=Risk Management and Healthcare Policy|volume=8|year=2015|pages=157–167 |doi=10.2147/RMHP.S62116|pmc=4598199 |pmid=26457058|issn=1179-1594 |doi-access=free }}</ref> A 2014 WHO report cautioned about potential risks of using e-cigarettes.{{sfn|WHO|2014|p=10}} Regulated US FDA products such as ] may be safer than e-cigarettes,<ref name=Drummond2014/> but e-cigarettes are generally seen as safer than combusted ]<ref name=KnorstBenedetto2014>{{cite journal |last1=Knorst|first1=Marli Maria|last2=Benedetto|first2=Igor Gorski|last3=Hoffmeister|first3=Mariana Costa|last4=Gazzana|first4=Marcelo Basso|title=The electronic cigarette: the new cigarette of the 21st century?|journal=Jornal Brasileiro de Pneumologia|volume=40|issue=5|year=2014|pages=564–572|issn=1806-3713|doi=10.1590/S1806-37132014000500013|pmc=4263338|pmid=25410845}}</ref><ref name=Burstyn2014/> such as cigarettes and cigars.<ref name=KnorstBenedetto2014/>


The risk of early death is anticipated to be similar to that of ].<ref name=BradyDeLaRosa2019/> Since vapor does not contain tobacco and does not involve combustion, users may avoid several ],<ref name=FarsalinosPolosa2014/> such as ], ], and ].<ref name=SmithBrar2016>{{cite journal|last1=Smith|first1=L|last2=Brar|first2=K|last3=Srinivasan|first3=K|last4=Enja|first4=M |last5=Lippmann|first5=S|title=E-cigarettes: How "safe" are they?|journal=J Fam Pract|date=June 2016 |volume=65|issue=6|pages=380–385|url=http://www.mdedge.com/jfponline/article/109243/addiction-medicine/e-cigarettes-how-safe-are-they|pmid=27474819}}</ref> However, e-cigarette use with or without nicotine cannot be considered risk-free<ref name=GloverBreier2016>{{cite journal|last1=Glover|first1=Marewa |last2=Breier|first2=Bernhard H.|last3=Bauld|first3=Linda|title=Could Vaping be a New Weapon in the Battle of the Bulge?|journal=Nicotine & Tobacco Research |volume=19|issue=12|year=2016|pages=1536–1540 |issn=1462-2203|doi=10.1093/ntr/ntw278|pmid=27798086|hdl=1893/26149|s2cid=3799963|hdl-access=free}}</ref> because the long-term effects of e-cigarette use are unknown.<ref name="BalsBoyd2019"/><ref name=Hartmann-BoyceMcRobbie2016>{{cite journal |last1=Hartmann-Boyce |first1=Jamie |last2=McRobbie |first2=Hayden |last3=Bullen |first3=Chris |last4=Begh |first4=Rachna |last5=Stead |first5=Lindsay F |last6=Hajek |first6=Peter |last7=Hartmann-Boyce |first7=Jamie |title=Electronic cigarettes for smoking cessation |journal=Cochrane Database Syst Rev |year=2016 |volume=9 |issue=9 |at=CD010216 |doi=10.1002/14651858.CD010216.pub3 |pmc=6457845 |pmid=27622384}}</ref><ref name=BradyDeLaRosa2019>{{cite journal|last1=Brady|first1=Benjamin R.|last2=De La Rosa |first2=Jennifer S.|last3=Nair|first3=Uma S.|last4=Leischow |first4=Scott J.|title=Electronic Cigarette Policy Recommendations: A Scoping Review|journal=American Journal of Health Behavior|volume=43|issue=1 |year=2019|pages=88–104|issn=1087-3244|doi=10.5993/AJHB.43.1.8|pmid=30522569 |s2cid=54566712}}</ref>
They appear to be similar in ] to other ], but there is not enough data to draw conclusions.<ref name=Caponnetto2013/> The evidence suggests that the US ] (FDA) accepted products such as a ] are probably a safer way to give nicotine than e-cigarettes.<ref name=Drummond2014/> A July 2014 WHO report cautioned about potential risks of using electronic cigarettes.<!-- <ref name=WHOPosition2014/> --> The report concluded that "the existing evidence shows that ENDS aerosol is not merely "water vapour" as is often claimed in the marketing for these products. ENDS use poses serious threats to adolescents and fetuses."<ref name=WHOPosition2014/> There are also risks from misuse or accidents (e.g., accidental fires caused by vaporizer malfunction, other vaporizer design issues, or accidental contact with liquid nicotine).<ref name=Grana2014/><ref name=FarsalinosPolosa2014/><ref name=Durmowicz2014/> A 2014 ] concluded that the risks of e-cigarettes have been exaggerated by health authorities and stated that it is apparent that there may be some remaining risk accompanied with e-cigarette use, though the risk of e-cigarette use is likely small compared to smoking tobacco.<ref name=FarsalinosPolosa2014/> A 2014 ] found no serious ]s reported in trials.<ref name=Cochrane2014/> Less serious adverse effects from e-cigarette use can include throat and mouth inflammation, vomiting, nausea, and cough.<ref name=Grana2014/> {{Asof|2015}}, the short and long term effects from using e-cigarettes remain unclear.<ref name=Orellana-Barrios2015>{{cite journal|last1=Orellana-Barrios|first1=Menfil A.|last2=Payne|first2=Drew|last3=Mulkey|first3=Zachary|last4=Nugent|first4=Kenneth|title=Electronic cigarettes-a narrative review for clinicians|journal=The American Journal of Medicine|year=2015|issn=00029343|doi=10.1016/j.amjmed.2015.01.033|pmid=25731134}}</ref> E-cigarette users are exposed to potentially harmful ].<ref name=Cheng2014/>


]s of ]<ref>Detailed reference list is located at a ].</ref>|alt=Possible side effects of nicotine include increased clotting tendency, atherosclerosis, enlargement of the aorta, bronchospasm, muscular tremor and pain, gastrointestinal nausea, dry mouth, dyspepsia, diarrhea, heartburn, peptic ulcer, cancer, lightheadedness, headache, sleep disturbances, abnormal dreams, irritability, dizziness, blood restriction, increased or decreased heart rate, increased blood pressure, tachycardia, more (or less) arrhythmias, coronary artery constriction, coronary artery disease, high insulin, insulin resistance, and risks to the child later in life during pregnancy include type 2 diabetes, obesity, hypertension, neurobehavioral defects, respiratory dysfunction, and infertility.]]
===Addiction===
The ] of e-liquids varies,<ref name=Cooke2015>{{cite journal|last1=Cooke|first1=Andrew |last2=Fergeson|first2=Jennifer|last3=Bulkhi|first3=Adeeb|last4=Casale|first4=Thomas B.|title=The Electronic Cigarette: The Good, the Bad, and the Ugly|journal=The Journal of Allergy and Clinical Immunology: In Practice|volume=3|issue=4|year=2015|pages=498–505|issn=2213-2198|pmid=26164573 |doi=10.1016/j.jaip.2015.05.022}}</ref> and contamination with various chemicals have been detected in the liquid.<ref name=Bertholon2013/> Metal parts of e-cigarettes in contact with the e-liquid can contaminate it with metal particles.<ref name=FarsalinosPolosa2014>{{cite journal |last1=Farsalinos |first1=K. E.|last2=Polosa|first2=R.|title=Safety evaluation and risk assessment of electronic cigarettes as tobacco cigarette substitutes: a systematic review|journal=Therapeutic Advances in Drug Safety |volume=5|issue=2|year=2014|pages=67–86|issn=2042-0986|doi=10.1177/2042098614524430|pmc=4110871 |pmid=25083263}}</ref> Many chemicals including ] such as ] can inadvertently be produced when the ] (heating element) that touches the e-liquid is heated and chemically reacted with the liquid.<ref name=Bekki2014/> Normal usage of e-cigarettes,{{sfn|Wilder|2016|p=82}} and reduced voltage (3.0&nbsp;V<ref name=Cheng2014/>) devices generate very low levels of formaldehyde.<ref name=Bekki2014/>
A number of organizations have concerns that e-cigarettes might increase addiction to and use of nicotine and tobacco products in the young.<ref name=MMWR2013>{{cite journal|last=Centers for Disease Control and Prevention|first=(CDC)|title=Notes from the field: electronic cigarette use among middle and high school students – United States, 2011–2012|url=http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6235a6.htm |journal=MMWR. Morbidity and mortality weekly report|date=6 September 2013|volume=62|issue=35|pages=729–30|pmid=24005229}}</ref><ref name=DrugFacts2014>{{cite web|title=DrugFacts: Electronic Cigarettes (e-Cigarettes)|url=http://www.drugabuse.gov/publications/drugfacts/electronic-cigarettes-e-cigarettes|work=National Institute on Drug Abuse|accessdate=15 October 2014|date=September 2014|quote=There is also the possibility that they could perpetuate the nicotine addiction and thus interfere with quitting.}}</ref><ref>{{cite web|title=Citing Health Concerns the American Cancer Society Calls for Action|url=http://www.cancer.org/myacs/eastern/areahighlights/cancernynj-news-ny-ecig-health-vote|work=American Cancer Society|accessdate=12 November 2013|quote=Government agencies and medical organizations, such as the FDA, the Centers for Disease Control and Prevention, and the American Academy of Pediatrics have also expressed concern that electronic cigarettes could increase nicotine addiction and tobacco use in young people.}}</ref> This including: the Centers for Disease Control and Prevention, the ], the ] and the Food and Drug Administration.<ref name=CDCQ&A/><ref name=IUATLD>{{cite web |title=Position Statement on Electronic Cigarettes or Electronic Nicotine Delivery Systems |url=http://www.theunion.org/what-we-do/publications/official/body/E-cigarette_statement_FULL.pdf |format=PDF |date=October 2013 |publisher=The International Union against Tuberculosis and Lung Disease}}</ref><ref>{{cite web|last=Korioth|first=Trisha|title=E-cigarettes easy to buy, can hook kids on nicotine|url=http://aapnews.aappublications.org/content/early/2013/10/04/aapnews.20131004-4|work=The American Academy of Pediatrics|accessdate=17 November 2013}}</ref><ref name=FDAConsumer2009>{{cite web|title=FDA Warns of Health Risks Posed by E-Cigarettes|url=http://www.fda.gov/forconsumers/consumerupdates/ucm173401.htm|work=FDA|accessdate=17 November 2013|date=23 July 2009|postscript=—Reviewed 17 September 2013}}</ref> The World Health Organization raised concern of addiction for nonsmokers from their use in July 2013.<ref name=WHOJuly2013/> The ] stated that there is a possibility that they could promote continuation of addiction to nicotine in those who are attempting to quit.<ref name=DrugFacts2014/>


The later-generation and "tank-style" e-cigarettes with a higher voltage (5.0&nbsp;V<ref name=Cooke2015/>) may generate equal or higher levels of formaldehyde compared to smoking.<ref name=Orellana-Barrios2015/> A 2015 report by Public Health England found that high levels of formaldehyde only occurred in overheated "dry-puffing".{{sfn|McNeill|2015|p=77}} Users detect the "dry puff" (also known as a "dry hit"{{sfnp|National Academies of Sciences, Engineering, and Medicine|2018|loc=Characteristics of E-Cigarette Devices |p=56}}) and avoid it, and they concluded that "There is no indication that EC users are exposed to dangerous levels of aldehydes."{{sfn|McNeill|2015|p=77}} However, e-cigarette users may "learn" to overcome the unpleasant taste due to elevated ] formation, when the nicotine craving is high enough.<ref name=Rowell2015>{{cite journal|last1=Rowell|first1=Temperance R|last2=Tarran|first2=Robert|title=Will Chronic E-Cigarette Use Cause Lung Disease?|journal=American Journal of Physiology. Lung Cellular and Molecular Physiology |year=2015|volume=309|issue=12|pages=L1398–L1409|issn=1040-0605|doi=10.1152/ajplung.00272.2015 |pmc=4683316|pmid=26408554}}</ref>
] ].]]
It is not clear whether using e-cigarettes will decrease or increase overall ].<ref name=Palazzolo/> The information concerning the drug action of the nicotine in e-cigarettes is limited.<ref name=Schroeder2014/> The evidence suggests that the nicotine in e-cigarettes is adequate to sustain nicotine dependence.<ref name=Schroeder2014>{{cite journal|last1=Schroeder|first1=M. J.|last2=Hoffman|first2=A. C.|title=Electronic cigarettes and nicotine clinical pharmacology|journal=Tobacco Control|volume=23|issue=Supplement 2|year=2014|pages=ii30–ii35|issn=0964-4563|doi=10.1136/tobaccocontrol-2013-051469|pmid=24732160}}</ref> The limited data suggests that the likelihood of abuse from e-cigarettes could be smaller compared to traditional cigarettes.<ref name=Evans2014>{{cite journal|last1=Evans|first1=S. E.|last2=Hoffman|first2=A. C.|title=Electronic cigarettes: abuse liability, topography and subjective effects|journal=Tobacco Control|volume=23|issue=Supplement 2|year=2014|pages=ii23–ii29|issn=0964-4563|doi=10.1136/tobaccocontrol-2013-051489|pmid=24732159}}</ref> A 2014 systematic review found that the concerns that e-cigarettes could cause non-smokers to begin smoking are unsubstantiated.<ref name=FarsalinosPolosa2014/> A 2014 review found no evidence that they are used regularly by those who have never smoked,<ref name=Hajek2014>{{cite journal|last1=Hajek|first1=P|last2=Etter|first2=JF|last3=Benowitz|first3=N|last4=Eissenberg|first4=T|last5=McRobbie|first5=H|title=Electronic cigarettes: review of use, content, safety, effects on smokers and potential for harm and benefit.|url=http://tobonline.com/Media/Default/Article/Addiction-%20Hajek%2014.pdf|journal=Addiction (Abingdon, England)|date=31 July 2014|pmid=25078252|doi=10.1111/add.12659|volume=109|issue=11|pages=1801–10}}</ref> while another 2014 review has found that in some populations nearly up to a third of youth who have ever used electronic cigarettes have never smoked traditional cigarettes.<ref name=Grana2014/> No long-term studies have been done on the effectiveness of e-cigarettes in treating tobacco addiction.<ref name=Drummond2014/> The degree to which teens are using e-cigarettes in ways it is not intended to be used, such as increasing the nicotine delivery, is unknown.<ref name=Durmowicz2014>{{cite journal|last1=Durmowicz|first1=E. L.|title=The impact of electronic cigarettes on the paediatric population|journal=Tobacco Control|volume=23|issue=Supplement 2|year=2014|pages=ii41–ii46|issn=0964-4563|doi=10.1136/tobaccocontrol-2013-051468|pmid=24732163}}</ref> The extent to which e-cigarette use will lead to abuse in youth is unknown.<ref name=Durmowicz2014/> The impact of e-cigarette use by children in respect to ] is unknown.<ref name=Durmowicz2014/>


Another common chemical found in e-cigarettes is ketene. When it enters the lungs after inhaled, this chemical causes damage to the cellular structure of lung tissue causing the cells to not function at maximum capacity and not absorb gasses as readily. This can cause shortness of breath which can lead to other health conditions such as tachycardia and respiratory failure. E-cigarette users who use devices that contain nicotine are exposed to its potentially harmful effects.<ref name=":04"/>
==History==
The earliest electronic cigarette can be traced to Herbert A. Gilbert, who in 1963 patented a device described as "a smokeless non-tobacco cigarette" that involved "replacing burning tobacco and paper with heated, moist, flavored air". This device heated the nicotine solution and produced steam. It was never commercialized.<ref>James Dunworth for the Ashtray Blog. 3 May 2012 </ref><ref>{{cite web|url=http://www.google.com/patents?id=RjlUAAAAEBAJ&printsec=abstract&zoom=4&source=gbs_overview_r&cad=0#v=onepage&q&f=false |title=US Patent 3200819. Smokeless non-tobacco cigarette|accessdate=29 February 2012}}</ref>


Nicotine is associated with ], possible birth defects, and poisoning.<ref name=Jerry2015/> '']'' studies of nicotine have associated it with cancer, but carcinogenicity has not been demonstrated '']''.<ref name=Jerry2015>{{cite journal|author1=Jerry JM|author2=Collins GB|author3=Streem D|title=E-cigarettes: Safe to recommend to patients?|journal=Cleve Clin J Med|volume=82|issue=8|pages=521–526|year=2015|pmid=26270431 |doi=10.3949/ccjm.82a.14054 |doi-access=free}}</ref> There is inadequate research to show that nicotine is associated with cancer in humans.{{sfn|SGUS|2014|p=115}} The risk is probably low from the inhalation of propylene glycol and glycerin.<ref name=Hajek2014/> No information is available on the long-term effects of the inhalation of flavors.<ref name=Bertholon2013/>
], a Chinese pharmacist and inventor, who worked as a research pharmacist for a company producing ] products, is credited with the invention of the electronic cigarette.<ref name=Demick2009>, ''Los Angeles Times''</ref><ref>, ]</ref> Hon had himself quit smoking, after his father, also a heavy smoker, had died of lung cancer. In 2003,<ref>{{cite web|url=http://inventors.about.com/od/estartinventions/a/Electronic-Cigarettes.htm |title=Who Invented Electronic Cigarettes? |publisher=Inventors.about.com |accessdate=20 November 2013}}</ref> he came up with the idea of using a ] ]-emitting element to vaporize a pressurized jet of liquid containing nicotine diluted in a propylene glycol solution.<ref name=wiki>{{cite web|url=http://www.wikipatents.com/CA-Patent-2518174/a-non-smokable-electronic-spray-cigarette|title=CA Patent 2518174 – A Non-Smokable Electronic Spray Cigarette|publisher=WikiPatents|accessdate=15 August 2012}}</ref> This design produces a smoke-like vapor that can be inhaled and provides a vehicle for nicotine delivery into the bloodstream via the lungs. He also proposed using propylene glycol to dilute nicotine and placing it in a disposable plastic cartridge which serves as a liquid reservoir and mouthpiece.


In October 2021, researchers at Johns Hopkins University reported over 2,000 unknown chemicals in the vape clouds that they tested from Vuse, Juul, Blu and Mi-Salt vape devices.<ref>{{Cite web|title=Johns Hopkins Finds Thousands of Unknown Chemicals in E-Cigarettes|url=https://releases.jhu.edu/2021/10/06/johns-hopkins-finds-thousands-of-unknown-chemicals-in-e-cigarettes/|publisher=]|access-date=24 November 2021|language=en-US}}</ref>
Hon patented the modern e-cigarette design in 2003.<ref name=Caponnetto2012/> Electronic cigarettes using a different design were first introduced to the Chinese domestic market in May 2004 as an aid for smoking cessation and replacement. Many versions made their way to the U.S., sold mostly over the Internet by small marketing firms.<ref name=Demick2009/> The company that Hon Lik worked for, Golden Dragon Holdings, changed its name to ] (如烟, literally "Resembling smoking"), and started exporting its products in 2005–2006<ref name=Demick2009/> before receiving its first international patent in 2007.<ref>{{cite web|url=http://worldwide.espacenet.com/publicationDetails/biblio?CC=US&NR=2007267031&KC=&FT=E&locale=en_EP|title=Electronic Atomizer Cigarette European patent |publisher=Worldwide.espacenet.com |date=22 November 2007|accessdate=29 February 2012}}</ref>


In 2019–2020, there was an outbreak of ] in the US and Canada, primarily related to vaping ] with ].<ref>{{Cite journal |last1=Layden|first1=Jennifer E.|last2=Ghinai|first2=Isaac|last3=Pray|first3=Ian|last4=Kimball|first4=Anne|last5=Layer|first5=Mark|last6=Tenforde|first6=Mark W.|last7=Navon|first7=Livia|last8=Hoots|first8=Brooke |last9=Salvatore|first9=Phillip P.|last10=Elderbrook|first10=Megan|last11=Haupt|first11=Thomas|date=6 September 2019|title=Pulmonary Illness Related to E-Cigarette Use in Illinois and Wisconsin — Final Report|journal=New England Journal of Medicine|volume=382|issue=10|pages=903–916|language=en|doi=10.1056/NEJMoa1911614|pmid=31491072|doi-access=free}}</ref><ref>{{Cite journal|last1=Blount|first1=Benjamin C.|last2=Karwowski|first2=Mateusz P. |last3=Shields|first3=Peter G.|last4=Morel-Espinosa|first4=Maria|last5=Valentin-Blasini|first5=Liza|last6=Gardner|first6=Michael|last7=Braselton|first7=Martha|last8=Brosius|first8=Christina R.|last9=Caron|first9=Kevin T. |last10=Chambers|first10=David|last11=Corstvet|first11=Joseph|date=20 December 2019|title=Vitamin E Acetate in Bronchoalveolar-Lavage Fluid Associated with EVALI|url= |journal=New England Journal of Medicine|volume=382 |issue=8|pages=697–705|language=en|doi=10.1056/NEJMoa1916433|pmc=7032996|pmid=31860793}}</ref>
The electronic cigarette continued to evolve from the first generation three-part device. In 2006 the "cartomizer" was invented by British entrepreneurs Umer and Tariq Sheikh of XL Distributors.<ref>{{cite web|url=http://www.cityam.com/article/brothers-who-took-punt-new-market/ |title=Brothers who took a punt on a new market |publisher=CityAM |accessdate=4 April 2014}}</ref> This is a mechanism which integrates the heating coil into the liquid chamber. The new device was launched in the UK in 2007 in their Gamucci brand and is now widely adopted by the majority of 'cigalike' brands. The grant of the UK patent for the "cartomizer" was made to XL Distributors in February 2013 and published by the UK Intellectual Property Office.<ref>{{cite web|url=http://www.ipo.gov.uk/p-ipsum/Case/PublicationNumber/GB2465247 |title=Patent document and information service (Ipsum) |publisher=] |accessdate=20 November 2013}}</ref>


E-cigarettes create vapor that consists of fine and ]s of ], with the majority of particles in the ultrafine range.<ref name=Grana2014/> The vapor have been found to contain propylene glycol, glycerin, nicotine, flavors, small amounts of ]s,<ref name=Grana2014/> ]s,<ref name=Hajek2014/> and ], as well as metal ]s, and other substances.<ref name=Grana2014/> Many carcinogenic compounds have been detected in e-cigarettes, such as N-Nitrosonornicotine (NNN), N-Nitrosoanatabine (NAT), etc., all of which have been proven to be harmful to human health.<ref>{{Cite journal |last1=Cetinkaya |first1=Pelin Duru |last2=Pazarli Bostan |first2=Pinar |last3=Salepci |first3=Banu |last4=Gorekdilektasli |first4=Asli |last5=Elbek |first5=Osman |last6=Uyanusta Kucuk |first6=Filiz Cagla |last7=Karadogan |first7=Dilek |last8=Arpaz |first8=Seren |last9=Dülger |first9=Seyhan |last10=Atilla Uysal |first10=Mehmet |last11=Uzaslan |first11=Esra |last12=Özge |first12=Cengiz |last13=Kılınç |first13=Oğuz |last14=Dağlı |first14=Elif |last15=Itil |first15=Oya |date=2022-07-18 |title=Turkish Thoracic Society's Statement Report on Electronic Cigarettes and Heated Tobacco Products |url=https://turkthoracj.org/en/turkish-thoracic-society-s-statement-report-on-electronic-cigarettes-and-heated-tobacco-products-132180 |journal=Turkish Thoracic Journal |volume=23 |issue=4 |pages=296–301 |doi=10.5152/TurkThoracJ.2022.22018 |pmc=9361150 |pmid=35848438}}</ref> Exactly what the ] across and within manufacturers, and depends on the contents of the liquid, the physical and electrical design of the device, and user behavior, among other factors.<ref name=Cheng2014/>
The international tobacco companies, recognising the development of a potential new market sector that could render traditional tobacco products obsolete,<ref>The Economist, 28 Sep 2013, , retrieved 11 March 2014</ref> are increasingly involved in the production and marketing of their own brands of e-cigarettes and in acquiring existing e-cigarette companies.<ref name=Esterl2014>{{cite web|url=http://online.wsj.com/news/articles/SB10001424052702304626804579360552508696542 |title=Altria Expands in E-Cigarettes With Green Smoke |publisher=Wall Street Journal |author=Mike Esterl|date=3 February 2014 |accessdate=7 March 2014}}</ref> Blu, a prominent US e-cigarette producer, was acquired by ] in 2012.<ref>CBS News, 11 June 1023, , retrieved 16 August 2013.</ref> ] launched Vype in 2013, while ]'s Fontem Ventures acquired the intellectual property owned by Hon Lik through Dragonite for $US 75 million in 2013 and launched Puritane in partnership with ].<ref>{{cite web|last=Gustafsson |first=Katarina |url=http://www.bloomberg.com/news/2013-09-02/imperial-tobacco-agrees-to-acquire-dragonite-s-e-cigarette-unit.html |title=Imperial Tobacco Agrees to Acquire Dragonite's E-Cigarette Unit |publisher=Bloomberg |date=2 September 2013 |accessdate=20 November 2013}}</ref><ref>{{cite web|url=http://www.puritane.co.uk/our-story |title=Our Story Puritane |accessdate=4 April 2014}}</ref> On October 1, 2013 ] acquired another e-cigarette company, this time a UK based company SKYCIG.<ref>{{cite web|url=http://finance.yahoo.com/news/lorillard-inc-acquires-british-based-120000550.html |title=Lorillard, Inc. Acquires British-based SKYCIG, Expanding its Electronic Cigarette Business |accessdate=1 October 2013}}</ref> On 3 February 2014, ] acquired popular electronic cigarette brand Green Smoke for $110 million. The deal was finalized in April 2014 for $110 million and $20 million in incentive payments.<ref>{{cite web | url=http://www.bloomberg.com/article/2014-04-01/ayIkoAxs1y8Y.html | title=Altria Completes Acquisition of Green Smoke | work=BusinessWire | date=1 April 2014 | accessdate=21 November 2014}}</ref> Altria also markets its own e-cigarette, the MarkTen, while ] has entered the sector with its Vuse product.<ref name=Esterl2014/>


E-cigarette vapor potentially contains harmful chemicals not found in tobacco smoke.<ref name=Hildick-SmithPesko2015/> The majority of toxic chemicals found in cigarette smoke are absent in e-cigarette vapor.<ref name=KimKabir2016/> E-cigarette vapor contains lower concentrations of potentially toxic chemicals than with cigarette smoke.<ref name="FernándezBallbè2015">{{cite journal|last1=Fernández |first1=Esteve|last2=Ballbè|first2=Montse|last3=Sureda|first3=Xisca|last4=Fu|first4=Marcela|last5=Saltó |first5=Esteve|last6=Martínez-Sánchez|first6=Jose M. |title=Particulate Matter from Electronic Cigarettes and Conventional Cigarettes: a Systematic Review and Observational Study|journal=Current Environmental Health Reports|volume=2|issue=4|pages=423–429|year=2015|issn=2196-5412|doi=10.1007/s40572-015-0072-x |pmid=26452675|doi-access=free|bibcode=2015CEHR....2..423F }}</ref> Those which are present, are mostly below 1% of the corresponding levels permissible by ].<ref name=Burstyn2014>{{cite journal|last1=Burstyn|first1=Igor|title=Peering through the mist: systematic review of what the chemistry of contaminants in electronic cigarettes tells us about health risks|journal=BMC Public Health|volume=14|issue=1|date=9 January 2014|pages=18|issn=1471-2458|doi=10.1186/1471-2458-14-18|pmc=3937158|pmid=24406205 |doi-access=free }}</ref> But workplace safety standards do not recognize exposure to certain vulnerable groups such as people with ], children, and infants who may be exposed to second-hand vapor.<ref name=Grana2014/>
==Society and culture==
Consumers of electronic cigarettes, sometimes referred to as "vapers", have shown evident and passionate support for the product that other nicotine replacement therapy did not receive.<ref name=NHE2014/><ref name=digitaltrends.com/> This suggests that electronic cigarettes have the potential mass appeal that could challenge the preeminence of combustible tobacco as the object of choice for nicotine users.<ref name=NHE2014/>


Concern exists that some of the mainstream vapor exhaled by e-cigarette users may be inhaled by bystanders, particularly indoors,<ref name=Rom2014/> although e-cigarette pollutant levels are much lower than for cigarettes and likely to pose a much lower risk, if any, compared to cigarettes.<ref name="Hajek2014"/> E-cigarette use by a parent might lead to inadvertent health risks to offspring.<ref name=England2015/> A 2014 review recommended that e-cigarettes should be regulated for ].<ref name=Saitta2014/> There is limited information available on the ]s around production, use, and disposal of e-cigarettes that use cartridges.<ref name=Chang2014>{{cite journal|last1=Chang|first1=H. |title=Research gaps related to the environmental impacts of electronic cigarettes|journal=Tobacco Control|volume=23|issue=Supplement 2|year=2014|pages=ii54–ii58|issn=0964-4563|doi=10.1136/tobaccocontrol-2013-051480 |pmc=3995274|pmid=24732165}}</ref> E-cigarettes that are not reusable may contribute to the problem of ].<ref name=Nowak2014/>
As the electronic cigarette industry grows, a ] has emerged which calls itself "the vaping community".<ref name=digitaltrends.com/><ref>{{cite web|last=Park |first=Andy |url=http://www.sbs.com.au/news/article/2013/06/18/feed-subculture-around-e-cigarettes |title=The Feed: The subculture around e-cigarettes |publisher=] |date=26 August 2013 |accessdate=20 November 2013}}</ref> Online forums like E-Cig-Reviews.com was one of the first major communities.<ref name=trading-addictions/> Another online forum UKVaper.org that focuses on e-cigarettes started the hobby of modding.<ref name=trading-addictions>{{cite news|title=Trading addictions: the inside story of the e-cig modding scene |url=http://www.engadget.com/2014/10/01/inside-story-e-cig-modding-uk/ |publisher=Engadget | author=Michael Grothaus | date=1 October 2014}}</ref> There are also groups on Facebook and Reddit.<ref name=pimpvape/> Members of this emerging subculture often view electronic cigarettes as a safer alternative to smoking<ref name=Hajek2014/> and some even view it as a ].<ref>{{cite journal|last1=Barbeau|first1=Amanda M|last2=Burda|first2=Jennifer|last3=Siegel|first3=Michael|title=Perceived efficacy of e-cigarettes versus nicotine replacement therapy among successful e-cigarette users: a qualitative approach|journal=Addiction Science & Clinical Practice|volume=8|issue=1|year=2013|pages=5|issn=1940-0640|doi=10.1186/1940-0640-8-5|pmid=23497603}}</ref> They tend to use highly ] devices that do not resemble what are known, by some, as "cig-a-likes", or electronic cigarettes that resemble real cigarettes.<ref name=fremonttrib>{{cite news|title=Crutch or cure: issues surround use of e-cigarettes |url=http://fremonttribune.com/news/local/crutch-or-cure-issues-surround-use-of-e-cigarettes/article_0c7c6547-458a-5d2f-8b3c-515f2c1f1c9b.html | work=Fremont Tribune | date=9 November 2013}}</ref> Online forums on modding have grown in the vaping community.<ref name=formsgain>{{cite news|title=CVape life: welcome to the weird world of e-cig evangelists |url=http://www.theverge.com/2014/2/25/5445662/vape-life-welcome-to-the-weird-world-of-e-cig-evangelists |publisher=The Verge | author=Molly Osberg | date=25 February 2014}}</ref> A 2014 editorial stated that e-cigarette companies have a substantial online existence, many seemingly from individual vapers who spend time blogging and tweeting about the e-cigarette products.<ref name=McKee2014/> They also undertake in uncivil online attacks on any person who implies that e-cigarettes are not an innovation.<ref name=McKee2014>{{cite journal|last1=McKee|first1=M.|title=Electronic cigarettes: peering through the smokescreen|journal=Postgraduate Medical Journal|volume=90|issue=1069|year=2014|pages=607–609|issn=0032-5473|url=http://pmj.bmj.com/content/90/1069/607.full.pdf+html|doi=10.1136/postgradmedj-2014-133029|pmid=25294933}}</ref> A 2014 review stated that tobacco and e-cigarette companies interact with consumers for their policy agenda.<!-- <ref name=Grana2014/> --> The companies use websites, social media, and marketing to get consumers involved in opposing bills that include e-cigarettes in smoke-free laws.<!-- <ref name=Grana2014/> --> This is similar to tobacco industry activity going back to the 1980s, showing coordinated 'vapers' like coordinated smokers.<!-- <ref name=Grana2014/> --> It was concluded that the companies used these approaches in Europe to minimize the EU Tobacco Product Directive in October 2013.<ref name=Grana2014/>


=== Addiction ===
Large gatherings of vapers, called vape meets, are happening around the United States which focus around e-cig devices, accessories, and the life style that accompanies them.<ref name=digitaltrends.com/> Vapefest, which started in 2010, is an annual show that goes to different cities.<ref name=pimpvape/> People attending these meetings are usually enthusiasts that use specialized, community-made products that are not found in typical places like ] or ].<ref name=digitaltrends.com/> These products are mostly available online or in dedicated "vape" storefronts where mainstream e-cigarettes brands from the ] and larger e-cig manufacturers are not available.<ref>{{cite news | url=http://www.wsj.com/articles/vaporizers-are-the-new-draw-in-e-cigarettes-1401378596 | title='Vaporizers' Are the New Draw in E-Cigarettes | author=Mike Esterl | publisher='']'' | date=29 May 2014}}</ref> {{Asof|2014}}, e-cigarettes are more available in retail stores in the U.S. in places with low tax and smoking ban regulations.<ref name=RoseBarker2014>{{cite journal|last1=Rose|first1=S. W.|last2=Barker|first2=D. C.|last3=D'Angelo|first3=H.|last4=Khan|first4=T.|last5=Huang|first5=J.|last6=Chaloupka|first6=F. J.|last7=Ribisl|first7=K. M.|title=The availability of electronic cigarettes in US retail outlets, 2012: results of two national studies|journal=Tobacco Control|volume=23|issue=Supplement 3|year=2014|pages=iii10–iii16|issn=0964-4563|doi=10.1136/tobaccocontrol-2013-051461|pmid=24935892}}</ref>
{{Further|Effects of electronic cigarettes on human brain development}}


<!-- Nicotine info -->
A growing subclass of vapers called "cloud-chasers" assemble their atomizers in such a way that can produce extremely large amounts of vapor by using heating coils of less than 1 ohm.<ref name=CloudChasers>{{cite news|title=The Cloud Chasers |url=http://vapenewsmagazine.com/february-2014/vapeview-the-cloud-chasers | date=29 January 2014}}</ref> This practice is known as "cloud-chasing". By using a coil at less that 1 ohm the batteries of PVs are stressed considerably more than what could be considered regular use and could represent a risk of dangerous battery failures.<ref name=vaporizers-explainer>{{cite news|title=What you need to know about vaporizers |url=http://www.engadget.com/2014/05/23/vaporizers-explainer/ |publisher=Engadget | author=Sean Cooper | date=23 May 2014}}</ref> As vaping comes under more and more scrutiny, some members of the vaping community have voiced their concerns about cloud-chasing claiming the practice gives vapers a bad reputation when doing it in public.<ref>{{cite news | url=http://www.newsweek.com/veteran-e-cigarette-users-fret-cloud-chasers-give-them-bad-name-238978 | title=Veteran E-Cigarette Users Fret 'Cloud Chasers' Give Them a Bad Name | author= Victoria Bekiempis | publisher='']'' | date=1 April 2015}}</ref> The Oxford Dictionaries' ] for 2014 is 'vape'.<ref name=Fallon2014>{{cite news|first=Claire|last=Fallon|title='Vape' Is Oxford Dictionaries' Word Of The Year|url=http://www.huffingtonpost.com/2014/11/18/vape-word-of-year_n_6178102.html|publisher=The Huffington Post|date=November 19, 2014|accessdate=}}</ref>
Nicotine, a key ingredient<ref name=KaisarPrasad2016>{{cite journal|last1=Kaisar|first1=Mohammad Abul|last2=Prasad|first2=Shikha|last3=Liles|first3=Tylor|last4=Cucullo|first4=Luca|title=A Decade of e-Cigarettes: Limited Research & Unresolved Safety Concerns|journal=Toxicology|volume=365|pages=67–75|year=2016|issn=0300-483X|doi=10.1016/j.tox.2016.07.020|pmc=4993660|pmid=27477296|bibcode=2016Toxgy.365...67K }}</ref> in most e-liquids,{{#tag:ref|Since 2016 the US ] (US FDA) regulated e-cigarettes under the classification of tobacco products and labeled them as electronic nicotine delivery systems.<ref name=CUMSH2018/> A 2018 report commissioned by the US FDA decided to use the term e-cigarettes, indicating that for some use e-liquids containing no nicotine.<ref name=CUMSH2018>{{cite web|url=https://www.mailman.columbia.edu/public-health-now/news/experts-clear-air-e-cigarettes |title=Experts Clear the Air on E-Cigarettes|publisher=]|date=26 January 2018}}</ref>|group=note}}<ref name=Weaver2014/> is well-recognized as one of the most ] substances, as addictive as ] and ].<ref name=JenssenBoykan2019/> Addiction is believed to be a disorder of experience-dependent ].<ref name=Kenny2014>{{cite journal|last1=Kenny|first1=PJ|title=Genetics of Substance Use Disorders|journal=Dialogues Clin Neurosci|volume=16|issue=3|date=September 2014|pages=335–344|doi=10.31887/DCNS.2014.16.3/pkenny|pmc=4214176|pmid=25364284}}</ref> The reinforcing effects of nicotine play a significant role in the beginning and continuing use of the drug.<ref name="D'Souza2015">{{cite journal|last1=D'Souza|first1=Manoranjan S.|title=Glutamatergic transmission in drug reward: implications for drug addiction|journal=Frontiers in Neuroscience|volume=9|pages=404|year=2015|issn=1662-453X|doi=10.3389/fnins.2015.00404|pmc=4633516|pmid=26594139|doi-access=free}}</ref> First-time nicotine users develop a dependence about 32% of the time.<ref name=MacDonald2016>{{cite journal|last1=MacDonald|first1=K|last2=Pappa|first2=K|title=WHY NOT POT?: A Review of the Brain-based Risks of Cannabis|journal=Innov Clin Neurosci |volume=13|issue=3–4|date=April 2016|pages=13–22|pmc=4911936|pmid=27354924}}</ref> Chronic nicotine use involves both ] and ].<ref name=KishiokaKiguchi2014>{{cite journal|last1=Kishioka|first1=Shiroh|last2=Kiguchi|first2=Norikazu|last3=Kobayashi|first3=Yuka|last4=Saika|first4=Fumihiro|title=Nicotine Effects and the Endogenous Opioid System|journal=Journal of Pharmacological Sciences |volume=125|issue=2|year=2014|pages=117–124|issn=1347-8613|doi=10.1254/jphs.14R03CP|pmid=24882143|doi-access=free}}</ref> Nicotine-containing e-cigarette vapor induces addiction-related neurochemical, physiological and behavioral changes.<ref name=HiemstraBals2016>{{cite journal|last1=Hiemstra|first1=Pieter S.|last2=Bals|first2=Robert|title=Basic science of electronic cigarettes: assessment in cell culture and in vivo models |journal=Respiratory Research|volume=17|issue=1|pages=127|year=2016|issn=1465-993X|doi=10.1186/s12931-016-0447-z|pmc=5055681|pmid=27717371 |doi-access=free }}</ref> Nicotine affects neurological, neuromuscular, cardiovascular, respiratory, immunological and gastrointestinal systems.<ref name=LeeFariss2016>{{cite journal|last1=Lee|first1=Peter N.|last2=Fariss|first2=Marc W.|title=A systematic review of possible serious adverse health effects of nicotine replacement therapy|journal=Archives of Toxicology|volume=91|issue=4|year=2016|pages=1565–1594|issn=0340-5761|doi=10.1007/s00204-016-1856-y|pmc=5364244|pmid=27699443}}</ref>


] within the brain's ] occurs as a result of long-term nicotine use, leading to ].<ref name="D'Souza2011">{{cite journal|author1=D'Souza MS |author2=Markou A|title=Neuronal mechanisms underlying development of nicotine dependence: implications for novel smoking-cessation treatments|journal=Addict Sci Clin Pract|volume=6|issue=1|pages=4–16|year=2011|pmc=3188825|pmid=22003417}}</ref> The neurophysiological activities that are the basis of nicotine dependence are intricate.<ref name=JacksonMuldoon2015/> It includes genetic components, age, gender, and the environment.<ref name=JacksonMuldoon2015>{{cite journal|last1=Jackson|first1=K.J. |last2=Muldoon|first2=P.P.|last3=De Biasi|first3=M.|last4=Damaj|first4=M.I.|title=New mechanisms and perspectives in nicotine withdrawal|journal=Neuropharmacology|volume=96|issue=Pt B|year=2015|pages=223–234|issn=0028-3908 |doi=10.1016/j.neuropharm.2014.11.009|pmc=4444410|pmid=25433149}}</ref> Nicotine addiction is a disorder which alters different neural systems such as dopaminergic, glutamatergic, GABAergic, serotoninergic, that take part in reacting to nicotine.<ref name=HadjiconstantinouNeff2011>{{cite journal|last1=Hadjiconstantinou|first1=Maria|last2=Neff|first2=Norton H.|title=Nicotine and endogenous opioids: Neurochemical and pharmacological evidence |journal=Neuropharmacology|volume=60|issue=7–8|year=2011|pages=1209–1220|issn=0028-3908|doi=10.1016/j.neuropharm.2010.11.010|pmid=21108953|s2cid=45539554}}</ref> Long-term nicotine use affects a broad range of genes associated with neurotransmission, signal transduction, and synaptic architecture.<ref name=KorpidenHollander2015/> The ability to quitting smoking is affected by genetic factors, including genetically based differences in the way nicotine is metabolized.<ref name=ChenowethTyndale2017>{{cite journal|last1=Chenoweth|first1=Meghan J.|last2=Tyndale|first2=Rachel F.|title=Pharmacogenetic Optimization of Smoking Cessation Treatment|journal=Trends in Pharmacological Sciences|volume=38|issue=1|year=2017|pages=55–66|issn=0165-6147|doi=10.1016/j.tips.2016.09.006|pmc=5195866|pmid=27712845}}</ref>
===Legal status===
{{main|Legal status of electronic cigarettes}}
The emerging phenomenon of electronic cigarettes has raised concerns among the health community, pharmaceutical industry, health regulators and state governments.<ref name=Saitta2014/> Some jurisdictions are now prohibiting or regulating the use of e-cigarettes in public spaces.


], such as ], are associated with its ability to excite the ] and ] systems.<ref name=DiMatteoPierucci2007>{{cite journal|last1=Di Matteo|first1=Vincenzo|last2=Pierucci |first2=Massimo|last3=Di Giovanni |first3=Giuseppe|last4=Benigno|first4=Arcangelo|last5=Esposito |first5=Ennio|title=The Neurobiological Bases for the Pharmacotherapy of Nicotine Addiction |journal=Current Pharmaceutical Design|volume=13|issue=12|year=2007 |pages=1269–1284|issn=1381-6128 |doi=10.2174/138161207780618920|pmid=17504235}}</ref><br/>''How does the nicotine in e-cigarettes affect the brain''?<ref name=SGUS-2016/> Until about age 25, the brain is still growing.<ref name=SGUS-2016/> Each time a new memory is created or a new skill is learned, stronger connections – or synapses – are built between brain cells.<ref name=SGUS-2016/> Young people's brains build synapses faster than adult brains.<ref name=SGUS-2016/> Because addiction is a form of learning, adolescents can get addicted more easily than adults.<ref name=SGUS-2016/> The nicotine in e-cigarettes and other tobacco products can also prime the adolescent brain for addiction to other drugs such as cocaine.<ref name=SGUS-2016>{{cite web|url=https://e-cigarettes.surgeongeneral.gov/knowtherisks.html#addiction|title=Know The Risks: E-Cigarettes & Young People – Addiction|publisher=Surgeon General of the United States|year=2016}}{{PD-notice}}</ref>|alt=An image of the human brain. The reinforcing effects of addictive drugs, such as nicotine, are associated with their ability to excite the mesolimbic and dopaminergic systems. How does the nicotine in e-cigarettes affect the brain? Until about age 25, the brain is still growing. Each time a new memory is created or a new skill is learned, stronger connections – or synapses – are built between brain cells. Young people's brains build synapses faster than adult brains. Because addiction is a form of learning, adolescents can get addicted more easily than adults. The nicotine in e-cigarettes and other tobacco products can also prime the adolescent brain for addiction to other drugs such as cocaine.]]
Because of the relative novelty of the technology and the possible relationship to tobacco laws and medical drug policies, electronic cigarette legislation and public health investigations are currently pending in many countries.<ref name=Etter2011/> With respect to determining legislation, regulators are examining the limited data at hand on e-cigarettes.<ref name=Rahman2014/> {{Asof|2014}}, they are largely unregulated.<ref name=Rom2014>{{cite journal|last1=Rom|first1=Oren|last2=Pecorelli|first2=Alessandra|last3=Valacchi|first3=Giuseppe|last4=Reznick|first4=Abraham Z.|title=Are E-cigarettes a safe and good alternative to cigarette smoking?|journal=Annals of the New York Academy of Sciences|year=2014|pages=n/a–n/a|issn=00778923|doi=10.1111/nyas.12609|pmid=25557889}}</ref> Current regulations vary widely, from regions with no regulations to others ] the devices entirely.<ref name=Etter2011>{{cite journal|last1=Etter|first1=J. F.|last2=Bullen|first2=C.|last3=Flouris|first3=A. D.|last4=Laugesen|first4=M.|last5=Eissenberg|first5=T.|title=Electronic nicotine delivery systems: a research agenda|journal=Tobacco control|date=May 2011|volume=20|issue=3|pages=243–8|pmid=21415064|doi=10.1136/tc.2010.042168|pmc=3215262}}</ref> For example, some countries such as Brazil, Canada, Singapore, the Seychelles, and Uruguay have banned e-cigarettes.<ref name=Grana2014/> {{Asof|2015}}, e-cigarettes are legal for minors to buy in many states in the U.S.<ref name=England2015>{{cite journal|last1=England|first1=Lucinda J.|last2=Bunnell|first2=Rebecca E.|last3=Pechacek|first3=Terry F.|last4=Tong|first4=Van T.|last5=McAfee|first5=Tim A.|title=Nicotine and the Developing Human|journal=American Journal of Preventive Medicine|year=2015|issn=07493797|doi=10.1016/j.amepre.2015.01.015|pmid=25794473}}</ref> {{Asof|2015}}, since e-cigarettes do not contain tobacco, they are not subject to restrictions from using commercials in the U.S.<ref name=MaloneyCappella2015>{{cite journal|last1=Maloney|first1=Erin K.|last2=Cappella|first2=Joseph N.|title=Does Vaping in E-Cigarette Advertisements Affect Tobacco Smoking Urge, Intentions, and Perceptions in Daily, Intermittent, and Former Smokers?|journal=Health Communication|year=2015|pages=1–10|issn=1041-0236|doi=10.1080/10410236.2014.993496|pmid=25758192}}</ref> E-cigarettes have been listed as "drug delivery devices" in several countries because they contain nicotine, and their advertising has been monetarily restricted until safety and efficacy ]s are conclusive.<ref name=Cervellin2013/> A 2014 review stated that the regulation of these products should be examined in view of the "reported adverse health effects".<ref name=Bekki2014/> E-cigarettes are regulated as a ] in some countries, but are not permitted to be used as a smoking cessation aid.<ref name=Bekki2014>{{cite journal|last1=Bekki|first1=Kanae|last2=Uchiyama|first2=Shigehisa|last3=Ohta|first3=Kazushi|last4=Inaba|first4=Yohei|last5=Nakagome|first5=Hideki|last6=Kunugita|first6=Naoki|title=Carbonyl Compounds Generated from Electronic Cigarettes|journal=International Journal of Environmental Research and Public Health|volume=11|issue=11|year=2014|pages=11192–11200|issn=1660-4601|doi=10.3390/ijerph111111192|pmid=25353061}}</ref>
Nicotine is a ] ]<ref name=BeebeMyers2012>{{cite book|author1=Richard Beebe|author2=Jeff Myers|title=Professional Paramedic, Volume I: Foundations of Paramedic Care |url=https://books.google.com/books?id=bS8KAAAAQBAJ&pg=PA640|date=19 July 2012|publisher=Cengage Learning|isbn=978-1-133-71465-1|pages=640–}}</ref> that binds to and activates ]s in the brain,<ref name=Bullen2014/> which subsequently causes the release of ] and other ]s, such as ], ], ], ], ], ]s,<ref name=BMJ2014>{{cite journal|title=Republished: Nicotine and health|journal=BMJ|volume=349|date=26 November 2014|at=2014.7.0264rep|issn=1756-1833 |doi=10.1136/bmj.2014.7.0264rep|pmid=25428425|s2cid=45426626 |author=Drug Therapeutics Bulletin}}</ref> and several ]s, including ]-derived ] and ].<ref name=RahmanReitz2005>{{cite book |author1=Atta-ur-Rahman |author2=Allen B. Reitz|title=Frontiers in Medicinal Chemistry|url=https://books.google.com/books?id=tCyDoIHToBQC&pg=PA279|date=1 January 2005|publisher=Bentham Science Publishers|isbn=978-1-60805-205-9|pages=279–}}</ref> Corticotropin-releasing factor, Neuropeptide Y, orexins, and norepinephrine are involved in nicotine addiction.<ref name=Bruijnzeel2012>{{cite journal|last1=Bruijnzeel|first1=Adrie W.|title=Tobacco addiction and the dysregulation of brain stress systems|journal=Neuroscience & Biobehavioral Reviews|volume=36|issue=5|year=2012|pages=1418–1441|issn=0149-7634|pmc=3340450 |pmid=22405889|doi=10.1016/j.neubiorev.2012.02.015}}</ref> Continuous exposure to nicotine can cause an increase in the number of nicotinic receptors, which is believed to be a result of receptor ] and subsequent receptor ].<ref name=BMJ2014/>


Long-term exposure to nicotine can also result in downregulation of ].<ref name=AlasmariAl-Rejaie2016>{{cite journal|last1=Alasmari|first1=Fawaz|last2=Al-Rejaie|first2=Salim S. |last3=AlSharari|first3=Shakir D.|last4=Sari|first4=Youssef|title=Targeting glutamate homeostasis for potential treatment of nicotine dependence|journal=Brain Research Bulletin |volume=121|year=2016 |pages=1–8|issn=0361-9230 |doi=10.1016/j.brainresbull.2015.11.010|pmc=4783195 |pmid=26589642}}</ref> Long-term nicotine exposure upregulates cortical nicotinic receptors, but it also lowers the activity of the nicotinic receptors in the cortical vasodilation region.<ref name=UchidaHotta2009/> These effects are not easily understood.<ref name=UchidaHotta2009>{{cite journal |last1=Uchida|first1=Sae|last2=Hotta|first2=Harumi|title=Cerebral Cortical Vasodilatation Mediated by Nicotinic Cholinergic Receptors: Effects of Old Age and of Chronic Nicotine Exposure|journal=Biological & Pharmaceutical Bulletin|volume=32|issue=3 |year=2009|pages=341–344|issn=0918-6158|pmid=19252275 |doi=10.1248/bpb.32.341|doi-access=free}}</ref> With constant use of nicotine, ] occurs at least partially as a result of the development of new nicotinic acetylcholine receptors in the brain.<ref name=BMJ2014/>
In the fall of 2013, the electronic cigarette industry ran "a determined lobbying campaign, marrying corporate interests in a fledgling but fast-growing industry with voices elicited from the general public" to defeat proposed European legislation to regulate e-cigarettes like medical devices.<ref name=Higgins2013>{{cite news|author=Andrew Higgins|title=Aided by Army of 'Vapers', E-Cigarette Industry Woos and Wins Europe|url=http://www.nytimes.com/2013/11/10/world/europe/aided-by-army-of-vapers-e-cigarette-industry-woos-and-wins-europe.html|accessdate=22 November 2014|publisher=The New York Times|date=9 November 2013}}</ref> Pharmaceutical manufacturers GlaxoSmithKline and Johnson & Johnson have lobbied the US government, the FDA, and the EU parliament for stricter regulation of e-cigarettes which compete with their products ] gum and ]es.<ref name=Kitamura2014>{{cite news|author1=Makiko Kitamura|title=Glaxo Memo Shows Drug Industry Lobbying on E-Cigarettes|url=http://www.bloomberg.com/news/2014-02-19/glaxo-memo-shows-drug-industry-lobbying-on-e-cigarettes.html|accessdate=22 November 2014|publisher=Bloomberg News|date=19 February 2014}}</ref>


After several months of nicotine abstinence, the number of receptors go back to normal.<ref name=Bullen2014/> The extent to which alterations in the brain caused by nicotine use are reversible is not fully understood.<ref name="KorpidenHollander2015">{{cite journal |last1=Korpi |first1=E. R. |last2=den Hollander |first2=B. |last3=Farooq |first3=U. |last4=Vashchinkina |first4=E. |last5=Rajkumar |first5=R. |last6=Nutt |first6=D. J. |last7=Hyytia |first7=P. |last8=Dawe |first8=G. S. |title=Mechanisms of Action and Persistent Neuroplasticity by Drugs of Abuse|journal=Pharmacological Reviews|volume=67|issue=4 |year=2015|pages=872–1004|issn=1521-0081 |doi=10.1124/pr.115.010967|pmid=26403687|doi-access=free}}</ref> Nicotine also stimulates nicotinic acetylcholine receptors in the ], resulting in increased levels of ] and ].<ref name=BMJ2014/> Its physiological effects stem from the stimulation of nicotinic acetylcholine receptors, which are located throughout the ] and ]s.{{sfn|SGUS|2014|p=111}}
In February 2014 the European Parliament passed regulations requiring standardization and quality control for liquids and vaporizers, disclosure of ingredients in liquids, and child-proofing and tamper-proofing for liquid packaging.<ref name=EURegs2014>{{cite web | url=http://europa.eu/rapid/press-release_MEMO-14-134_en.htm Memo/14/134 | title=Questions & Answers: New rules for tobacco products| publisher=European Commission | date=26 February 2014}}</ref><ref>{{cite news | url=http://time.com/10290/europe-sets-new-rules-for-e-cigs-while-the-u-s-drags-its-feet/ | title=Europe Sets New Rules for E-Cigs While the U.S. Drags Its Feet | author=Eliza Gray | publisher=''Time'' (magazine) | date=27 February 2014}}</ref>


When nicotine intake stops, the upregulated nicotinic acetylcholine receptors induce ].<ref name=Bullen2014/> These symptoms can include cravings for nicotine, anger, irritability, anxiety, depression, impatience, trouble sleeping, restlessness, hunger, weight gain, and difficulty concentrating.<ref name=Martin2016>{{cite web|publisher=Medline Plus |title=Nicotine and Tobacco|author1=Laura J. Martin |author2=David Zieve|author3=Isla Ogilvie|date=7 June 2016|url=https://www.nlm.nih.gov/medlineplus/ency/article/000953.htm}}</ref> When trying to quit smoking with vaping a base containing nicotine, symptoms of withdrawal can include irritability, restlessness, poor concentration, anxiety, depression, and hunger.<ref name=KhoudigianDevji2016/> The changes in the brain cause a nicotine user to feel abnormal when not using nicotine.<ref name=NIDA2007/> In order to feel normal, the user has to keep his or her body supplied with nicotine.<ref name=NIDA2007>{{cite web|url=https://www.drugabuse.gov/publications/brain-power/grades-6-9/legal-doesn%27t-mean-harmless-module-2/background|title=Nicotine|publisher=National Institute on Drug Abuse|date=June 2007 |access-date=2 June 2019|url-status=dead|archive-date=11 June 2019|archive-url=https://web.archive.org/web/20190611224353/https://www.drugabuse.gov/publications/brain-power/grades-6-9/legal-doesn%27t-mean-harmless-module-2/background}}{{PD-notice}}</ref> E-cigarettes may reduce cigarette craving and withdrawal symptoms.<ref name=ShahabBrose2013>{{cite journal|last1=Shahab |first1=Lion|last2=Brose|first2=Leonie S.|last3=West|first3=Robert|title=Novel Delivery Systems for Nicotine Replacement Therapy as an Aid to Smoking Cessation and for Harm Reduction: Rationale, and Evidence for Advantages over Existing Systems|journal=CNS Drugs|volume=27 |issue=12|year=2013|pages=1007–1019|issn=1172-7047|doi=10.1007/s40263-013-0116-4|pmid=24114587 |s2cid=207486096}}</ref>
In April 2014 the US FDA published proposed regulations for e-cigarettes along similar lines.<ref name=FederalRegister2014>{{cite web|url=https://www.federalregister.gov/articles/2014/04/25/2014-09491/deeming-tobacco-products-to-be-subject-to-the-federal-food-drug-and-cosmetic-act-as-amended-by-the|title=Deeming Tobacco Products To Be Subject to the Federal Food, Drug, and Cosmetic Act, as Amended by the Family Smoking Prevention and Tobacco Control Act; Regulations on the Sale and Distribution of Tobacco Products and Required Warning Statements for Tobacco Products|publisher=US FDA Federal Register: A Proposed Rule by the Food and Drug Administration on 04/25/2014}}</ref><ref name=Tavernise2014>{{cite news|url=http://www.nytimes.com/2014/04/24/health/fda-will-propose-new-regulations-for-e-cigarettes.html?_r=0 |title=F.D.A. Will Propose New Regulations for E-Cigarettes |author=Sabrina Tavernise |publisher=The New York Times |date=24 April 2014}}</ref>


It is not clear whether e-cigarette use will decrease or increase overall ],<ref name=Palazzolo2013>{{cite journal|title=Electronic cigarettes and vaping: a new challenge in clinical medicine and public health. A literature review|first1=Dominic L.|last1=Palazzolo|journal=Frontiers in Public Health |volume=1|issue=56|pages=56|date=November 2013|doi=10.3389/fpubh.2013.00056 |pmc=3859972 |pmid=24350225 |doi-access=free}}</ref> but the nicotine content in e-cigarettes is adequate to sustain nicotine dependence.<ref name=Schroeder2014>{{cite journal|last1=Schroeder|first1=M. J.|last2=Hoffman |first2=A. C. |title=Electronic cigarettes and nicotine clinical pharmacology|journal=Tobacco Control|volume=23|issue=Supplement 2|year=2014|pages=ii30–ii35|issn=0964-4563|doi=10.1136/tobaccocontrol-2013-051469 |pmc=3995273 |pmid=24732160}}</ref> Chronic nicotine use causes a broad range of neuroplastic adaptations, making quitting hard to accomplish.<ref name=JacksonMuldoon2015/> A 2015 study found that users vaping non-nicotine e-liquid exhibited signs of dependence.<ref name=BoldSussman2017>{{cite journal|last1=Bold|first1=Krysten W.|last2=Sussman|first2=Steve|last3=O'Malley|first3=Stephanie S.|last4=Grana|first4=Rachel|last5=Foulds|first5=Jonathan |last6=Fishbein|first6=Howard|last7=Krishnan-Sarin|first7=Suchitra|title=Measuring E-cigarette dependence: Initial guidance|journal=Addictive Behaviors|volume=79|pages=213–218|year=2018|issn=0306-4603|pmc=5807200 |pmid=29174664|doi=10.1016/j.addbeh.2017.11.015}}</ref> Experienced users tend to take longer puffs which may result in higher nicotine intake.<ref name=BrelandSpindle2014/> It is difficult to assess the impact of nicotine dependence from e-cigarette use because of the wide range of e-cigarette products.<ref name=Schroeder2014/> The addiction potential of e-cigarettes may have risen because as they have progressed, they have delivered nicotine better.{{sfn|McNeill|2018|p=12}}
In March 2014 Western Australia banned sale of electronics cigarettes.<ref>{{cite web|url=http://www.watoday.com.au/wa-news/ecigarette-message-goes-up-in-smoke-20140626-zsljx.html|title=E-cigarette message goes up in smoke}}</ref>


<!-- General concerns -->
In October 2014 the UK's Advertising Standards Authority changed the regulations on e-cigarette advertising, allowing the devices to appear in television ads from 10 November.<ref>{{cite news | url=http://www.bbc.com/news/uk-29553288 | title=E-cigarettes can appear in TV adverts, watchdog rules | publisher=] | date=9 October 2014}}</ref> The first advert to take advantage of the change, promoting KiK Electronic Cigarettes, aired on the day it came into force.<ref>{{cite news | url=http://www.manchestereveningnews.co.uk/business/business-news/e-cigarette-firm-kik-make-tv-8076005 | title=E-cigarette firm KiK to make TV history | author=Alex Bell | publisher='']'' | date=10 November 2014}}</ref>
A 2015 American Academy of Pediatrics (AAP) policy statement stressed "the potential for these products to addict a new generation of youth to nicotine and reverse more than 50 years of public health gains in tobacco control."<ref name=JenssenWilson2017>{{cite journal|last1=Jenssen|first1=Brian P.|last2=Wilson|first2=Karen M.|title=Tobacco Control and Treatment for the Pediatric Clinician: Practice, Policy, and Research Updates |journal=Academic Pediatrics|volume=17|issue=3|pages=233–242|year=2017|issn=1876-2859|doi=10.1016/j.acap.2016.12.010|pmid=28069410}}</ref> The World Health Organization (WHO) is concerned about starting nicotine use among non-smokers,{{sfn|WHO|2014|p=6}} and the ] said e-cigarettes could maintain nicotine addiction in those who are attempting to quit.<ref name=DrugFacts2014>{{cite web |url=http://www.drugabuse.gov/publications/drugfacts/electronic-cigarettes-e-cigarettes|title=DrugFacts: Electronic Cigarettes (e-Cigarettes)|work=National Institute on Drug Abuse|date=September 2014}}</ref> The limited available data suggests that the likelihood of excessive use of e-cigarettes is smaller than traditional cigarettes.<ref name=Evans2014>{{cite journal|last1=Evans|first1=S. E.|last2=Hoffman|first2=A. C.|title=Electronic cigarettes: abuse liability, topography and subjective effects|journal=Tobacco Control|volume=23|issue=Supplement 2|year=2014|pages=ii23–ii29|issn=0964-4563|doi=10.1136/tobaccocontrol-2013-051489|pmc=3995256|pmid=24732159}}</ref> No long-term studies have been done on the effectiveness of e-cigarettes in treating tobacco addiction,<ref name=Drummond2014/> but some evidence suggests that dual use of e-cigarettes and traditional cigarettes may be associated with greater nicotine dependence.<ref name=Orellana-Barrios2015>{{cite journal|last1=Orellana-Barrios|first1=Menfil A.|last2=Payne|first2=Drew|last3=Mulkey|first3=Zachary|last4=Nugent|first4=Kenneth |title=Electronic cigarettes-a narrative review for clinicians|journal=The American Journal of Medicine|year=2015|volume=128|issue=7|pages=674–81|issn=0002-9343|doi=10.1016/j.amjmed.2015.01.033|pmid=25731134|doi-access=free}}</ref>


<!-- Youth specific -->
===Economics===
There is concern that children may progress from vaping to smoking.{{sfn|WHO|2014|p=6}} Adolescents are likely to underestimate nicotine's addictiveness.{{sfn|Chapman|2015|p=5}} Vulnerability to the brain-modifying effects of nicotine, along with youthful experimentation with e-cigarettes, could lead to a lifelong addiction.<ref name=Schraufnagel2015/> A long-term nicotine addiction from using a vape may result in using other tobacco products.<ref>{{cite web|url=http://www.cancer.org/cancer/cancercauses/tobaccocancer/childandteentobaccouse/child-and-teen-tobacco-use-other-types|title=Teens like different forms of tobacco and nicotine|publisher=American Cancer Society|archive-url=https://web.archive.org/web/20150920232939/http://www.cancer.org/cancer/cancercauses/tobaccocancer/childandteentobaccouse/child-and-teen-tobacco-use-other-types|archive-date=20 September 2015}}</ref> The majority of addiction to nicotine starts during youth and young adulthood.<ref name=SinghArrazola2016>{{cite journal|last1=Singh|first1=Tushar|last2=Arrazola|first2=René A.|last3=Corey|first3=Catherine G.|last4=Husten |first4=Corinne G.|last5=Neff|first5=Linda J.|last6=Homa|first6=David M.|last7=King|first7=Brian A.|title=Tobacco Use Among Middle and High School Students — United States, 2011–2015|journal=MMWR. Morbidity and Mortality Weekly Report|volume=65|issue=14|year=2016|pages=361–367|issn=0149-2195|doi=10.15585/mmwr.mm6514a1|pmid=27077789|doi-access=free}}</ref> Adolescents are more likely to become nicotine dependent than adults.<ref name=ChatterjeeAlzghoul2016/>


The adolescent brain seems to be particularly sensitive to neuroplasticity as a result of nicotine.<ref name=KorpidenHollander2015/> Minimal exposure could be enough to produce neuroplastic alterations in the very sensitive adolescent brain.<ref name=KorpidenHollander2015/> A 2014 review found that in studies up to a third of young people who have not tried a traditional cigarette have used e-cigarettes.<ref name=Grana2014/> The degree to which teens are using e-cigarettes in ways the manufacturers did not intend, such as increasing the nicotine delivery, is unknown,<ref name=Durmowicz2014>{{cite journal|last1=Durmowicz|first1=E. L.|title=The impact of electronic cigarettes on the paediatric population|journal=Tobacco Control|volume=23|issue=Supplement 2|year=2014|pages=ii41–ii46|issn=0964-4563|doi=10.1136/tobaccocontrol-2013-051468|pmc=3995262 |pmid=24732163}}</ref> as is the extent to which e-cigarette use may lead to addiction or ] in young people.<ref name=Durmowicz2014/>
Hon Lik, the inventor of the modern electronic cigarette sees the electronic cigarette as comparable to the "digital camera taking over from the analogue camera." He has stated: "My fame will follow the development of the e-cigarette industry. Maybe in 20 or 30 years I will be very famous."<ref name=Hancock2013>{{cite news | url=http://www.foxnews.com/world/2013/10/01/china-e-cigarette-inventor-fights-for-financial-rewards | title=China's e-cigarette inventor fights for financial rewards | author=Tom Hancock | publisher=Fox News Channel | date=1 October 2013}}</ref> Many US and Chinese e-cig manufacturers copied his designs illegally, and as a result Hon Lik did not get the expected financial rewards for his invention (although some US manufacturers have compensated him through out of court settlements).<ref name=Hancock2013/> Hon Lik's 2003 patents were purchased by ] in 2013, for $75 million.<ref name=Hancock2013/>
E-cigarette devices are mostly manufactured in China.<!-- <ref name=Grana2014/> --> E-cigarette brands have been increasing advertising at a fast rate, the aggressive marketing used is similar to that used to sell cigarettes in the 1950s and 1960s.<!-- <ref name=Grana2014/> --> While ] products was banned long ago, television and radio e-cigarette advertising in a number of countries may be indirectly creating a desire for traditional ].<ref name=Grana2014/>


===Positions ===
Tobacco manufacturers initially dismissed electronic cigarettes as a fad; however, the purchase of ] by ] for ]135 million in April 2012 signaled their entry into the market. A national advertising campaign starred ] exhaling a "thick flume" of what the ad describes as 'vapor, not tobacco smoke', exhorting smokers with the message "We are all adults here, it's time to take our freedom back." Jason Healy, founder of blu, called the product "a lifestyle brand for smokers". The ads, occurring against the backdrop of longstanding prohibition of ] on television, were criticized by organizations such as Campaign for Tobacco-Free Kids as undermining anti-tobacco efforts. Cynthia Hallett of Americans for Non-Smokers' Rights described the advertising campaign as attempting to "re-establish a norm that smoking is okay, that smoking is glamorous and acceptable". University of Pennsylvania communications professor Joseph Cappella suggested that the sight of Dorff's exhaled "smoke" would induce tobacco smokers to consume cigarettes, even as the setting of the ad near an ocean was meant to suggest an association of clean air with the nicotine product.<ref>{{cite web|url=http://www.bbc.com/news/magazine-20583902|title=Electronic cigarettes challenge anti-smoking efforts|publisher=BBC|author=Daniel Nasaw|date=2012-12-05}}</ref>
{{Main|Positions of medical organizations on electronic cigarettes}}


<!-- Regulatory (was Legislative, Legal) -->
A sizable share of the e-cigarette business is done on the internet.<ref name=Rom2014/> Approximately 30–50% of total e-cigarettes sales are handled on the internet.<ref name=Rom2014/> A 2014 review stated that e-cigarettes are aggressively promoted, mostly via the internet, as a healthy alternative to smoking.<ref name=Rom2014>{{cite journal|last1=Rom|first1=Oren|last2=Pecorelli|first2=Alessandra|last3=Valacchi|first3=Giuseppe|last4=Reznick|first4=Abraham Z.|title=Are E-cigarettes a safe and good alternative to cigarette smoking?|journal=Annals of the New York Academy of Sciences|year=2014|pages=n/a–n/a|issn=00778923|doi=10.1111/nyas.12609|pmid=25557889}}</ref> E-cigarette retail websites often made non-scientific health claims to consumers in order to sell them products.<ref>{{cite journal |authors=Grana RA, Ling PM |title="Smoking revolution": a content analysis of electronic cigarette retail websites |journal=Am J Prev Med |volume=46 |issue=4 |pages=395–403 |year=2014 |doi=10.1016/j.amepre.2013.12.010 |pmid=24650842}}</ref> According to ], convenience store e-cigarette sales went down for the first time during the four-week period ending on 10 May 2014. This decline is attributed by Wells Fargo analyst Bonnie Herzog to a shift in consumers behavior, buying more specialized devices or what she refers to as "vapor/tank/mods (VTMs)" that are not tracked by Neilsen.<ref>{{cite news | url=http://www.cspnet.com/category-news/tobacco/articles/nielsen-electronic-cigarette-dollar-sales-decline | title=Nielsen: Electronic Cigarette Dollar Sales Decline | author= Melissa Vonder Haar | publisher=''CSP Magazine'' | date=28 May 2014}}</ref> According to Herzog these products, produced and sold by stand alone makers are now (2014) growing 2 times faster than traditional electronic cigarettes marketed by the major players (Lorillard, Logic Technology, NJOY etc...) and account for a third of the 2.2 billion dollar market for vapor products.<ref>{{cite news | url=http://blogs.wsj.com/corporate-intelligence/2014/04/14/are-e-cigarettes-losing-ground-in-the-vapor-market/ | title=Are E-Cigarettes Losing Ground in the Vapor Market? | author=Tom Gara | publisher=''The Wall Street Journal'' | date=14 April 2014}}</ref> There is no evidence that the cigarette brands are selling e-cigarettes as part of a plan to phase out traditional cigarettes, despite some claiming to want to cooperate in "harm reduction".<ref name=Grana2014/>
Because of overlap with tobacco laws and medical drug policies, ] is being debated{{When|date=February 2021}} in many countries.<ref name=KimKabir2016/> The revised EU ] came into effect in May 2016, providing stricter regulations for e-cigarettes.<ref name=BI2016/> In February 2010 the ] ruled against the ]'s seizure of E-Cigarettes as a "drug-device" and in December 2010 the ] confirmed them to be tobacco products which were by then subject to regulation under the 2009 ].<ref name="Sottera_v_FDA">{{cite web |title=Sottera v US Food and Drug Administration |url=https://www.publichealthlawcenter.org/content/sottera-inc-v-us-food-and-drug-administration |publisher=Public Health Law Center |access-date=23 February 2020 |archive-date=23 February 2020 |archive-url=https://web.archive.org/web/20200223235707/https://www.publichealthlawcenter.org/content/sottera-inc-v-us-food-and-drug-administration |url-status=dead }}</ref> In August 2016, the US FDA extended its regulatory power to include e-cigarettes, cigars, and "all other tobacco products".<ref name=FDA-August-2017/> ] companies have{{When|date=February 2021}} greatly increased their ].<ref name=Drummond2014/>


<!-- Scientific community -->
There is concern with some financial analysts that the rapid growth of the e-cigarette market is accelerating the decline of $87 billion outstanding in ].<ref name=WSJ2014>{{cite web | url=http://online.wsj.com/articles/tobacco-bonds-feel-heat-from-e-cigarettes-1403648086 | title=Tobacco Bonds Feel Heat From E-Cigarettes | publisher=WSJ | date=24 June 2014 | accessdate=30 October 2014 | author=Kuriloff, A}}</ref><ref name=YF2014>{{cite web | url=http://finance.yahoo.com/news/e-cigarettes-could-stub-tobacco-110000689.html | title=E-cigarettes could stub out tobacco bonds sooner than thought | publisher=Yahoo! Finance | date=24 June 2014 | accessdate=30 October 2014 | author=Respaut, Robin}}</ref> States with large populations, such as New York and California, are affected to a greater degree than others.<ref name=YF2014/>
The ] in US and Europe are primarily concerned with their possible effect on ].<ref name=Gualano2015>{{cite journal|last1=Gualano|first1=Maria Rosaria|last2=Passi |first2=Stefano |last3=Bert|first3=Fabrizio|last4=La Torre|first4=Giuseppe|last5=Scaioli|first5=Giacomo|last6=Siliquini|first6=Roberta|title=Electronic cigarettes: assessing the efficacy and the adverse effects through a systematic review of published studies|journal=Journal of Public Health|volume=37|issue=3|date=September 2015|pages=488–497|issn=1741-3842|doi=10.1093/pubmed/fdu055|pmid=25108741|doi-access=free}}</ref> There is concern among public health experts that e-cigarettes could renormalize smoking, weaken measures to ],<ref name=HSF2014>{{cite web|title=Heart and Stroke Foundation: E-cigarettes in Canada |url=http://www.heartandstroke.com/site/c.ikIQLcMWJtE/b.9207931/k.D09C/Heart_and_Stroke_Foundation_Ecigarettes_in_Canada.htm|publisher=Heart and Stroke Foundation|date=September 2014|archive-url=https://web.archive.org/web/20141006173717/http://www.heartandstroke.com/site/c.ikIQLcMWJtE/b.9207931/k.D09C/Heart_and_Stroke_Foundation_Ecigarettes_in_Canada.htm|archive-date=6 October 2014|url-status=dead}}</ref> and serve as a gateway for smoking among young people.<ref name=WLF2014/> The public health community is divided over whether to support e-cigarettes, because their safety and efficacy for ] is unclear.<ref name=FranckFilion2016>{{cite journal|last1=Franck|first1=Caroline|last2=Filion|first2=Kristian B.|last3=Kimmelman|first3=Jonathan|last4=Grad|first4=Roland|last5=Eisenberg|first5=Mark J.|title=Ethical considerations of e-cigarette use for tobacco harm reduction|journal=Respiratory Research|volume=17|issue=1|pages=53|year=2016|issn=1465-993X|doi=10.1186/s12931-016-0370-3|pmc=4869264|pmid=27184265 |doi-access=free }}{{CC-notice|cc=by4|url=https://respiratory-research.biomedcentral.com/articles/10.1186/s12931-016-0370-3|author(s)=Caroline Franck, Kristian B. Filion, Jonathan Kimmelman, Roland Grad and Mark J. Eisenberg}}</ref> Many in the public health community acknowledge the potential for their quitting smoking and decreasing harm benefits, but there remains a concern over their long-term safety and potential for a new era of users to get addicted to nicotine and then tobacco.<ref name=WLF2014>{{cite web|url=https://www.vitalstrategies.org/press/who-right-to-call-for-e-cigarette-regulation/|title=WHO Right to Call for E-Cigarette Regulation|publisher=World Lung Federation|date=26 August 2014}}</ref> There is concern among tobacco control academics and advocates that prevalent universal vaping "will bring its own distinct but as yet unknown health risks in the same way tobacco smoking did, as a result of chronic exposure", among other things.<ref name=BullenKnight-West2016>{{cite journal|last1=Bullen|first1=Chris|last2=Knight-West|first2=Oliver|title=E-cigarettes for the management of nicotine addiction|journal=Substance Abuse and Rehabilitation|volume=7|date=August 2016|pages=111–118|issn=1179-8467|doi=10.2147/SAR.S94264|pmc=4993405|pmid=27574480 |doi-access=free }}</ref>


<!-- Medical community -->
In the United-States, the vaping community and small businesses fear that the proposed regulations by the FDA (2014) concerning electronic cigarette products will impede innovation.<ref>{{cite news | url=http://finance.yahoo.com/news/e-cigarette-tech-takes-off-080141387.html;_ylt=A0SO80tMewtVqPUA5fJXNyoA;_ylu=X3oDMTEza2JubnJxBGNvbG8DZ3ExBHBvcwMyBHZ0aWQDVklQNTk1XzEEc2VjA3Ny | title=E-cigarette tech takes off as regulation looms | author=Michael Felberbaum | publisher=Yahoo! Finance | date=8 December 2014}}</ref> and will only benefit the tobacco giants and the pharmaceutical industry by creating a financial burden that specialized, independent companies will not be able to afford, driving them out of business.<ref>{{cite news | url=http://motherboard.vice.com/read/the-e-cig-industry-will-choke-on-new-fda-regulations-but-not-big-tobacco | title=The E-Cig Industry Will Choke on New FDA Regulations—Except Big Tobacco | author=Meghan Neal | publisher=Motherboard | date=6 May 2014}}</ref> A 2014 review stated that "these products need to be adequately regulated, primarily to protect users."<ref name=Saitta2014/>
Medical organizations differ in their views about the health implications of vaping.<ref name=FCA2014>{{cite web|url=http://www.fctc.org/images/stories/policy_brief.pdf|title=FCA Policy briefing Electronic Nicotine Delivery Systems|publisher=Framework Convention Alliance on Tobacco Control|date=13–18 October 2014|access-date=2 March 2016|archive-date=6 March 2016|archive-url=https://web.archive.org/web/20160306092109/http://www.fctc.org/images/stories/policy_brief.pdf|url-status=dead}}</ref> There is general agreement that e-cigarettes expose users to fewer ]s than ]s.<ref name=Hartmann-BoyceMcRobbie2016/> Some healthcare groups and policy makers have hesitated to recommend e-cigarettes for quitting smoking, because of limited evidence of effectiveness and safety.<ref name=Hartmann-BoyceMcRobbie2016/> Some have advocated bans on e-cigarette sales and others have suggested that e-cigarettes may be regulated as ] but with less nicotine content or be regulated as a ].<ref name=McRobbieBullen2014/>


A 2019 ] (WHO) report found that the ] "does not support the tobacco industry's claim that these products are less harmful relative to conventional tobacco products" and that there is insufficient evidence to support vaping as a smoking cessation tool.<ref>{{cite report |author=World Health Organization |year=2019 |section=Offer help to quit tobacco use |section-url=https://apps.who.int/iris/handle/10665/326043 |title=WHO report on the global tobacco epidemic, 2019 |publisher=World Health Organization |isbn=9789241516204}}</ref><ref>{{cite report |author=WHO Study Group on Tobacco Product Regulation |title=Report on the Scientific Basis of Tobacco Product Regulation: Fifth Report of a WHO Study Group |date=2015 |series=WHO Technical Report Series |volume=989 |publisher=World Health Organization |location=Geneva |isbn=9789240693807 |url=https://apps.who.int/iris/rest/bitstreams/715269/retrieve |access-date=14 November 2022}}</ref><ref name="Farber2021_ATS">{{cite journal |last1=Farber |first1=Harold J. |last2=Conrado Pacheco Gallego |first2=Manuel |last3=Galiatsatos |first3=Panagis |last4=Folan |first4=Patricia |last5=Lamphere |first5=Thomas |last6=Pakhale |first6=Smita |title=Harms of Electronic Cigarettes: What the Healthcare Provider Needs to Know |journal=Annals of the American Thoracic Society |date=1 April 2021 |volume=18 |issue=4 |pages=567–572 |doi=10.1513/AnnalsATS.202009-1113CME |pmid=33284731 |s2cid=227948907 |issn=2329-6933}}</ref> Healthcare organizations in the UK (including the ] and ]) have encouraged smokers to switch to e-cigarettes or other nicotine replacements if they cannot quit, as this would potentially save millions of lives.<ref name="RCP_report">{{cite web |last1=Royal College of Physicians |title=Nicotine Without Smoke -- Tobacco Harm Reduction |url=https://www.rcplondon.ac.uk/file/3563/download?token=Mu0K_ZR0 |access-date=30 September 2020 |pages=125 |quote=Use of nicotine alone, in the doses used by smokers, represents little if any hazard to the user.}}</ref><ref name=PHE2015>{{cite web |url=https://www.gov.uk/government/news/e-cigarettes-an-emerging-public-health-consensus|title=E-cigarettes: an emerging public health consensus |publisher=Public Health England|location=UK|date=15 September 2015}}</ref> The ],{{refn|group=note|"The ACS does not recommend the use of e-cigarettes as a cessation method. No e-cigarette has been approved by the Food and Drug Administration (FDA) as a safe and effective cessation product. The long-term risks of exclusive use of e-cigarettes are not fully known but evidence is accumulating that e-cigarette use has negative effects on the cardiovascular system and lungs. Without immediate measures to stop epidemic use of these products, the long-term adverse health effects will increase."<ref>{{cite web |title=Position Statement on Electronic Cigarettes |publisher=American Cancer Society |date=19 November 2019 |url=https://www.cancer.org/healthy/stay-away-from-tobacco/e-cigarettes-vaping/e-cigarette-position-statement.html |access-date=15 November 2022}}</ref>}} ],{{refn|group=note|"Companies should not be able to claim that e-cigarettes are a cessation aid unless they are approved by the FDA for that purpose...There is not yet enough evidence for clinicians to counsel their patients who are using combustible tobacco products to use e-cigarettes as a primary cessation aid. The association will continue to monitor the evidence concerning e-cigarettes as cessation devices to determine whether they might be integrated into comprehensive cessation strategies. For patients with existing cardiovascular disease and stroke, or at risk of a cardiovascular disease event, intensive cessation counseling should be offered as soon as possible."<ref name=Bhatnagar2014>{{cite journal |last1=Bhatnagar |first1=Aruni |last2=Whitsel |first2=Laurie P. |last3=Ribisl |first3=Kurt M. |last4=Bullen |first4=Chris |last5=Chaloupka |first5=Frank |last6=Piano |first6=Mariann R. |last7=Robertson |first7=Rose Marie |last8=McAuley |first8=Timothy |last9=Goff |first9=David |last10=Benowitz |first10=Neal |title=Electronic Cigarettes: A Policy Statement From the American Heart Association |journal=Circulation |date=14 October 2014 |volume=130 |issue=16 |pages=1418–1436 |doi=10.1161/CIR.0000000000000107 |doi-access=free |pmid=25156991 |pmc=7643636 |orig-year=Published online 24 August 2014}}</ref>}} and the ] have cautioned that accumulating evidence indicates e-cigarettes may have negative effects on the heart and lungs and should not be used to quit smoking without sufficient evidence that they are safe and effective.<ref name=SGUSReport2016/>
==Related technologies==
There are other technologies currently under development that seek to deliver nicotine for oral inhalation in an effort to mimic both the ritualistic and behavioral aspects of traditional cigarettes.


In 2016, the US ] (US FDA) stated that "Although ENDS may potentially provide cessation benefits to individual smokers, no ENDS have been approved as effective cessation aids."<ref name="FDA2016">{{cite journal|title=Deeming Tobacco Products To Be Subject to the Federal Food, Drug, and Cosmetic Act, as Amended by the Family Smoking Prevention and Tobacco Control Act; Restrictions on the Sale and Distribution of Tobacco Products and Required Warning Statements for Tobacco Products |journal=Federal Register|volume=81 |issue=90|pages=28974–29106|date=10 May 2016|publisher=United States Food and Drug Administration|url=https://www.federalregister.gov/articles/2016/05/10/2016-10685/deeming-tobacco-products-to-be-subject-to-the-federal-food-drug-and-cosmetic-act-as-amended-by-the}}</ref> In 2019 the ] stated that "The long-term effects of ECIG use are unknown, and there is therefore no evidence that ECIGs are safer than tobacco in the long term"<ref name=BalsBoyd2019/> and that "he tobacco harm reduction strategy is based on well-meaning but incorrect or undocumented claims or assumptions."<ref name="Pisinger2019ERS">{{cite journal |last1=Pisinger |first1=Charlotta |last2=Dagli |first2=Elif |last3=Filippidis |first3=Filippos T. |last4=Hedman |first4=Linnea |last5=Janson |first5=Christer |last6=Loukides |first6=Stelios |last7=Ravara |first7=Sofia |last8=Saraiva |first8=Isabel |last9=Vestbo |first9=Jørgen |title=ERS and tobacco harm reduction |journal=European Respiratory Journal |date=December 2019 |volume=54 |issue=6 |pages=1902009 |doi=10.1183/13993003.02009-2019|pmid=31801824 |s2cid=208642811|hdl=10044/1/75851 |hdl-access=free }}</ref><ref name="Farber2021_ATS"/> Following hundreds of possible cases of severe ] and five confirmed deaths associated with vaping in the US, the ] stated on 6 September 2019 that people should consider not using vaping products while their investigation is ongoing.<ref>{{cite web |author=((CDC's Office on Smoking and Health)) |date=3 August 2021 |title=Smoking and Tobacco Use; Electronic Cigarettes |website=Centers for Disease Control and Prevention |url=https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html}}</ref>
], through their subsidiary Nicoventures Limited, licensed a nicotine delivery system based on existing asthma ] technology from UK-based healthcare company ].<ref>{{cite news | url=http://www.tobaccojournal.com/BAT_unit_to_market__innovative__nicotine_inhaler.50583.0.html | title=BAT unit to market nicotine inhaler | publisher=Tobacco Journal International | date=2011}}</ref> In September 2014 a product based on this - named Voke - obtained approval from the United Kingdom's Medicines and Healthcare Products Regulatory Agency.<ref name=FTVoke>{{cite web|last1=Financial Times|title=British American Tobacco nicotine inhaler wins regulatory approval|url=http://www.ft.com/cms/s/0/ecff7448-3a86-11e4-bd08-00144feabdc0.html|accessdate=18 September 2014}}</ref>


== History ==
] (PMI) bought the rights to a nicotine ] technology developed by Jed Rose at Duke University.<ref>{{cite web|url=http://www.pmi.com/eng/media_center/press_releases/pages/201105261249.aspx |title=News Release: Philip Morris International (PMI) Enters into a Patent Purchase Agreement of New Technology with the Potential to Reduce the Harm of Smoking |publisher=Philip Morris International |date=26 May 2011 |accessdate=27 August 2013}}</ref> The technology is based on the chemical reaction between nicotine acid and a base, which produces an inhalable nicotine pyruvate vapor.<ref>{{cite web|url=http://esciencenews.com/articles/2010/02/27/new.smoking.cessation.therapy.proves.promising |title=New smoking cessation therapy proves promising |publisher=Esciencenews.com |date=27 February 2010 |accessdate=27 August 2013}}</ref>


It is commonly stated that the modern e-cigarette was invented in 2003 by Chinese pharmacist ], but tobacco companies had been developing nicotine aerosol generation devices since as early as 1963.<ref name="DutraGrana2016">{{cite journal|last1=Dutra|first1=Lauren M|last2=Grana|first2=Rachel|last3=Glantz|first3=Stanton A|year=2016|title=Philip Morris research on precursors to the modern e-cigarette since 1990|journal=Tobacco Control|volume=26|issue=e2|pages=tobaccocontrol–2016–053406|doi=10.1136/tobaccocontrol-2016-053406|issn=0964-4563|pmc=5432409|pmid=27852893}}</ref>
] is a heated tobacco product marketed under the brand ] by PMI.<ref>{{cite news|author1=Harriet Hernando|title=Now it's the Marlboro HeatStick: Cigarette maker Philip Morris to sell new product that heats tobacco rather than burning it|url=http://www.dailymail.co.uk/news/article-2671505/Philip-Morris-Intl-sell-Marlboro-HeatSticks.html|publisher=Mail Online|date=June 26, 2014}}</ref>

===Early prototypes and barriers to entry: 1920s–1990s===
In 1927, Joseph Robinson applied for a patent for an electronic vaporizer to be used with medicinal compounds.<ref name=Sharma2018>{{cite news|url=https://www.techpluto.com/a-modern-device-with-an-illustrious-history/|title=A Modern Device with an Illustrious History|publisher=TechPluto|author=Prashant Sharma|date=6 November 2015}}</ref> The patent was approved in 1930 but the device was never marketed.<ref name=CASAA2016>{{cite news|url=http://www.casaa.org/historical-timeline-of-electronic-cigarettes/|title=A Historical Timeline of Electronic Cigarettes|publisher=The Consumer Advocates for Smoke-free Alternatives Association|year=2016}}</ref> In 1930, the ] reported a patent stating, "for holding medicinal compounds which are electrically or otherwise heated to produce vapors for inhalation."<ref name="FarsalinosGillman2016">{{cite book |last1=Farsalinos |first1=Konstantinos E. |url=https://books.google.com/books?id=j20kDAAAQBAJ |title=Analytical Assessment of e-Cigarettes: From Contents to Chemical and Particle Exposure Profiles |last2=Gillman |first2=I. Gene |last3=Hecht |first3=Stephen S. |last4=Polosa |first4=Riccardo |last5=Thornburg |first5=Jonathan |date=16 November 2016 |publisher=Elsevier Science |isbn=978-0-12-811242-7 |page=1 |author-link4=Riccardo Polosa}}</ref> In 1934 and 1936, further similar patents were applied for.<ref name=FarsalinosGillman2016/>

The earliest e-cigarette can be traced to American Herbert A. Gilbert.<ref>{{cite news|url=http://www.salon.com/2014/12/07/americas_vaping_revolution_how_suspicious_should_we_really_be_of_the_e_cigarette_craze|title=America's vaping revolution: How suspicious should we really be of the e-cigarette craze?|work=]|author=Noah Charney|date=7 December 2014}}</ref> In 1963, Gilbert applied for a patent for "a smokeless non-tobacco cigarette" that involved "replacing burning tobacco and paper with heated, moist, flavored air".<ref>{{cite web|url=https://www.google.com/patents?id=RjlUAAAAEBAJ&printsec=abstract&zoom=4&source=gbs_overview_r&cad=0#v=onepage&q&f=false|archive-url=https://web.archive.org/web/20111012190130/http://www.google.com/patents?id=RjlUAAAAEBAJ&printsec=abstract&zoom=4&source=gbs_overview_r&cad=0#v=onepage&q&f=false|url-status=dead|archive-date=12 October 2011|title=US Patent 3200819. Smokeless non-tobacco cigarette|date=17 August 1965}}</ref><ref name=Bellis2015/> This device produced flavored steam without nicotine.<ref name=Bellis2015/> The patent was granted in 1965.<ref name=PH2014>{{cite news|url=https://www.economist.com/blogs/schumpeter/2014/03/e-cigarette-patent-wars|title=A case of the vapers|publisher=]|author=P.H.|date=17 March 2014}}</ref> Gilbert's invention was ahead of its time.<ref name=Beck2014>{{cite news|url=https://www.theatlantic.com/health/archive/2014/06/schrodingers-cigarette-is-electronic-safer/372671/|title=Schrödinger's Cigarette: Is Electronic Safer?|work=The Atlantic|author=Julie Beck|date=13 June 2014}}</ref> However, it received little attention<ref name=Millstein2009>{{cite news|url=https://timeline.com/stories/e-cigarettes-vape-ban-health-nicotine-smoking|title=The Push to Ban E-Cigarettes: Where's the Proof?|last1=Millstein|first1=Seth|work=TimeLine|date=25 April 2009|url-status=dead|archive-url=https://web.archive.org/web/20150702161454/https://timeline.com/stories/e-cigarettes-vape-ban-health-nicotine-smoking|archive-date=2 July 2015}}</ref> and was never commercialized<ref name=Bellis2015>{{cite web|url=http://inventors.about.com/od/estartinventions/a/Electronic-Cigarettes.htm|title=Who Invented Electronic Cigarettes?|publisher=About.com|author=Mary Bellis|year=2015|access-date=21 September 2013|archive-date=1 August 2022|archive-url=https://web.archive.org/web/20220801004411/https://www.thoughtco.com/famous-inventions-4133301|url-status=dead}}</ref> because smoking was still fashionable at that time.<ref>{{cite news|url=http://www.walesonline.co.uk/special-features/electronic-cigarette-sales-rise-1817925|title=Electronic Cigarette Sales on the Rise|publisher=]|date=24 August 2011}}</ref> Gilbert said in 2013 that today's electric cigarettes follow the basic design set forth in his original patent.<ref name=PH2014/>

The Favor cigarette, introduced in 1986 by public company Advanced Tobacco Products, was another early noncombustible product promoted as an alternative nicotine-containing tobacco product.<ref name=SGUSReport2016/> Favor was conceptualized by Phil Ray, one of the founders of ] and inventors of the microprocessor. Development started in 1979 by Phil Ray and Norman Jacobson.<ref>{{cite web | url=https://www.ecigarettedirect.co.uk/ashtray-blog/2014/06/favor-cigarette-interview-dr-norman-jacobson.html | publisher=Ashtray Blog | title=Vaping 1970's Style: An Interview with One of the Pioneers | first=James | last=Dunworth | date=June 2014 | access-date=27 June 2021}}</ref> Favor was a "plastic, smoke-free product shaped and colored like a conventional cigarette that contained a filter paper soaked with liquid nicotine so users could draw a small dose by inhaling. There was no electricity, combustion, or smoke; it delivered only nicotine."<ref>{{cite thesis |last=MCGonegal |first=Matthew |date=November 2019 |title="Can I rip your Juul?" |type=Bsc |chapter= |publisher=University of Oregon | url=https://scholarsbank.uoregon.edu/xmlui/handle/1794/25781 | access-date=27 June 2021}}</ref>

Favor cigarettes were sold in California and several Southwestern states, marketed as "an alternative to smokers, and only to smokers, to use where smoking is unacceptable or prohibited."<ref>{{cite news | url=https://www.chicagotribune.com/news/ct-xpm-1986-05-27-8602070938-story.html | title=Company sniffs profits from a smokeless cigarette | newspaper=] | date=27 May 1986 | access-date=27 June 2021}}</ref> In 1987, the ] exercised jurisdiction over products analogous to E-Cigarettes.<ref>{{cite web | title=FDA's Brief in Opposition to Motion for Preliminary Injunction | date=11 May 2009 | url=https://www.fda.gov/media/77379/download | publisher=Food and Drug Administration}}</ref> Advanced Tobacco Products never challenged the Warning Letter and ceased all distribution of Favor.<ref>{{cite web | title=Spotlight on Tobacco {{!}} Future Developments in the Regulation of Electronic Nicotine Delivery Systems: Potential Over-the-Counter Pathway | url=https://www.fdli.org/2018/10/spotlight-on-tobacco-future-developments-in-the-regulation-of-electronic-nicotine-delivery-systems-potential-over-the-counter-pathway/ | first1=Azim | last1=Chowdhury | first2=Samuel | last2=Jockel | publisher=Food and Drug Law Institute | series=Update magazine | date=October–November 2018 | access-date=27 June 2021}}</ref> Ray's wife Brenda Coffee coined the term ''vaping''.<ref>{{cite web | url=https://www.1010parkplace.com/a-deadly-addicting-lie/ | first=Brenda | last=Coffee | publisher=1010ParkPlace | title=A deadly addicting lie | date=22 December 2018 | access-date=27 June 2021}}</ref> Philip Morris' division NuMark, launched in 2013 the MarkTen e-cigarette that Philip Morris had been working on since 1990.<ref name="DutraGrana2016" />

===Modern electronic cigarette: 2000s===
Despite these earlier efforts, ], a Chinese pharmacist and inventor, who worked as a research pharmacist for a company producing ] products,<ref name=Demick2009>{{cite news|url=https://www.latimes.com/archives/la-xpm-2009-apr-25-fg-china-cigarettes25-story.html|author=Barbara Demick|title=A high-tech approach to getting a nicotine fix|work=Los Angeles Times|date=25 April 2009}}</ref> is frequently credited with the invention of the modern e-cigarette.<ref name=DutraGrana2016/> Hon quit smoking after his father, also a heavy smoker, died of lung cancer.<ref name=Demick2009/> In 2001, he thought of using a ], ] ]-emitting element to vaporize a pressurized jet of liquid containing nicotine.<ref name=Sridi2013>{{cite web|url=http://www.sciencesetavenir.fr/sante/20131007.OBS0070/i-was-sure-that-the-electronic-cigarette-would-be-welcomed-with-open-arms.html|title=I was sure that the electronic cigarette would be welcomed with open arms|last1=Sridi|first1=Nicolas|publisher=Sciences et Avenir|date=10 July 2013}}</ref> This design creates a smoke-like vapor.<ref name=Demick2009/> Hon said that using resistance heating obtained better results and the difficulty was to scale down the device to a small enough size.<ref name=Sridi2013/> Hon's invention was intended to be an alternative to smoking.<ref name=Sridi2013/> Hon Lik sees the e-cigarette as comparable to the "digital camera taking over from the analogue camera."<ref name=Hancock2013/> Ultimately, Hon Lik did not quit smoking. He is now a dual user, both smoking and vaping.<ref name=Times2021>{{cite news|url=https://www.thetimes.co.uk/article/vape-nation-how-did-britain-end-up-so-hooked-on-e-cigarettes-q5r5vg89s|title=Vape nation: how did Britain end up so hooked on e‑cigarettes?|date=30 October 2021|work=]|last1=Spencer|first1=Ben|last2=Calver|first2=Tom}}</ref>

] e-cigar was first launched in China in 2004.<ref>{{cite news|url=https://www.nbcnews.com/id/29435175/ns/health-addictions/t/e-cigarettes-attracting-attention-scrutiny/#.V7guajZRE5s|archive-url=https://web.archive.org/web/20160306082410/http://www.nbcnews.com/id/29435175/ns/health-addictions/t/e-cigarettes-attracting-attention-scrutiny/#.V7guajZRE5s|url-status=dead|archive-date=6 March 2016|title=E-cigarettes attracting attention — and scrutiny|work=] |agency=Associated Press|date=27 February 2009}}</ref>|alt=Ruyan first-generation electronic cigar.]]
Hon Lik registered a patent for the modern e-cigarette design in 2003.<ref name=Sridi2013/> Hon is credited with developing the first commercially successful electronic cigarette.<ref>{{cite news|url=http://www.japantimes.co.jp/news/2013/10/04/business/chinese-e-cigarette-inventor-fights-for-royalties/#.VWv8ulJI3s1|title=Chinese e-cigarette inventor fights for royalties|work=]|author=Tom Hancock|date=4 October 2013|access-date=1 June 2015|archive-date=1 August 2022|archive-url=https://web.archive.org/web/20220801004413/https://www.japantimes.co.jp/article-expired/#.VWv8ulJI3s1|url-status=dead}}</ref> The e-cigarette was first introduced to the Chinese domestic market in 2004.<ref name=Demick2009/> Many versions made their way to the US, sold mostly over the Internet by small marketing firms.<ref name=Demick2009/> E-cigarettes entered the European market and the US market in 2006 and 2007.<ref name=HiemstraBals2016/> The company that Hon worked for, Golden Dragon Holdings, registered an international patent in November 2007.<ref name=Espacenet2007>{{cite web|url=http://worldwide.espacenet.com/publicationDetails/biblio?CC=US&NR=2007267031&KC=&FT=E&locale=en_EP|title=Electronic Atomization Cigarette |website=Worldwide.espacenet.com|date=22 November 2007}}</ref> The company changed its name to Ruyan (如烟, literally "like smoke"<ref name=Demick2009/>) later the same month,<ref name=CSDStaff2013/> and started exporting its products.<ref name=Demick2009/>

Many US and Chinese e-cigarette makers copied his designs illegally, so Hon has not received much financial reward for his invention (although some US manufacturers have compensated him through out-of-court settlements).<ref name=Hancock2013>{{cite news |url=https://www.foxnews.com/world/chinas-e-cigarette-inventor-fights-for-financial-rewards/ |title=China's e-cigarette inventor fights for financial rewards |author=Tom Hancock|publisher=Fox News Channel|date=1 October 2013}}</ref> Ruyan later changed its company name to ].<ref name=CSDStaff2013>{{cite news |url=http://www.cstoredecisions.com/2013/08/21/dragonite-sells-e-vapor-business-to-itg/#_|title=Dragonite Sells E-Vapor Business To ITG|publisher=Convenient Store Decisions|author=Staff|date=21 August 2013}}</ref> As of 2014, most e-cigarettes used a battery-powered heating element rather than the earlier ultrasonic technology design.<ref name=Bhatnagar2014/>

Initially, their performance did not meet the expectations of users.<ref name=GarnerStevens2014/> The e-cigarette continued to evolve from the first-generation three-part device.<ref name=Bhatnagar2014/> In 2007, British entrepreneurs Umer and Tariq Sheikh invented the cartomizer.<ref name=E2015>{{cite web|url=http://stevevape.com/what-does-the-future-hold-for-vaping-technology/|title=What Does The Future Hold For Vaping Technology?|publisher=Steve K's Vaping World|author=Mike K|date=9 June 2015}}</ref> This is a mechanism that integrates the heating coil into the liquid chamber.<ref name=E2015/> They launched this new device in the UK in 2008 under their Gamucci brand<ref name=Denham2013>{{cite web|url=http://www.cityam.com/article/brothers-who-took-punt-new-market/|title=Brothers who took a punt on a new market|publisher=CityAM|author=Annabel Denham|date=10 June 2013|archive-url=https://web.archive.org/web/20160507042819/http://www.cityam.com/article/brothers-who-took-punt-new-market/|archive-date=7 May 2016|url-status=dead}}</ref> and the design is now widely adopted by most "cigalike" brands.<ref name=Bhatnagar2014/> Other users tinkered with various parts to produce more satisfactory homemade devices, and the hobby of "modding" was born.<ref name=Grothaus2014/> The first mod to replace the e-cigarette's case to accommodate a longer-lasting battery, dubbed the "screwdriver", was developed by Ted and Matt Rogers<ref name=Grothaus2014/> in 2008.<ref name=GarnerStevens2014>{{cite web |url=https://www.coresta.org/sites/default/files/technical_documents/main/ECIG-RefRep_Ecig-History-Operation-Regulation_Feb2014b.pdf|title=A Brief Description of History, Operation and Regulation |last1=Garner|first1=Charles|last2=Stevens|first2=Robert|website=Coresta|date=February 2014|archive-url=https://web.archive.org/web/20160303041105/http://www.coresta.org/Reports/ECIG-RefRep_Ecig-History-Operation-Regulation_Feb2014b.pdf|archive-date=3 March 2016|url-status=dead}}</ref> Other enthusiasts built their own mods to improve functionality or aesthetics.<ref name=Grothaus2014/> When pictures of mods appeared at online vaping forums many people wanted them, so some mod makers produced more for sale.<ref name=Grothaus2014/>

In 2008, a consumer created an e-cigarette called the screwdriver.<ref name=GarnerStevens2014/> The device generated a lot of interest back then, as it let the user to vape for hours at one time.<ref name=Grothaus2014/> The invention led to demand for customizable e-cigarettes, prompting manufacturers to produce devices with interchangeable components that could be selected by the user.<ref name=GarnerStevens2014/> In 2009, Joyetech developed the eGo series<ref name=E2015/> which offered the power of the screwdriver model and a user-activated switch to a wide market.<ref name=GarnerStevens2014/> The clearomizer was invented in 2009.<ref name=E2015/> Originating from the cartomizer design, it contained the wicking material, an e-liquid chamber, and an atomizer coil within a single clear component.<ref name=E2015/> The clearomizer allows the user to monitor the liquid level in the device.<ref name=E2015/> Soon after the clearomizer reached the market, replaceable atomizer coils and variable voltage batteries were introduced.<ref name=E2015/> Clearomizers and eGo batteries became the best-selling customizable e-cigarette components in early 2012.<ref name=GarnerStevens2014/>

===International growth: 2010s – present===
{|class="wikitable" style="float:right; margin-left:0.4em;"
|+Large tobacco companies have acquired some of the e-cigarette companies.<ref name=Orellana-Barrios2015/>
!Tobacco company
!Subsidiary company
!Electronic cigarette
|-
|]
|Fontem Ventures and Dragonite
|Puritane<ref name=Cooke2015/> ]<ref name=Mangan2014/>
|-
|]
|CN Creative and Nicoventures
|Vype<ref name=Cooke2015/>
|-
|]
|]
|]<ref name=Cooke2015/>
|-
| rowspan=2 | ]
|Nu Mark, LLC<ref name=Cooke2015/>
|MarkTen, Green Smoke<ref name=Crook2018>{{cite news|url=https://techcrunch.com/2018/12/20/juul-labs-gets-12-8-billion-investment-from-marlboro-maker-altria-group/|title=Juul Labs gets $12.8 billion investment from Marlboro Maker Altria Group|first=Jordan |last=Crook|work=]|date=20 December 2018}}</ref>{{refn|group=note|Alteria no longer sells e-cigarettes.<ref name=Crook2018/>}}
|-
|Acquired a 35% stake in ].<ref name=Younkman2019>{{cite news|url=https://www.fool.com/investing/2019/11/12/altria-has-a-juul-in-the-rough.aspx|title=Altria Has a Juul in the Rough |last1=Younkman|first1=Jon |work=]|date=12 November 2019}}</ref>
|
|-
|]
|]
|E-lites<ref name=Cooke2015/> ]<ref name=CSN2015/>
|-
|}

International tobacco companies dismissed e-cigarettes as a fad at first.<ref name=Akam2015>{{cite news|url=http://europe.newsweek.com/big-tobacco-fights-back-how-cigarette-kings-bought-vaping-industry-327758|title=Big Tobacco fights back: how the cigarette kings bought the vaping industry|last1=Akam|first1=Simon|work=Newsweek|date=27 May 2015}}</ref> However, recognizing the development of a potential new market sector that could render traditional tobacco products obsolete,<ref>{{Cite news|url=https://www.economist.com/news/business/21586867-regulators-wrestle-e-smokes-tobacco-industry-changing-fast-kodak-moment|title=Kodak moment|newspaper=The Economist |date=28 September 2013}}</ref> they began to produce and market their own brands of e-cigarettes and acquire existing e-cigarette companies.<ref name=Esterl2014>{{cite web |url=https://www.wsj.com/news/articles/SB10001424052702304626804579360552508696542|title=Altria Expands in E-Cigarettes With Green Smoke|author=Mike Esterl|work=The Wall Street Journal|date=3 February 2014}}</ref> They bought the largest e-cigarette companies.<ref name=FranckFilion2016/> ], a prominent US e-cigarette manufacturer, was acquired by ]<ref>{{cite web|url=https://www.cbsnews.com/news/tobacco-companies-bet-on-electronic-cigarettes/|title=Tobacco companies bet on electronic cigarettes|author=Brian Montopoli|work=CBS News|date=11 June 2013}}</ref> for ]135 million in April 2012.<ref name=Nasaw2012/>

] was the first tobacco business to sell e-cigarettes in the UK.<ref name=Manning2013/> They launched the e-cigarette Vype in July 2013,<ref name=Manning2013>{{cite news |url=https://www.independent.co.uk/news/uk/home-news/british-american-tobacco-enters-electronic-cigarette-market-in-britain-with-the-vype-8737286.html|author=Sanchez Manning|title=British American Tobacco enters electronic cigarette market in Britain with the 'Vype'|work=The Independent|date=29 July 2013}}</ref> while ]'s Fontem Ventures acquired the intellectual property owned by Hon Lik through Dragonite International Limited for $US 75 million in 2013 and launched Puritane in partnership with ].<ref>{{cite news|url=https://www.bloomberg.com/news/2013-09-02/imperial-tobacco-agrees-to-acquire-dragonite-s-e-cigarette-unit.html |title=Imperial Tobacco Agrees to Acquire Dragonite's E-Cigarette Unit|last1=Gustafsson|first1=Katarina|work=]|date=2 September 2013}}</ref> On 1 October 2013 Lorillard Inc. acquired another e-cigarette company, this time the UK based company SKYCIG.<ref>{{cite news|url=http://www.bizjournals.com/triad/blog/2013/10/lorillard-acquires-british-e-cig.html|title=Lorillard acquires British e-cig maker for $48.6M|last1=Arcieri |first1=Katie|publisher=]|date=1 October 2013}}</ref> SKY was rebranded as blu.<ref>{{cite news|url=http://www.csnews.com/product-categories/tobacco/lorillard-rebrand-skycig-blu-ecigs?nopaging=1 |title=Lorillard to Rebrand SKYCIG as blu eCigs|work=Convenience Store News|date=27 March 2014}}</ref>

]]]
On 3 February 2014, ] acquired popular e-cigarette brand Green Smoke for $110 million.<ref name="ReutersAltria2014">{{cite news |title=RPT-Fitch: Altria Green Smoke Buy Highlights Industry e-Cig Interest |url=https://www.reuters.com/article/fitch-altria-green-smoke-buy-highlights/rpt-fitch-altria-green-smoke-buy-highlights-industry-e-cig-interest-idUSFit68990920140205 |access-date=13 November 2022 |work=Reuters |date=5 February 2014 |language=en}}</ref> The deal was finalized in April 2014 for $110 million with $20 million in incentive payments.<ref name="FoxBizAltria2016">{{cite news |last1=Egan |first1=Matt |title=Altria Bolsters E-Cigarette Business With $110M Buy of Green Smoke |url=https://www.foxbusiness.com/markets/altria-bolsters-e-cigarette-business-with-110m-buy-of-green-smoke |access-date=13 November 2022 |work=FOXBusiness |date=9 January 2016}}</ref> Altria also markets its own e-cigarette, the MarkTen, while ] has entered the sector with its ] product.<ref name=Esterl2014/> Philip Morris, the world's largest tobacco company, purchased UK's Nicocigs in June 2014.<ref>{{cite news |url=https://www.independent.co.uk/news/business/news/philip-morris-buys-ecigarette-maker-nicocigs-as-it-warns-of-falling-profits-9565087.html|author=Gideon Spanier|title=Philip Morris buys e-cigarette maker Nicocigs as it warns of falling profits|work=The Independent|date=26 June 2014}}</ref> On 30 April 2015, ] bought the US ] e-cigarette brand.<ref name=CSN2015/> Japan Tobacco also bought the UK E-Lites brand in June 2014.<ref name=CSN2015>{{cite news|url=https://csnews.com/japan-tobaccos-global-ambitions-lead-logic-acquisition|title=Japan Tobacco's Global Ambitions Lead to Logic Acquisition |work=Convenience Store News|date=30 April 2015}}</ref> On 15 July 2014, Lorillard sold blu to Imperial Tobacco as part of a deal for $7.1 billion.<ref name=Mangan2014>{{cite news |url=https://www.cnbc.com/2014/07/15/feeling-blu-e-cig-company-spun-off-in-major-tobacco-deal.html|title=Feeling blu? E-cig company spun off in major tobacco deal|first1=Dan |last1=Mangan|publisher=]|date=15 July 2014}}</ref> {{As of|2018}}, 95% of e-cigarettes were made in China.<ref name=JenssenBoykan2019/>

In the UK, where most vaping uses refillable sets and e-liquid, there is now support from the ],<ref>{{Cite web |date=24 November 2021 |title=Using e-cigarettes to stop smoking |url=https://www.nhs.uk/live-well/quit-smoking/using-e-cigarettes-to-stop-smoking/ |access-date=7 April 2022 |website=nhs.uk |language=en}}</ref> and other medical bodies now embrace the use of e-cigarettes as a viable way to quit smoking. This has contributed to record numbers of people vaping, with estimated 3.6 million in 2019, 3.2 million in 2020, rising to 3.6 million in 2021.<ref>{{Cite journal |last=(ASH) |first=Action on Smoking and Health |date=June 2021 |title=Use of e-cigarettes (vapes) among adults in Great Britain. 2021 |url=https://ash.org.uk/wp-content/uploads/2021/06/Use-of-e-cigarettes-vapes-among-adults-in-Great-Britain-2021.pdf |journal=Use of E-cigarettes (Vapes) Among Adults in Great Britain. 2021}}</ref> Current vapers being 2.2 million as of 2024.<ref>{{Cite news |last1=Thomas |first1=Tobi |last2=Health |first2=Tobi Thomas |date=2024-08-11 |title=Number of UK adults who vape reaches record level, report finds |url=https://www.theguardian.com/politics/article/2024/aug/12/number-of-uk-adults-who-vape-reaches-record-level-report-finds#:~:text=The%20proportion%20of%20adults%20who,equivalent%20of%202.2%20million%20people. |access-date=2024-08-22 |work=The Guardian |language=en-GB |issn=0261-3077}}</ref>

== Society and culture ==
{{Redirect-distinguish|Vaper|Vapor}}
Consumers have shown passionate support for e-cigarettes that other nicotine replacement products did not receive.<ref name=Britton2014/> They have a mass appeal that could challenge combustible tobacco's market position.<ref name=Britton2014/>

By 2013, a ] had emerged calling itself "the vaping community".<ref name=Couts2013>{{cite web|url=http://www.digitaltrends.com/features/inside-the-world-of-vapers-the-subculture-that-might-save-smokers-lives/ |title=Inside the world of vapers, the subculture that might save smokers' lives|date=13 May 2013|last1=Couts|first1=Andrew|publisher=]}}</ref><ref>{{cite news|last1=Park |first1=Andy|date=26 August 2013 |url=http://www.sbs.com.au/news/article/2013/06/18/feed-subculture-around-e-cigarettes|title=The Feed: The subculture around e-cigarettes|publisher=]}}</ref> Members often see e-cigarettes as a safer alternative to smoking,<ref name=Hajek2014>{{cite journal|last1=Hajek|first1=P|last2=Etter|first2=JF|last3=Benowitz|first3=N|last4=Eissenberg|first4=T|last5=McRobbie|first5=H|title=Electronic cigarettes: review of use, content, safety, effects on smokers and potential for harm and benefit|journal=Addiction|date=31 July 2014|volume=109|issue=11|pages=1801–1810 |doi=10.1111/add.12659|pmc=4487785|pmid=25078252}}</ref> and some view it as a ].<ref>{{cite journal|last1=Barbeau|first1=Amanda M|last2=Burda|first2=Jennifer|last3=Siegel|first3=Michael |title=Perceived efficacy of e-cigarettes versus nicotine replacement therapy among successful e-cigarette users: a qualitative approach|journal=Addiction Science & Clinical Practice|volume=8|issue=1 |year=2013|pages=5|issn=1940-0640|doi=10.1186/1940-0640-8-5|pmc=3599549|pmid=23497603 |doi-access=free }}</ref> The online forum E-Cig-Reviews.com was one of the first major communities.<ref name=Grothaus2014/> It and other online forums, such as UKVaper.org, were where the hobby of modding started.<ref name=Grothaus2014>{{cite news|title=Trading addictions: the inside story of the e-cig modding scene|author=Michael Grothaus|date=1 October 2014|work=Engadget|url=https://www.engadget.com/2014/10/01/inside-story-e-cig-modding-uk/}}</ref> There are also groups on ] and ].<ref name=Larson2014>{{cite news|author1=Eric Larson|title=Pimp My Vape: The Rise of E-Cigarette Hackers|url=http://mashable.com/2014/01/25/vaping-subculture/|publisher=Mashable|date=25 January 2014}}</ref> Online forums based around modding have grown in the vaping community.<ref name=Osberg2014>{{cite news|title=CVape life: welcome to the weird world of e-cig evangelists|url=https://www.theverge.com/2014/2/25/5445662/vape-life-welcome-to-the-weird-world-of-e-cig-evangelists|work=]|author=Molly Osberg|date=25 February 2014}}</ref>

Vapers embrace activities associated with e-cigarettes and sometimes evangelise for them.<ref name=Sanford2014>{{cite journal|author1=Sanford Z |author2=Goebel L|title=E-cigarettes: an up to date review and discussion of the controversy|journal=W V Med J|volume=110|issue=4|pages=10–5|year=2014|pmid=25322582}}</ref> E-cigarette companies have a substantial online presence, and there are many individual vapers who blog and tweet about e-cigarette related products.<ref name=McKee2014/> A 2014 '']'' editorial said vapers "also engage in grossly offensive online attacks on anyone who has the temerity to suggest that ENDS are anything other than an innovation that can save thousands of lives with no risks".<ref name=McKee2014>{{cite journal|last1=McKee |first1=M.|title=Electronic cigarettes: peering through the smokescreen|journal=Postgraduate Medical Journal|volume=90|issue=1069|year=2014|pages=607–609|issn=0032-5473|doi=10.1136/postgradmedj-2014-133029|pmid=25294933|doi-access=free|url=http://pmj.bmj.com/content/90/1069/607.full.pdf+html}}</ref>

Contempt for ] is part of vaping culture.<ref name=Gara2014>{{cite news|title=Are E-Cigarettes Losing Ground in the Vapor Market?|author=Tom Gara|work=The Wall Street Journal|date=14 April 2014 |url=https://blogs.wsj.com/corporate-intelligence/2014/04/14/are-e-cigarettes-losing-ground-in-the-vapor-market/}}</ref><ref name=Sottile2014>{{cite news|last1=Sottile|first1=Leah|title=The Right to Vape |url=https://www.theatlantic.com/health/archive/2014/10/the-right-to-vape/381145/|work=The Atlantic |date=8 October 2014}}</ref> A 2014 review stated that tobacco and e-cigarette companies interact with consumers for their policy agenda.<ref name=Grana2014/> The companies use websites, social media, and marketing to get consumers involved in opposing bills that include e-cigarettes in smoke-free laws.<ref name=Grana2014/> This is similar to ] activity going back to the 1980s.<ref name=Grana2014/> These approaches were used in Europe to minimize the EU Tobacco Products Directive in October 2013.<ref name=Grana2014/> ] lobbying also influenced the Tobacco Products Directive decision.<ref name=JacobsRobinson2014>{{cite news|last1=Jacobs|first1=Emma|last2=Robinson |first2=Duncan|title=E-cigarettes: no smoke without fear |url=http://www.ft.com/cms/s/2/ed185b54-c5e0-11e3-a7d4-00144feabdc0.html|work=FT Magazine|date=17 April 2014}}</ref> Tobacco companies have worked with organizations conceived to promote e-cigarette use, and these organizations have worked to hamper legislation intended at restricting e-cigarette use.<ref name=Drummond2014/>

].<ref>{{cite news|author=Gavin Haynes|date=22 April 2015 |url=https://www.theguardian.com/society/shortcuts/2015/apr/22/cloud-chasing-competitive-sport-blowing-vape-clouds|title=Daft vapers: the competitive world of e-cigarette smoking|work=The Guardian}}</ref> |alt=E-cigarette user blowing a large cloud of aerosol (vapor). This activity is known as cloud-chasing.]]

Large gatherings of vapers, called vape meets, take place around the US.<ref name=Couts2013/> They focus on e-cigarette devices, accessories, and the lifestyle that accompanies them.<ref name=Couts2013/> Vapefest, which started in 2010, is an annual show hosted by different cities.<ref name=Larson2014/> People attending these meetings are usually enthusiasts that use specialized, community-made products not found in ]s or ].<ref name=Couts2013/> These products are mostly available online or in dedicated "vape" storefronts where mainstream e-cigarettes brands from the tobacco industry and larger e-cig manufacturers are not as popular.<ref>{{cite news|url=https://www.wsj.com/articles/vaporizers-are-the-new-draw-in-e-cigarettes-1401378596|title='Vaporizers' Are the New Draw in E-Cigarettes|author=Mike Esterl|work=The Wall Street Journal|date=29 May 2014}}</ref> Some ]s have a vape bar where patrons can test out different e-liquids and socialize.<ref>{{cite news|url=http://www.dailynebraskan.com/news/generation-v-e-cigarettes-and-vape-bar-aims-to-convert/article_f79f2130-9466-11e3-b3d8-0017a43b2370.html|title=Generation V E-Cigarettes and Vape Bar aims to convert smokers to e-cigarettes|author=Staff|work=]|date=13 February 2014}}</ref> The Electronic Cigarette Convention in North America which started in 2013, is an annual show where companies and consumers meet up.<ref>{{cite news|url=http://www.dailybulletin.com/business/20140904/vaping-convention-coming-to-ontario-convention-center-friday|title=Vaping convention coming to Ontario Convention Center Friday|author=Neil Nisperos|work=]|date=4 September 2014}}</ref>

A subclass of vapers configure their atomizers to produce large amounts of vapor by using low-resistance heating coils.<ref name=Plass2014>{{cite news|url=http://vapenewsmagazine.com/february-2014/vapeview-the-cloud-chasers|title=The Cloud Chasers|author=Mary Plass|publisher=Vape News Magazine|date=29 January 2014}}</ref> This practice is called "]".<ref name=Mosbergenf2014>{{cite news|url=https://huffingtonpost.com/2014/08/05/cloud-chasing-vaping-competition_n_5652528.html|title=This Man Is An Athlete In The Sport Of 'Cloud Chasing'|author=Dominique Mosbergen|work=HuffPost|date=5 August 2014}}</ref> By using a coil with very low resistance, the batteries are stressed to a potentially unsafe extent.<ref name=Cooper2014/> This could present a risk of dangerous battery failures.<ref name=Cooper2014>{{cite news|title=What you need to know about vaporizers|url=https://www.engadget.com/2014/05/23/vaporizers-explainer/|work=Engadget|author=Sean Cooper|date=23 May 2014}}</ref> As vaping comes under increased scrutiny, some members of the vaping community have voiced their concerns about cloud-chasing, stating the practice gives vapers a bad reputation when doing it in public.<ref>{{cite news|url=http://www.newsweek.com/veteran-e-cigarette-users-fret-cloud-chasers-give-them-bad-name-238978|title=Veteran E-Cigarette Users Fret 'Cloud Chasers' Give Them a Bad Name|author=Victoria Bekiempis|work=]|date=1 April 2015}}</ref> The Oxford Dictionaries' ] for 2014 was "vape".<ref name=Fallon2014>{{cite news|first1=Claire|last1=Fallon|title='Vape' Is Oxford Dictionaries' Word Of The Year|url=https://huffingtonpost.com/2014/11/18/vape-word-of-year_n_6178102.html|work=HuffPost|date=19 November 2014}}</ref>

=== Regulation ===
{{Main|Regulation of electronic cigarettes|List of vaping bans in the United States}}
Regulation of e-cigarettes varies across countries and states, ranging from no regulation to ] them entirely.<ref name=Etter2011>{{cite journal|last1=Etter|first1=J. F.|last2=Bullen|first2=C.|last3=Flouris|first3=A. D.|last4=Laugesen|first4=M.|last5=Eissenberg|first5=T.|title=Electronic nicotine delivery systems: a research agenda|journal=Tobacco Control|date=May 2011|volume=20|issue=3|pages=243–8|doi=10.1136/tc.2010.042168|pmc=3215262|pmid=21415064}}</ref> For instance, e-cigarettes containing nicotine are illegal in Japan, forcing the market to use ]s for cigarette alternatives.<ref name=TabuchiGallus2018>{{cite journal|last1=Tabuchi|first1=Takahiro|last2=Gallus|first2=Silvano|last3=Shinozaki|first3=Tomohiro|last4=Nakaya|first4=Tomoki|last5=Kunugita|first5=Naoki|last6=Colwell|first6=Brian|title=Heat-not-burn tobacco product use in Japan: its prevalence, predictors and perceived symptoms from exposure to secondhand heat-not-burn tobacco aerosol|journal=Tobacco Control|volume=27|issue=e1|year=2018|pages=e25–e33|issn=0964-4563|doi=10.1136/tobaccocontrol-2017-053947|pmc=6073918|pmid=29248896}}</ref> Others have introduced strict restrictions and some have licensed devices as medicines such as in the UK.<ref name=BeardShahab2016/> However, {{as of|February 2018|lc=y}}, there is no e-cigarette device that has been given a medical license that is commercially sold or available by prescription in the UK.{{sfn|McNeill|2018|p=46}} {{As of|2015}}, around two thirds of major nations have regulated e-cigarettes in some way.<ref>{{cite news|url=http://ecigintelligence.com/worlds-law-makers-favour-e-cig-regulation-based-on-tobacco/|title=World's law-makers favour basing e-cig rules on tobacco|author=Barnaby Page|work=ECigIntelligence|publisher=Tamarind Media Limited|date=5 March 2015}}</ref>

Because of the potential relationship with tobacco laws and medical drug policies, e-cigarette legislation is being debated in many countries.<ref name=KimKabir2016>{{cite journal|last1=Kim|first1=Ki-Hyun|last2=Kabir|first2=Ehsanul|last3=Jahan|first3=Shamin Ara|title=Review of electronic cigarettes as tobacco cigarette substitutes: their potential human health impact|journal=Journal of Environmental Science and Health, Part C|volume=34|issue=4|year=2016|pages=262–275|issn=1059-0501|doi=10.1080/10590501.2016.1236604|pmid=27635466|bibcode=2016JESHC..34..262K |s2cid=42660975}}</ref> The companies that make e-cigarettes have been pushing for laws that support their interests.<ref name=LempertGrana2016>{{cite journal|last1=Lempert|first1=Lauren K|last2=Grana|first2=Rachel|last3=Glantz|first3=Stanton A|title=The importance of product definitions in US e-cigarette laws and regulations|journal=Tobacco Control|volume=25|issue=e1|year=2016|pages=e44–e51|issn=0964-4563|doi=10.1136/tobaccocontrol-2014-051913|pmc=4466213|pmid=25512432}}</ref> In 2016 the ] banned the use of e-cigarettes on commercial flights.<ref name=Airflight2016/> This regulation applies to all flights to and from the US.<ref name=Airflight2016>{{cite web|url=https://www.transportation.gov/briefing-room/us-department-transportation-explicitly-bans-use-electronic-cigarettes-commercial|title=U.S. Department of Transportation Explicitly Bans the Use of Electronic Cigarettes on Commercial Flights|publisher=]|date=2 March 2016}}</ref> In 2018, the Royal College of Physicians asked that a balance is found in regulations over e-cigarettes that ensure product safety while encouraging smokers to use them instead of tobacco, as well as keep an eye on any effects contrary to the control agencies for tobacco.<ref name=RCP2018>{{cite web|url=https://www.rcplondon.ac.uk/projects/outputs/what-rcp-thinks-about-tobacco|title=What the RCP thinks about tobacco|location=UK|publisher=Royal College of Physicians|pages=1–2|date=1 February 2018}}</ref>

The ] is currently pending in many countries.<ref name=Grana2014/> Many countries such as Brazil, Singapore, Uruguay,<ref name=BeardShahab2016>{{cite journal|last1=Beard|first1=Emma|last2=Shahab|first2=Lion|last3=Cummings|first3=Damian M.|last4=Michie|first4=Susan|last5=West|first5=Robert|title=New Pharmacological Agents to Aid Smoking Cessation and Tobacco Harm Reduction: What Has Been Investigated, and What Is in the Pipeline?|journal=CNS Drugs|volume=30|issue=10|pages=951–83|year=2016|issn=1172-7047|doi=10.1007/s40263-016-0362-3|pmid=27421270|s2cid=40411008|url=http://discovery.ucl.ac.uk/1498793/1/Beard%20et%20al%202016%20%20New%20Pharmacological%20Agents%20to%20Aid%20Smoking%20Cessation%20and%20Tobacco%20Harm%20Reduction.pdf}}</ref> and India have banned e-cigarettes.<ref name=Robertson2019>{{cite news|url=https://www.theverge.com/2019/9/18/20872967/india-e-cigarette-vaping-ban-epidemic-health-risks|title=India bans e-cigarette sales and says there's an 'epidemic' of kids vaping|last1=Robertson|first1=Adi|work=The Verge|date=18 September 2019}}</ref> Canada-wide in 2014, they were technically illegal to sell, as no nicotine-containing e-cigarettes are not regulated by ], but this is generally unenforced and they are commonly available for sale Canada-wide.<ref name=Sienuic2014>{{cite news|last1=Sienuic|first1=Kat|url=https://www.theglobeandmail.com/life/health-and-fitness/health/health-officials-set-rules-but-decisions-belong-to-each-person/article20809598/|title=Public health officers tackle hazy issue of e-cigarettes|work=]|date=29 September 2014}}</ref> In 2016, Health Canada announced plans to regulate vaping products.<ref>{{cite news|url=http://www.cbc.ca/news/health/vaping-health-canada-legislation-1.3862589|title=Vaping, e-cigarettes to be regulated by Health Canada|publisher=]|date=22 November 2016}}</ref> In the US and the UK, the use and sale to adults of e-cigarettes are legal.<ref name=Kadowaki2015>{{cite journal|last1=Kadowaki|first1=Joy|last2=Vuolo|first2=Mike|last3=Kelly|first3=Brian C.|title=A review of the current geographic distribution of and debate surrounding electronic cigarette clean air regulations in the United States|journal=Health & Place|volume=31|year=2015|pages=75–82|issn=1353-8292|doi=10.1016/j.healthplace.2014.11.003|pmc=4305454|pmid=25463920}}</ref>{{rp|US}}<ref>{{cite news|url=https://www.bbc.co.uk/news/uk-25900542|title=E-cigarettes to be stubbed out for under-18s|date=26 January 2014|work=]}}</ref>{{rp|UK}} The revised EU Tobacco Products Directive came into effect in May 2016, providing stricter regulations for e-cigarettes.<ref name=BI2016>{{cite news|url=http://www.businessinsider.com/ap-european-court-tougher-rules-on-electronic-cigarettes-2016-5|title=European court: Tougher rules on electronic cigarettes|work=]|agency=Associated Press|date=4 May 2016|access-date=2 June 2019|archive-date=2 June 2019|archive-url=https://web.archive.org/web/20190602164019/https://www.businessinsider.com/ap-european-court-tougher-rules-on-electronic-cigarettes-2016-5|url-status=dead}}</ref> It limits e-cigarette advertising in print, on television and radio, along with reducing the level of nicotine in liquids and reducing the flavors used.<ref name=Washtell2016>{{cite news|url=http://www.cityam.com/240410/eu-tobacco-products-directive-chokes-off-the-uks-e-cigarette-and-vaping-market-|title=EU Tobacco Products Directive chokes off the UK's e-cigarette and vaping market|author=Francesca Washtell|work=City A.M.|date=5 May 2016}}</ref> It does not ban vaping in public places.<ref name=ZainolAbidinZainalAbidin2017>{{cite journal|last1=Zainol Abidin|first1=Najihah|last2=Zainal Abidin|first2=Emilia|last3=Zulkifli|first3=Aziemah|last4=Karuppiah|first4=Karmegam|last5=Syed Ismail|first5=Sharifah Norkhadijah|last6=Amer Nordin|first6=Amer Siddiq|title=Electronic cigarettes and indoor air quality: a review of studies using human volunteers|journal=Reviews on Environmental Health|volume=32|issue=3|pages=235–244|year=2017|issn=2191-0308|doi=10.1515/reveh-2016-0059|pmid=28107173|s2cid=6885414|url=http://psasir.upm.edu.my/id/eprint/61699/1/Electronic%20cigarettes%20and%20indoor%20air%20quality.pdf}}</ref> It requires the purchaser for e-cigarettes to be at least 18 and does not permit buying them for anyone less than 18 years of age.{{sfn|McNeill|2018|p=39}} The updated Tobacco Products Directive has been disputed by ] whose businesses could be impacted by these revisions.<ref name=Euronews2013>{{cite news|url=http://www.euronews.com/2013/07/10/new-tobacco-products-directive-adopted-regulations-on-e-cigarettes-announced|title=Anger over tobacco lobbyists as Europe nears new rules on e-cigarettes|author=Ashitha Nagesh|publisher=]|date=10 July 2013}}</ref>

As of 8 August 2016, the US FDA extended its regulatory power to include e-cigarettes, e-liquid and all related products.<ref name=FDA-August-2017>{{cite web|url=https://www.fda.gov/tobaccoproducts/labeling/rulesregulationsguidance/ucm394909.htm|title=FDA's New Regulations for E-Cigarettes, Cigars, and All Other Tobacco Products|publisher=United States Food and Drug Administration|date=17 August 2017}}</ref> Under this ruling the FDA will evaluate certain issues, including ingredients, product features and health risks, as well their appeal to minors and non-users.<ref name=FDATobaccoRule2017/> The FDA rule also bans access to minors.<ref name=FDATobaccoRule2017/> A photo ID is now required to buy e-cigarettes,<ref name=FDARetailer2017>{{cite web|url=https://www.fda.gov/TobaccoProducts/GuidanceComplianceRegulatoryInformation/Retail/ucm205021.htm|title=Summary of Federal Rules for Tobacco Retailers|publisher=United States Food and Drug Administration|date=23 August 2017}}</ref> and their sale in all-ages vending machines is not permitted in the US.<ref name=FDATobaccoRule2017>{{cite web|title=The Facts on the FDA's New Tobacco Rule|url=https://www.fda.gov/ForConsumers/ConsumerUpdates/ucm506676.htm|publisher=United States Food and Drug Administration|date=2 May 2017}}</ref> As of August 2017, regulatory compliance deadlines relating to premarket review requirements for most e-cigarette and e-liquid products have been extended from November 2017 to 8 August 2022,<ref name=FDA-2017>{{cite web|url=https://www.fda.gov/TobaccoProducts/Labeling/RulesRegulationsGuidance/ucm557714.htm|title=Extension of Certain Tobacco Product Compliance Deadlines Related to the Final Deeming Rule (Revised)|publisher=United States Food and Drug Administration|date=4 August 2017}}</ref><ref name=FDAAugust2017>{{cite web|url=https://www.fda.gov/downloads/TobaccoProducts/Labeling/RulesRegulationsGuidance/UCM557716.pdf|title=Guidance: Extension of Certain Tobacco Product Compliance Deadlines Related to the Final Deeming Rule (Revised*)|publisher=United States Food and Drug Administration|date=August 2017}}</ref> which attracted a lawsuit filed by the American Heart Association, American Academy of Pediatrics, the ], and other plaintiffs.<ref>{{cite news|url=https://www.dddmag.com/news/2018/03/lawsuit-challenges-fda-delay-e-cigarette-review|title=Lawsuit Challenges FDA Delay of E-cigarette Review|last1=Perrone|first1=Matthew|publisher=]|agency=Associated Press|date=28 March 2018}}</ref>

In May 2016, the US FDA used its authority under the ] to deem e-cigarette devices and e-liquids to be tobacco products, which meant it intended to regulate the marketing, labelling, and manufacture of devices and liquids; vape shops that mix e-liquids or make or modify devices were considered manufacturing sites that needed to register with US FDA and comply with ] regulation.<ref name=FDA2016/> E-cigarette and tobacco companies have recruited lobbyists in an effort to prevent the US FDA from evaluating e-cigarette products or banning existing products already on the market.<ref name=Lipton2016>{{cite news|url=https://www.nytimes.com/2016/09/03/us/politics/e-cigarettes-vaping-cigars-fda-altria.html?module=Promotron&region=Body&action=click&pgtype=article|title=A Lobbyist Wrote the Bill. Will the Tobacco Industry Win Its E-Cigarette Fight?|author=Eric Lipton|work=The New York Times|date=2 September 2016}}</ref>

In February 2014, the ] passed regulations requiring standardization and quality control for liquids and vaporizers, disclosure of ingredients in liquids, and child-proofing and tamper-proofing for liquid packaging.<ref name=EURegs2014>{{cite web|url=http://europa.eu/rapid/press-release_MEMO-14-134_en.htm|title=Questions & Answers: New rules for tobacco products|publisher=European Commission|date=26 February 2014}}</ref> In April 2014 the US FDA published proposed regulations for e-cigarettes.<ref name="FDA2014">{{cite journal|url=https://www.federalregister.gov/articles/2014/04/25/2014-09491/deeming-tobacco-products-to-be-subject-to-the-federal-food-drug-and-cosmetic-act-as-amended-by-the|title=Deeming Tobacco Products To Be Subject to the Federal Food, Drug, and Cosmetic Act, as Amended by the Family Smoking Prevention and Tobacco Control Act; Regulations on the Sale and Distribution of Tobacco Products and Required Warning Statements for Tobacco Products|journal=Federal Register|publisher=United States Food and Drug Administration|volume=79|issue=80|pages=23142–23207|date=25 April 2014}}</ref><ref name=Tavernise2014>{{cite news|url=https://nytimes.com/2014/04/24/health/fda-will-propose-new-regulations-for-e-cigarettes.html|title=F.D.A. Will Propose New Regulations for E-Cigarettes|author=Sabrina Tavernise|work=The New York Times|date=24 April 2014}}</ref> In the US some states ], and some state and regional governments have broadened their indoor smoking bans to include e-cigarettes.<ref name=Crowley2015>{{cite journal|last1=Crowley|first1=Ryan A.|title=Electronic Nicotine Delivery Systems: Executive Summary of a Policy Position Paper From the American College of Physicians |journal=Annals of Internal Medicine|volume=162|issue=8|year=2015|pages=583–4|issn=0003-4819|doi=10.7326/M14-2481|pmid=25894027|doi-access=free}}</ref> {{As of|April 2017}}, 12 US states and 615 localities had prohibited the use of e-cigarettes in venues in which traditional cigarette smoking was prohibited.<ref name=GlantzBareham2018/> In 2015, at least 48 states and 2 territories had banned e-cigarette sales to minors.<ref name=NCSL2017>{{cite web|url=http://www.ncsl.org/research/health/alternative-nicotine-products-e-cigarettes.aspx|title=Alternative Nicotine Products – Electronic Cigarettes|publisher=]|date=3 March 2017}}</ref>

In November 2020, the New Zealand government passed a vaping regulation that requires vape stores to register as specialist vape retailers before they can sell e-cigarettes, the wider range of flavoured e-liquids, and other related vaping products. Vaping products are required to be notified by the government before they can be sold to ensure that the products are following safety requirements and ingredients in liquids do not contain prohibited substances.<ref>{{Cite web|title=Vaping Law FAQ - Vaping Regulations Explained {{!}} Shosha NZ|url=https://www.shosha.co.nz/vaping-law|access-date=25 June 2021|website=www.shosha.co.nz|archive-date=25 June 2021|archive-url=https://web.archive.org/web/20210625045235/https://www.shosha.co.nz/vaping-law|url-status=dead}}</ref>

E-cigarettes containing nicotine have been listed as drug delivery devices in a number of countries, and the marketing of such products has been restricted or put on hold until safety and efficacy clinical trials are conclusive.<ref name=Cervellin2013>{{cite journal|last1=Cervellin|first1=Gianfranco|last2=Borghi|first2=Loris|last3=Mattiuzzi|first3=Camilla|last4=Meschi|first4=Tiziana|last5=Favaloro|first5=Emmanuel|last6=Lippi |first6=Giuseppe|title=E-Cigarettes and Cardiovascular Risk: Beyond Science and Mysticism|journal=Seminars in Thrombosis and Hemostasis|volume=40|issue=1|year=2013|pages=060–065|issn=0094-6176|doi=10.1055/s-0033-1363468 |pmid=24343348|doi-access=free}}</ref> Since they do not contain tobacco, television advertising in the US is not restricted.<ref name=MaloneyCappella2015>{{cite journal|last1=Maloney|first1=Erin K.|last2=Cappella |first2=Joseph N.|title=Does Vaping in E-Cigarette Advertisements Affect Tobacco Smoking Urge, Intentions, and Perceptions in Daily, Intermittent, and Former Smokers?|journal=Health Communication|year=2015|volume=31 |issue=1|pages=1–10|issn=1041-0236|doi=10.1080/10410236.2014.993496|pmid=25758192|s2cid=31328176}}</ref> Some countries have regulated e-cigarettes as a ] even though they have not approved them as a smoking cessation aid.<ref name="Bekki2014">{{cite journal|last1=Bekki|first1=Kanae|last2=Uchiyama|first2=Shigehisa|last3=Ohta|first3=Kazushi|last4=Inaba|first4=Yohei|last5=Nakagome|first5=Hideki|last6=Kunugita |first6=Naoki|title=Carbonyl Compounds Generated from Electronic Cigarettes|journal=International Journal of Environmental Research and Public Health|volume=11|issue=11|year=2014|pages=11192–11200|issn=1660-4601 |doi=10.3390/ijerph111111192|pmc=4245608|pmid=25353061|doi-access=free}}{{CC-notice|cc=by4|url=http://www.mdpi.com/1660-4601/11/11/11192/htm|author(s)=Kanae Bekki, Shigehisa Uchiyama, Kazushi Ohta, Yohei Inaba, Hideki Nakagome and Naoki Kunugita}}</ref> A 2014 review stated the emerging phenomenon of e-cigarettes has raised concerns in the health community, governments, and the general public and recommended that e-cigarettes should be regulated to protect consumers.<ref name=Saitta2014/> It added, "heavy regulation by restricting access to e-cigarettes would just encourage continuing use of much unhealthier tobacco smoking."<ref name=Saitta2014/> A 2014 review said regulation of the e-cigarette should be considered on the basis of reported adverse health effects.<ref name=Bekki2014/>

===Criticism of vaping bans===
Critics of vaping bans state that vaping is a much safer alternative to smoking tobacco products and that vaping bans incentivize people to return to smoking cigarettes.<ref name="reason.com">{{Cite web |title=California Is Forcing Smokers To Buy More Dangerous Products |url=https://reason.com/2022/05/06/californias-is-forcing-smokers-to-buy-more-dangerous-products/|date=6 May 2022}}</ref> For example, critics cite the British Journal of Family Medicine in August 2015 which stated, "E-cigarettes are 95% safer than traditional smoking."<ref>{{Cite web |title=Vaping 95% less harmful than smoking |url=https://www.gmjournal.co.uk/vaping-95-less-harmful-than-smoking#:~:text=E%2Dcigarettes%20are%2095%25%20safer,help%20people%20give%20up%20smoking.|date=August 2015}}</ref> Additionally, San Francisco's chief economist, Ted Egan, when discussing the San Francisco vaping ban stated the city's ban on e-cigarette sales will increase smoking as vapers switch to combustible cigarettes.<ref>{{Cite web |title=San Francisco's Top Economist Confirms Vape Ban Means More Smoking |url=https://reason.com/2019/07/15/san-franciscos-top-economist-confirms-vape-ban-means-more-smoking/|date=15 July 2019}}</ref> Critics of smoking bans stress the absurdity of criminalizing the sale of a safer alternative to tobacco while tobacco continues to be legal. Prominent proponents of smoking bans are not in favor of criminalizing tobacco either, but rather allowing consumers to have the choice to choose whatever products they desire.<ref name="reason.com"/>

In 2022, after two years of review, the ] (FDA) denied ] application to keep its tobacco and menthol flavored vaping products on the market.<ref>{{Cite news |title=FDA to Order Juul E-Cigarettes Off U.S. Market |newspaper=Wall Street Journal |url=https://www.wsj.com/articles/fda-to-order-juul-e-cigarettes-off-u-s-market-11655904689|date=22 June 2022|last1=Maloney |first1=Jennifer }}</ref> Critics of this denial note that research published in Nicotine and Tobacco Research found that smokers who transitioned to Juuls in North America were significantly more likely to switch to vaping than those in the United Kingdom who only had access to lower-strength nicotine products.<ref>{{Cite web |title=Differences in Switching Away From Smoking Among Adult Smokers Using JUUL Products in Regions With Different Maximum Nicotine Concentrations: North America and the United Kingdom |url=https://academic.oup.com/ntr/article/23/11/1821/6276234?login=false|date=18 May 2021}}</ref> This happens as the Biden administration seeks to mandate low-nicotine cigarettes which, critics note, is not what makes cigarettes dangerous.<ref>{{Cite web |title=Mandating Low-Nicotine Cigarettes Could Make Smoking More Dangerous|url=https://reason.com/2022/06/22/mandating-low-nicotine-cigarettes-could-make-smoking-more-dangerous/|date=22 June 2022}}</ref> They also note that vaping does not contain many of the components that make smoking dangerous such as the combustion process and certain chemicals that are present in cigarettes that are not present in vape products.

=== Product liability ===
Multiple reports from the ] conclude that electronic cigarettes have been combusting and injuring people and surrounding areas.<ref name=":12">{{Cite web |url=https://www.usfa.fema.gov/downloads/pdf/publications/electronic_cigarettes.pdf |title=Electronic Cigarette Fires and Explosions in the United States 2009-2016}}</ref><ref name=":02">{{Cite web |url=https://www.icao.int/safety/dangerousgoods/dgpwg15/dgpwg.15.ip.004.2.en.app.pdf|title=E-Cigarette Fire Risks and Reported Incidents}}</ref> The composition of a cigarette is the cause of this, as the cartridges that are meant to contain the liquid mixture are in such close proximity to the battery.<ref name=Bhatnagar2014/> A research report by the ] supports this, stating that, "Unlike mobile phones, some e-cigarette lithium-ion batteries within e-cigarettes offer no protection to stop the coil overheating".<ref name=":02" />

In 2015, the ] noted in their report that electronic cigarettes are not created by ] or other tobacco companies, but by independent factories that have little quality control.<ref name=":02" /> Because of this low quality control when made, electronic cigarettes have led to incidents in which people are hurt, or in which the surrounding area is damaged.<ref name=":02" /><ref name=":12" />

=== Marketing ===
{{Main|Electronic cigarette and e-cigarette liquid marketing}}

They are marketed to men, women, and children as being safer than traditional cigarettes.<ref name=CrottyVyas2015>{{cite journal|last1=Crotty LE|first1=Alexander|last2=Vyas|first2=A |last3=Schraufnagel|first3=DE |last4=Malhotra|first4=A|title=Electronic cigarettes: the new face of nicotine delivery and addiction|journal=Journal of Thoracic Disease|volume=7|issue=8|year=2015 |pages=E248–E251|doi=10.3978/j.issn.2072-1439.2015.07.37 |pmc=4561260|pmid=26380791}}</ref> They are also marketed to non-smokers.<ref name=CaiWang2017/> E-cigarette marketing is common.<ref name=HSF2014/> There are growing concerns that e-cigarette ]s unjustifiably focus on young adults, adolescents, and women.<ref name=SmithBrar2016/> ] companies have greatly increased their marketing efforts.<ref name=Drummond2014/> This marketing trend may expand the use of e-cigarettes and contribute to re-glamorizing smoking.<ref>{{cite web |url=http://wiki.cancer.org.au/policy/Position_statement_-_Electronic_cigarettes#Key_health_concerns |title=Position Statement Electronic Cigarettes|publisher=Cancer Council Australia; National Heart Foundation of Australia|year=2014}}</ref> Some companies may use e-cigarette advertising to advocate smoking, deliberately, or inadvertently, is an area of concern.<ref name=RinkooKaur2017>{{cite journal|last1=Rinkoo|first1=ArvindVashishta |last2=Kaur|first2=Jagdish|title=Getting real with the upcoming challenge of electronic nicotine delivery systems: The way forward for the South-East Asia region|journal=Indian Journal of Public Health|volume=61|issue=5 |year=2017|pages=S7–S11|issn=0019-557X|doi=10.4103/ijph.IJPH_240_17|pmid=28928312|doi-access=free}}</ref> A 2014 review said, "the e-cigarette companies have been rapidly expanding using aggressive marketing messages similar to those used to ]."<ref name=Grana2014/>

E-cigarette companies are using methods that were once used by the tobacco industry to persuade young people to start using cigarettes.<ref name=McCauslandMaycock2017/> E-cigarettes are promoted to a certain extent to forge a vaping culture that entices non-smokers.<ref name=McCauslandMaycock2017/> Themes in e-cigarette marketing, including sexual content and customer satisfaction, are parallel to themes and techniques that are appealing to young people and young adults in traditional cigarette advertising and promotion.<ref name=SGUSReport2016/> A 2017 review found "The tobacco industry sees a future where ENDS accompany and perpetuate, rather than supplant, tobacco use, especially targeting the youth."<ref name=RinkooKaur2017/> E-cigarettes and nicotine are regularly promoted as safe and even healthy in the media and on brand websites, which is an area of concern.<ref name=England2015/>

While ] products is banned in most countries, television and radio e-cigarette advertising in several countries may be indirectly encouraging traditional ].<ref name=Grana2014/> E-cigarette advertisements are also in magazines, newspapers, online, and in retail stores.{{sfn|Chapman|2015|p=7}} Between 2010 and 2014, e-cigarettes were second only to cigarettes as the top advertised product in magazines.<ref name=CollinsGlasser2018>{{cite journal|last1=Collins|first1=Lauren|last2=Glasser|first2=Allison M|last3=Abudayyeh|first3=Haneen |last4=Pearson|first4=Jennifer L|last5=Villanti |first5=Andrea C|title=E-Cigarette Marketing and Communication: How E-Cigarette Companies Market E-Cigarettes and the Public Engages with E-cigarette Information|journal=Nicotine & Tobacco Research|volume=21|issue=1|pages=14–24|year=2018|issn=1462-2203 |doi=10.1093/ntr/ntx284|pmc=6610165|pmid=29315420}}</ref> As cigarette companies have acquired the largest e-cigarette brands, they currently benefit from a dual market of smokers and e-cigarette users while simultaneously presenting themselves as agents of harm reduction.<ref name=FranckFilion2016/> This raises concerns about the appropriateness of endorsing a product that directly profits the tobacco industry.<ref name=FranckFilion2016/> There is no evidence that the cigarette brands are selling e-cigarettes as part of a plan to phase out traditional cigarettes, despite some stating to want to cooperate in "harm reduction".<ref name=Grana2014/> E-cigarette advertising for using e-cigarettes as a quitting tool have been seen in the US, UK, and China, which have not been supported by regulatory bodies.<ref name="Kalkhoran2016">{{cite journal |last1=Kalkhoran|first1=Sara|last2=Glantz|first2=Stanton A|year=2016|title=E-cigarettes and smoking cessation in real-world and clinical settings: a systematic review and meta-analysis|journal=The Lancet Respiratory Medicine|volume=4|issue=2|pages=116–128 |doi=10.1016/S2213-2600(15)00521-4|issn=2213-2600|pmc=4752870|pmid=26776875}}</ref>

In the US, six large e-cigarette businesses spent $59.3 million on promoting e-cigarettes in 2013.<ref>{{cite journal |last1=Wasowicz|first1=Adam|last2=Feleszko|first2=Wojciech|last3=Goniewicz|first3=Maciej L|title=E-Cigarette use among children and young people: the need for regulation|journal=Expert Rev Respir Med |volume=9|issue=5|pages=1–3|year=2015|doi=10.1586/17476348.2015.1077120|pmid=26290119|s2cid=207206915|doi-access=free}}</ref> In the US and Canada, over $2 million is spent yearly on promoting e-cigarettes online.<ref name=McCauslandMaycock2017>{{cite journal|last1=McCausland|first1=Kahlia|last2=Maycock|first2=Bruce |last3=Jancey|first3=Jonine|title=The messages presented in online electronic cigarette promotions and discussions: a scoping review protocol|journal=BMJ Open|volume=7|issue=11|year=2017|pages=e018633 |issn=2044-6055|doi=10.1136/bmjopen-2017-018633|pmc=5695349|pmid=29122804}}</ref> E-cigarette websites often made unscientific health statements in 2012.<ref name=GranaLing2014>{{cite journal |last1=Grana|first1=Rachel A.|last2=Ling|first2=Pamela M.|title="Smoking revolution": a content analysis of electronic cigarette retail websites|journal=Am J Prev Med|volume=46 |issue=4|pages=395–403 |year=2014|doi=10.1016/j.amepre.2013.12.010|pmc=3989286|pmid=24650842}}</ref> The ease to get past the ] system at e-cigarette company websites allows underage individuals to access and be exposed to marketing.<ref name=GranaLing2014/> Around half of e-cigarette company websites have a minimum age notice that prohibited underage individuals from entering.<ref name=CaiWang2017/>

] are used to encourage e-cigarette use.{{sfn|Bauld|2014|p=11}} A 2012 national US television advertising campaign for e-cigarettes starred ] exhaling a "thick flume" of what the advertisement describes as "vapor, not tobacco smoke", exhorting smokers with the message "We are all adults here, it's time to take our freedom back."<ref name=Nasaw2012/> Opponents of the tobacco industry state that the Blu advertisement, in a context of longstanding prohibition of tobacco advertising on television, seems to have resorted to advertising tactics that got former generations of people in the US addicted to traditional cigarettes.<ref name=Nasaw2012/> Cynthia Hallett of Americans for Non-Smokers' Rights described the US advertising campaign as attempting to "re-establish a norm that smoking is okay, that smoking is glamorous and acceptable".<ref name=Nasaw2012/>

University of Pennsylvania communications professor Joseph Cappella stated that the setting of the advertisement near an ocean was meant to suggest an association of clean air with the nicotine product.<ref name=Nasaw2012>{{cite news|url=https://www.bbc.com/news/magazine-20583902|title=Electronic cigarettes challenge anti-smoking efforts|work=BBC News|author=Daniel Nasaw|date=5 December 2012}}</ref> In 2012 and 2013, e-cigarette companies advertised to a large television audience in the US which included 24 million young people.<ref name=Duke2014>{{cite journal|last1=Duke|first1=J. C.|last2=Lee|first2=Y. O.|last3=Kim|first3=A. E. |last4=Watson|first4=K. A.|last5=Arnold|first5=K. Y.|last6=Nonnemaker|first6=J. M.|last7=Porter|first7=L.|title=Exposure to Electronic Cigarette Television Advertisements Among Youth and Young Adults|journal=Pediatrics |volume=134|issue=1|year=2014|pages=e29–e36|doi=10.1542/peds.2014-0269|pmid=24918224|doi-access=free}}</ref> The channels to which e-cigarette advertising reached the largest numbers of young people (ages 12–17) were AMC, Country Music Television, Comedy Central, WGN America, TV Land, and VH1.<ref name=Duke2014/>

]
Since at least 2007, e-cigarettes have been heavily promoted across media outlets globally.<ref name=ChatterjeeAlzghoul2016/> They are vigorously advertised, mostly through the Internet, as a safe substitute to traditional cigarettes, among other things.<ref name=Rom2014/> E-cigarette companies promote their e-cigarette products on ], ],{{sfn|Chapman|2015|p=7}} ], and ].<ref name=Payne2016>{{cite journal|last1=Payne|first1=JD|last2=Orellana-Barrios|first2=M|last3=Medrano-Juarez|first3=R|last4=Buscemi|first4=D|last5=Nugent|first5=K|title=Electronic cigarettes in the media.|journal=Proc (Bayl Univ Med Cent).|volume=29|issue=3|pages=280–3|year=2016|doi=10.1080/08998280.2016.11929436|pmc=4900769|pmid=27365871}}</ref> They are promoted on YouTube by movies with sexual material and music icons, who encourage minors to "take their freedom back."<ref name=RinkooKaur2017/> They have partnered with a number of sports and music icons to promote their products.<ref name=Bryan2014>{{cite book|last1=Bryan|first1=Christiansen|title=Handbook of Research on Global Business Opportunities|url=https://books.google.com/books?id=PyKXBQAAQBAJ&pg=PA411|date=31 October 2014|publisher=IGI Global|isbn=978-1-4666-6552-1|pages=411–}}</ref> Tobacco companies intensely market e-cigarettes to young people,<ref>{{cite web|archive-url=https://web.archive.org/web/20151004030055/https://www.lung.org/stop-smoking/smoking-facts/e-cigarettes-and-lung-health.html|url=https://www.lung.org/stop-smoking/smoking-facts/e-cigarettes-and-lung-health.html|archive-date=4 October 2015|publisher=American Lung Association|year=2015|title=E-cigarettes and Lung Health}}</ref> with industry strategies including cartoon characters and candy flavors.<ref>{{cite web|archive-url=https://web.archive.org/web/20151204074154/http://www.lung.org/stop-smoking/smoking-facts/myths-and-facts-about-e-cigs.html|url=http://www.lung.org/stop-smoking/smoking-facts/myths-and-facts-about-e-cigs.html|archive-date=4 December 2015|publisher=American Lung Association|year=2015|title=Myths and Facts About E-cigarettes}}</ref> Fruit flavored e-liquid is the most commonly marketed e-liquid flavor on social media.<ref name=Liang2015>{{cite conference|last1=Liang|first1=Yunji|last2=Zheng|first2=Xiaolong|last3=Dajun Zheng|first3=Daniel|last4=Zhou|first4=Xingshe|editor1-first=Xiaolong|editor1-last=Zheng|editor2-first=Daniel|editor2-last=Dajun Zeng|editor3-first=Hsinchun|editor3-last=Chen|editor4-first=Scott J.|editor4-last=Leischow|title=Impact of Flavor on Electronic Cigarette Marketing in Social Media|conference=Smart Health: International Conference, ICSH 2015|location=Phoenix, AZ, USA|date=22 January 2016|url=https://books.google.com/books?id=cM5yCwAAQBAJ&pg=PA279|publisher=Springer|isbn=978-3-319-29175-8|page=283}}</ref>

E-cigarette companies commonly promote that their products contain only water, nicotine, glycerin, propylene glycol, and flavoring but this assertion is misleading as researchers have found differing amounts of heavy metals in the vapor, including chromium, nickel, tin, silver, cadmium, mercury, and aluminum.<ref name=Hildick-SmithPesko2015>{{cite journal|last1=Hildick-Smith|first1=Gordon J.|last2=Pesko|first2=Michael F.|last3=Shearer|first3=Lee|last4=Hughes|first4=Jenna M.|last5=Chang |first5=Jane|last6=Loughlin|first6=Gerald M.|last7=Ipp|first7=Lisa S.|title=A Practitioner's Guide to Electronic Cigarettes in the Adolescent Population|journal=Journal of Adolescent Health|volume=57|issue=6|pages=574–579 |year=2015|issn=1054-139X|doi=10.1016/j.jadohealth.2015.07.020|pmid=26422289|doi-access=free}}</ref> The widespread assertion that e-cigarettes emit "only water vapor" is not true because the evidence demonstrates e-cigarette vapor contains possibly harmful chemicals such as nicotine, carbonyls, metals, and ]s, in addition to particulate matter.<ref name="FernándezBallbè2015"/> Massive advertising included the assertion that they would present little risk to non-users.<ref name=HeydariAhmady2017/> However, "disadvantages and side effects have been reported in many articles, and the unfavorable effects of its secondhand vapor have been demonstrated in many studies",<ref name=HeydariAhmady2017>{{cite journal|last1=Heydari|first1=Gholamreza|last2=Ahmady|first2=ArezooEbn|last3=Chamyani|first3=Fahimeh|last4=Masjedi|first4=Mohammadreza|last5=Fadaizadeh |first5=Lida|title=Electronic cigarette, effective or harmful for quitting smoking and respiratory health: A quantitative review papers|journal=Lung India|volume=34|issue=1|year=2017|pages=25–28|issn=0970-2113 |doi=10.4103/0970-2113.197119|pmc=5234193|pmid=28144056 |doi-access=free }}</ref> and evidence indicates that use of e-cigarettes degrades ].<ref name=":1"/>

Many e-cigarette companies market their products as a smoking cessation aid without evidence of effectiveness.<ref name=SchivoAvdalovic2014>{{cite journal|last1=Schivo|first1=Michael|last2=Avdalovic|first2=Mark V.|last3=Murin|first3=Susan|title=Non-Cigarette Tobacco and the Lung |journal=Clinical Reviews in Allergy & Immunology|volume=46|issue=1|date=February 2014|pages=34–53|issn=1080-0549|doi=10.1007/s12016-013-8372-0|pmid=23673789|s2cid=23626872}}</ref> E-cigarette marketing has been found to make unsubstantiated health statements (e.g., that they help one quit smoking) including statements about improving psychiatric symptoms, which may be particularly appealing to smokers with mental illness.<ref name=HefnerValentine2017/> E-cigarette marketing advocate weight control and emphasize use of nicotine with many flavors.<ref name=VerhaegenVanGaal2017/> These marketing angles could particularly entice overweight people, young people, and vulnerable groups.<ref name=VerhaegenVanGaal2017>{{cite journal|last1=Verhaegen|first1=A.|last2=Van Gaal|first2=L.|title=Do E-cigarettes induce weight changes and increase cardiometabolic risk? A signal for the future|journal=Obesity Reviews|volume=18|issue=10|pages=1136–1146|year=2017|issn=1467-7881|doi=10.1111/obr.12568|pmid=28660671|s2cid=29298086}}</ref> Some e-cigarette companies state that their products are ] without supporting evidence which may be purely to increase their sales.<ref name=KimKabir2016/>

=== Economics ===
The number of e-cigarettes sold increased every year from 2003 to 2014.<ref name=Bhatnagar2014/> In 2015 a slowdown in the growth in usage occurred in the US.<ref name=Mickle2015>{{cite news |url=https://www.wsj.com/articles/e-cig-sales-rapidly-lose-steam-1447798921|title=E-Cigarette Sales Rapidly Lose Steam|last1=Mickle|first1=Tripp|date=17 November 2015|work=]}}</ref> As of January 2018, the growth in usage in the UK has slowed down since 2013.<ref name="West2018">{{cite web|last1=West|first1=Robert|last2=Beard|first2=Emma|last3=Brown|first3=Jamie|date=9 January 2018|title=Electronic cigarettes in England - latest trends (STS140122)|url=http://www.smokinginengland.info/latest-statistics/|publisher=Smoking in England|page=28|access-date=6 December 2015|archive-date=18 December 2015|archive-url=https://web.archive.org/web/20151218144711/http://www.smokinginengland.info/latest-statistics/|url-status=dead}}</ref> {{As of|2014}}, there were at least 466 e-cigarette brands.<ref name=Born2015>{{cite journal|last1=Born|first1=H.|last2=Persky|first2=M.|last3=Kraus|first3=D. H.|last4=Peng|first4=R.|last5=Amin|first5=M. R.|last6=Branski|first6=R. C.|title=Electronic Cigarettes: A Primer for Clinicians|journal=Otolaryngology–Head and Neck Surgery|year=2015|volume=153|issue=1|pages=5–14|issn=0194-5998|doi=10.1177/0194599815585752|pmid=26002957|s2cid=10199442}}</ref> Worldwide e-cigarette sales in 2014 were around US$7 billion.<ref name=Evans2015>{{cite news|url=https://www.wsj.com/articles/e-cigarette-makers-face-rise-of-counterfeits-1424441348|title=E-Cigarette Makers Face Rise of Counterfeits|author=Peter Evans|work=The Wall Street Journal|date=20 February 2015}}</ref> Worldwide e-cigarette sales in 2019 were about $19.3 billion.<ref name=Janes2019>{{cite news|url=https://www.bbc.com/news/business-44295336|title=Vaping: How popular are e-cigarettes? - Spending on e-cigarettes is growing|last1=Jones|first1=Lora|work=BBC News|date=15 September 2019}}</ref> E-cigarette sales could exceed traditional cigarette sales by 2023.<ref name=ChunMoazed2017>{{cite journal|last1=Chun|first1=Lauren F|last2=Moazed|first2=Farzad|last3=Calfee|first3=Carolyn S|author-link3=Carolyn Calfee|last4=Matthay|first4=Michael A.|last5=Gotts|first5=Jeffrey Earl|title=Pulmonary Toxicity of E-cigarettes|journal=American Journal of Physiology. Lung Cellular and Molecular Physiology|volume=313|issue=2|year=2017|pages=L193–L206|issn=1040-0605|doi=10.1152/ajplung.00071.2017|pmc=5582932|pmid=28522559}}</ref> Approximately 30–50% of total e-cigarettes sales are handled on the internet.<ref name=Rom2014>{{cite journal|last1=Rom|first1=Oren|last2=Pecorelli|first2=Alessandra|last3=Valacchi|first3=Giuseppe|last4=Reznick|first4=Abraham Z.|year=2014|title=Are E-cigarettes a safe and good alternative to cigarette smoking?|journal=Annals of the New York Academy of Sciences|volume=1340|issue=1|pages=65–74|bibcode=2015NYASA1340...65R|doi=10.1111/nyas.12609 |issn=0077-8923|pmid=25557889|s2cid=26187171}}</ref> Established tobacco companies have a significant share of the e-cigarette market.<ref name=Schraufnagel2015/><ref>{{cite news|url=http://www.cnn.com/2015/03/23/health/e-cigarettes-smoking-addiction-nicotine/index.html|title=E-cigarettes: Helping smokers quit, or fueling a new addiction?|author=Meera Senthilingam|publisher=CNN|date=23 March 2015}}</ref>

<!-- China -->
{{As of|2018}}, 95% of e-cigarette devices were made in China,<ref name=JenssenBoykan2019>{{cite journal|last1=Jenssen|first1=Brian P.|last2=Boykan|first2=Rachel|title=Electronic Cigarettes and Youth in the United States: A Call to Action (at the Local, National and Global Levels)|journal=Children|volume=6|issue=2|year=2019|pages=30|issn=2227-9067|doi=10.3390/children6020030|pmc=6406299|pmid=30791645|doi-access=free}}{{CC-notice|cc=by4 |url=https://www.mdpi.com/2227-9067/6/2/30/htm|author(s)=Brian P. Jenssen and Rachel Boykan}}</ref> mainly in ].<ref name=Jourdan2014>{{cite news|last1=Jourdan|first1=Adam|title="Vaping" a slow burner in China, world's maker of e-cigarettes|url=https://www.reuters.com/article/us-china-smoking-idUSBREA0E1JX20140115|work=Reuters|date=25 May 2014}}</ref><ref name=Liao2015>{{cite news|last1=Liao|first1=Allen|title=Chinese E-cigarette Makers Shift to Domestic Markets|url=http://www.tobaccoasia.com/features/chinese-e-cigarette-makers-shift-to-domestic-markets/|work=Tobacco Asia|date=1 September 2015}}</ref> Chinese companies' market share of e-liquid is low.<ref name=Kessel2014>{{cite news|last1=Kessel|first1=Jonah M.|title=China's E-Cigarette Boom|url=https://www.nytimes.com/2014/12/14/business/international/chinas-e-cigarette-boom-lacks-oversight-for-safety-.html?pagewanted=all&_r=1|work=The New York Times|date=13 December 2014}}</ref> In 2014, online and offline sales started to increase.<ref name=Yao2015/> Since combustible cigarettes are relatively inexpensive in China a lower price may not be a large factor in marketing vaping products over there.<ref name=Yao2015>{{cite news|last1=Yao Min-G|title=The e-cigarette is taking off in nation that invented it|url=http://www.shanghaidaily.com/feature/news-feature/The-ecigarette-is-taking-off-in-nation-that-invented-it/shdaily.shtml|work=Shanghai Daily|date=30 May 2015}}</ref>

<!-- United States -->
In 2015, 80% of all e-cigarette sales in convenience stores in the US were products made by tobacco companies.<ref name=Craver2015>{{cite web|url=http://www.journalnow.com/business/business_news/local/vuse-overwhelming-e-cig-competition/article_01f18c48-7ba1-5520-af32-b007025c6f9f.html|title=Vuse overwhelming e-cig competition|work=]|author=Richard Craver|date=29 May 2015}}</ref> According to ], convenience store e-cigarette sales in the US went down for the first time during the four-week period ending on 10 May 2014.<ref name=Haar2014/> Wells Fargo analyst Bonnie Herzog attributes this decline to a shift in consumers' behavior, buying more specialized devices or what she calls "vapors-tanks-mods (VTMs)" that are not tracked by Nielsen.<ref name=Haar2014>{{cite news|url=https://www.cspdailynews.com/tobacco/nielsen-electronic-cigarette-dollar-sales-decline|title=Nielsen: Electronic Cigarette Dollar Sales Decline|author=Melissa Vonder Haar|work=CSP Magazine|date=28 May 2014}}</ref> Wells Fargo estimated that VTMs accounted for 57% of the 3.5 billion dollar market in the US for vapor products in 2015.<ref name=Mickle-2015>{{cite news|last1=Mickle|first1=Tripp|date=7 July 2015|title=FDA Cloud Hangs Over Vape Shops|work=The Wall Street Journal |url=https://www.wsj.com/articles/SB10130211234592774869404581088451777513530}}</ref>

In 2014, dollar sales of customizable e-cigarettes and e-liquid surpassed sales of cigalikes in the US, even though, overall, customizables are a less expensive vaping option.<ref name=Koebler2014>{{cite news|last1=Koebler|first1=Jason|title=Big Tobacco Has Officially Lost Its Hold on the E-Cigarette Market|url=http://motherboard.vice.com/read/big-tobacco-has-officially-lost-its-hold-on-the-e-cigarette-market|work=Motherboard|date=25 September 2014}}</ref> In 2014, the Smoke-Free Alternatives Trade Association estimated that there were 35,000 vape shops in the US, more than triple the number a year earlier.<ref name=EsterlAug2014>{{cite news|last1=Esterl|first1=Mike|title=Big Tobacco's E-Cigarette Push Gets a Reality Check|url=https://www.wsj.com/articles/big-tobaccos-e-cig-push-gets-a-reality-check-1409078319|work=The Wall Street Journal|date=26 August 2014}}</ref> However the 2015 slowdown in market growth affected VTMs as well.<ref name=Mickle2015/>

Large tobacco retailers are leading the cigalike market.<ref name=DasProchaska2017>{{cite journal|last1=Das|first1=Smita|last2=Prochaska|first2=Judith J.|title=Innovative approaches to support smoking cessation for individuals with mental illness and co-occurring substance use disorders|journal=Expert Review of Respiratory Medicine|volume=11|issue=10|pages=841–850|year=2017|issn=1747-6348|doi=10.1080/17476348.2017.1361823|pmc=5790168|pmid=28756728}}</ref> "We saw the market's sudden recognition that the cigarette industry seems to be in serious trouble, disrupted by the rise of vaping," '']'''s ] stated April 2018.<ref name=Elizabeth2018/> "Over the course of three short days, the tobacco stocks were bent, they were spindled and they were mutilated by the realization that electronic cigarettes have become a serious threat to the old-school cigarette makers," he added.<ref name=Elizabeth2018>{{cite news |url=https://www.cnbc.com/2018/04/23/cramer-vaping-is-killing-the-cigarette-industry-and-it-may-get-worse.html|title=Cramer: Vaping is decimating the cigarette industry—and it could get even worse|last=Gurdus|first=Elizabeth |publisher=CNBC|date=23 April 2018}}</ref> In 2019, a vaping industry organization released a report stating that a possible US ban on e-cigarettes flavors can potentially effect greater than 150,000 ] around the US.<ref>{{cite news|url=https://www.reuters.com/article/us-health-vaping-idUSKBN1XW20K|title=Ban on flavored vapes could lead to loss of 150,000 jobs, $8.4 billion sales hit: report|work=Reuters|date=22 November 2019}}</ref>

The leading seller in the e-cigarette market in the US is the Juul e-cigarette,<ref name=Richtel2018>{{cite news|url=https://www.nytimes.com/2018/08/27/science/juul-vaping-teen-marketing.html|title=Did Juul Lure Teenagers and Get 'Customers for Life'?|last1=Richtel|first1=Matt|last2=Kaplan|first2=Sheila|work=The New York Times|date=27 August 2018}}</ref> which was introduced in June 2015.<ref name=Yakowicz2015/> {{As of|2018|08}}, Juul accounts for over 72% of the US e-cigarette market monitored by Nielsen, and its closest competitor—]' ]—makes up less than 10% of the market.<ref name=Craver0818/> Juul rose to popularity quickly, growing by 700% in 2016 alone.<ref name=Suiters2018>{{cite news|url=http://wjla.com/features/7-on-your-side/are-your-kids-juuling-at-school-7-on-your-side-investigates|title=Are your kids juuling at school? 7 On Your Side investigates |author=Kimberly Suiters|publisher=]|date=31 January 2018|access-date=29 September 2018|archive-date=22 June 2018|archive-url=https://web.archive.org/web/20180622140236/http://wjla.com/features/7-on-your-side/are-your-kids-juuling-at-school-7-on-your-side-investigates|url-status=dead}}</ref> On 17 July 2018 Reynolds announced it will debut in August 2018 a ] type device similar Juul.<ref name=Craver0818>{{cite news|url=https://www.journalnow.com/business/juul-expands-e-cig-market-share-gap-with-reynolds-vuse/article_0bb4d442-fc0f-5c00-8b05-29bbf95dc985.html|title=Juul expands e-cig market share gap with Reynolds' Vuse|last1=Craver|first1=Richard|work=Winston-Salem Journal|date=25 August 2018}}</ref> The popularity of the Juul pod system has led to a flood of other pod devices hitting the market.<ref>{{cite web |url=https://truthinitiative.org/news/juul-copycats-are-flooding-market|title=JUUL copycats are flooding the e-cigarette market|publisher=Truth Initiative|date=8 August 2018}}</ref>

<!-- Canada -->
In Canada, e-cigarettes had an estimated value of 140 million CAD in 2015.<ref name=Yuen2015>{{cite news|url=http://www.torontosun.com/2015/07/04/wild-west-for-e-cigarette-use-in-canada-critic-says|title='Wild West' for e-cigarette use in Canada, critic says|last1=Yuen|first1=Jenny|newspaper=Toronto Sun|date=4 July 2015}}</ref> There are numerous e-cigarette retail shops in Canada.<ref>{{cite news|url=http://www.ottawasun.com/2014/04/06/e-cig-retailers-stand-up-to-health-canada|title=E-cig retailers stand up to Health Canada|author=Aedan Helmer|work=]|date=6 April 2014}}</ref> A 2014 audit of retailers in four Canadian cities found that 94% of grocery stores, convenience stores, and tobacconist shops which sold e-cigarettes sold nicotine-free varieties only, while all vape shops stocked at least one nicotine-containing product.<ref name=Hammond2015>{{cite journal |last1=Hammond|first1=D|last2=White|first2=CM|last3=Czoli|first3=CD|last4=Martin|first4=CL|last5=Magennis|first5=P|last6=Shiplo|first6=S|title=Retail availability and marketing of electronic cigarettes in Canada |journal=Canadian Journal of Public Health|date=9 October 2015|volume=106|issue=6|pages=e408–12|url=http://davidhammond.ca/wp-content/uploads/2014/12/2015-Ecig-Retail-in-Canada-CJPH-Hammond.pdf|doi=10.17269/cjph.106.5105 |pmid=26680433|pmc=6972063}}</ref>

<!-- UK -->
By 2015, the e-cigarette market had only reached a twentieth of the size of the tobacco market in the UK.<ref name=HiscockBranston2017>{{cite journal|last1=Hiscock|first1=Rosemary|last2=Branston|first2=J Robert|last3=McNeill |first3=Ann|last4=Hitchman|first4=Sara C|last5=Partos|first5=Timea R|last6=Gilmore|first6=Anna B|title=Tobacco industry strategies undermine government tax policy: evidence from commercial data|journal=Tobacco Control |volume=27|issue=5|year=2017|pages=tobaccocontrol–2017–053891|issn=0964-4563|doi=10.1136/tobaccocontrol-2017-053891|pmc=6109235|pmid=28993519}}{{CC-notice|cc=by4|url=http://tobaccocontrol.bmj.com/content/early/2017/10/09/tobaccocontrol-2017-053891.long#ref-73|author(s)=Rosemary Hiscock, J Robert Branston, Ann McNeill, Sara C Hitchman, Timea R Partos, Anna B Gilmore}}</ref> In the UK in 2015 the "most prominent brands of cigalikes" were owned by tobacco companies, however, with the exception of one model, all the tank types came from "non-tobacco industry companies".{{sfn|McNeill|2015|p=15}} Yet some tobacco industry products, while using prefilled cartridges, resemble tank models.{{sfn|McNeill|2015|p=15}}

<!-- France -->
France's e-cigarette market was estimated by Groupe Xerfi to be ]130 million in 2015.<ref name=Lastennet2016/> Additionally, France's e-liquid market was estimated at €265 million.<ref name=Lastennet2016>{{cite news|url=http://www.letelegramme.fr/bretagne/cigarettes-electroniques-le-marche-de-la-vape-en-deux-cartes-07-02-2016-10949003.php|title=Cigarettes électroniques. Le marché de la vape en deux cartes|last1=Lastennet |first1=Vincent|work=Le Télégramme|date=7 February 2016}}</ref> In December 2015, there were 2,400 vape shops in France, 400 fewer than in March of the same year.<ref name=Lastennet2016/> Industry organization Fivape said the reduction was due to consolidation, not to reduced demand.<ref name=Lastennet2016/>

In ], the e-cigarette market is growing rapidly, with the use rate increasing 18 times from 2015 to 2020.<ref>{{Cite web |title=Thuốc lá điện tử, nung nóng độc hại, vì sao có sức hút lớn với giới trẻ Việt Nam? - Tin tổng hợp - Cổng thông tin Bộ Y tế |url=https://moh.gov.vn/tin-tong-hop/-/asset_publisher/k206Q9qkZOqn/content/thuoc-la-ien-tu-nung-nong-oc-hai-vi-sao-co-suc-hut-lon-voi-gioi-tre-viet-nam- |access-date=2023-12-15 |website=moh.gov.vn}}</ref><ref>{{Cite web |last=Võ |first=Thu |title=5 năm, tỷ lệ hút thuốc lá điện tử ở cả nam và nữ tại Việt Nam tăng 18 lần |url=https://vietnamnet.vn/5-nam-ty-le-hut-thuoc-la-dien-tu-o-ca-nam-va-nu-tang-18-lan-2178336.html |access-date=2023-12-15 |website=VietNamNet News |language=vietnamese}}</ref> The use rate of e-cigarettes in adolescents aged 13–15 is 3.5%, up 1.6% from 2019.<ref>{{Cite web |title=Tỷ lệ dùng thuốc lá điện tử ở nhóm 13-15 tuổi là 3,5% |url=https://tuoitrethudo.com.vn/ty-le-dung-thuoc-la-dien-tu-o-nhom-13-15-tuoi-la-35-214306.html |access-date=2023-12-15 |website=Báo Tuổi Trẻ Thủ Đô |language=vi}}</ref><ref>{{Cite web |last=Lê |first=Nga |title=Học sinh 13-15 tuổi hút thuốc lá điện tử tăng |url=https://vnexpress.net/hoc-sinh-13-15-tuoi-hut-thuoc-la-dien-tu-tang-4552652.html |access-date=2023-12-15 |website=vnexpress.net |language=vi}}</ref><ref>{{Cite web |last=VnExpress |title=Học sinh 13-15 tuổi hút thuốc lá điện tử tăng |url=https://baoquangninh.vn/hoc-sinh-13-15-tuoi-hut-thuoc-la-dien-tu-tang-3219632.html |access-date=2023-12-15 |website=baoquangninh.vn |language=vi}}</ref> According to estimates by the ] (WHO), the global economic losses caused by tobacco each year are $1.4 trillion.<ref>{{Cite web |date=2023-11-14 |title=Tổn thất kinh tế toàn cầu do thuốc lá gây ra mỗi năm là 1.400 tỷ USD |url=https://vtc.vn/ton-that-kinh-te-toan-cau-do-thuoc-la-gay-ra-moi-nam-la-1-400-ty-usd-ar837864.html |access-date=2023-12-15 |website=Báo điện tử VTC News |language=vi}}</ref> Economic losses caused by tobacco are estimated to account for 1% of GDP.<ref>{{Cite web |title=Đề xuất cấm lưu hành thuốc lá điện tử tại Việt Nam |url=https://dangcongsan.vn/y-te/de-xuat-cam-luu-hanh-thuoc-la-dien-tu-tai-viet-nam-653229.html |access-date=2023-12-15 |website=dangcongsan.vn |language=en-US}}</ref><ref>{{Cite web |date=2023-11-23 |title=Gần 97% bệnh nhân ung thư phổi có hút thuốc lá |url=https://moha.gov.vn/chuyen-doi-so/tin-tong-hop/gan-97-benh-nhan-ung-thu-phoi-co-hut-thuoc-la-d611-t55698.html#:~:text=Th%E1%BB%91ng%20k%C3%AA%20c%E1%BB%A7a%20T%E1%BB%95%20ch%E1%BB%A9c,n%C4%83m%20l%C3%A0%201.400%20t%E1%BB%B7%20USD. |access-date=2023-12-15}}</ref> The ] is making efforts to control the e-cigarette market.<ref>{{Cite web |last=Phương |first=Thảo |title=Sớm "chốt" giải pháp kiểm soát thuốc lá điện tử |url=https://laodongthudo.vn/som-chot-giai-phap-kiem-soat-thuoc-la-dien-tu-157892.html |access-date=2023-12-15 |website=Báo Lao động thủ đô |language=vi}}</ref><ref>{{Cite web |date=2023-10-24 |title=Vapor Store |url=http://vaporstore.vn/ |access-date=2023-12-15 |website=Báo Nhân Dân điện tử |language=vi}}</ref><ref>{{Cite web |date=2023-10-31 |title=Ưu tiên hỗ trợ Việt Nam thực hiện các mục tiêu của Chiến lược Quốc gia về phòng chống tác hại thuốc lá |url=https://moha.gov.vn/chuyen-doi-so/tin-tong-hop/uu-tien-ho-tro-viet-nam-thuc-hien-cac-muc-tieu-cua-d611-t55636.html |access-date=2023-12-15}}</ref> However, here are still many challenges to be addressed, such as consumer's lack of understanding of the harm of e-cigarettes, unclear legal regulations, and fierce competition from imported e-cigarette products.<ref>{{Cite web |last=Theo |first=TTXVN |date=2015-05-29 |title=Kiểm soát thuốc lá tại Việt Nam: Vẫn nhiều thách thức |url=https://tuyengiao.vn/kiem-soat-thuoc-la-tai-viet-nam-van-nhieu-thach-thuc-75140 |access-date=2023-12-15}}</ref><ref>{{Cite web |date=2023-10-26 |title=Cần sớm quản lý đồng thời thuốc lá điện tử và thuốc lá làm nóng |url=https://moha.gov.vn/chuyen-doi-so/tin-tong-hop/can-som-quan-ly-dong-thoi-thuoc-la-dien-tu-va-thuo-d611-t55628.html |access-date=2023-12-15}}</ref>

== Environmental impact ==
{{main|Environmental impact of electronic cigarettes}}
]

Compared to traditional cigarettes, reusable e-cigarettes do not create waste and potential litter from every use in the form of discarded ].<ref name=Howard2012/> Traditional cigarettes tend to end up in the ocean where they cause pollution,<ref name=Howard2012>{{cite web|url=http://voices.nationalgeographic.com/2012/04/11/cigarettes-vs-e-cigarettes-which-is-less-environmentally-harmful/ |archive-url=https://web.archive.org/web/20150324142409/http://voices.nationalgeographic.com/2012/04/11/cigarettes-vs-e-cigarettes-which-is-less-environmentally-harmful/ |url-status=dead |archive-date=24 March 2015 |title=Cigarettes vs. e-Cigarettes: Which Is Less Environmentally Harmful?|first1=Brian Clark|last1=Howard|work=]|date=11 April 2012}}</ref> though once discarded they undergo ] and ]. Although some brands have begun recycling services for their e-cigarette cartridges and batteries, the prevalence of recycling is unknown.<ref name=Chang2014/>

E-cigarettes that are not reusable contribute to the problem of ], which can create a hazard for people and other organisms.<ref name=Nowak2014/> If improperly disposed of, they can release ], nicotine, and other chemicals from batteries and unused e-liquid.<ref name="KimKabir2016" /><ref name=SmithBrar2016/> A July 2018–April 2019 garbology study found e-cigarette products composed 19% of the waste from all traditional and electronic tobacco and cannabis products collected at 12 public high schools in Northern California.<ref name=Mock2019>{{cite journal|last1=Mock|first1=Jeremiah|title=Notes from the Field: Environmental Contamination from E-cigarette, Cigarette, Cigar, and Cannabis Products at 12 High Schools — San Francisco Bay Area, 2018–2019|journal=MMWR Morb Mortal Wkly Rep|volume=68|issue=40|year=2019 |pages=897–899|doi=10.15585/mmwr.mm6840a4|pmc=6788397 |pmid=31600185}}</ref>

Councils in England and Wales are pushing for a 2024 ban on single-use vapes due to environmental and health risks, as 1.3 million are thrown away weekly. Recycling challenges, waste issues, and fire hazards are cited. Concerns about youth vaping are also raised. The ] defends disposables as quitting aids but warns of potential black market products if banned.<ref>{{Cite news |last= Davey |first= James |date=2023-07-15 |title= UK councils call for ban on disposable vapes by 2024 |language=en |work=Reuters |url= https://www.reuters.com/world/uk/uk-councils-call-ban-disposable-vapes-by-2024-2023-07-15/ |access-date=2023-07-24}}</ref>

== Related technologies ==
Other devices to deliver inhaled nicotine have been developed.<ref name=Giroudde2015/> They aim to mimic the ritual and behavioral aspects of traditional cigarettes.<ref name="Giroudde2015">{{cite journal |last1=Giroud |first1=Christian|last2=de Cesare|first2=Mariangela|last3=Berthet|first3=Aurélie |last4=Varlet|first4=Vincent|last5=Concha-Lozano|first5=Nicolas|last6=Favrat|first6=Bernard|title=E-Cigarettes: A Review of New Trends in Cannabis Use|journal=International Journal of Environmental Research and Public Health|volume=12|issue=8|year=2015|pages=9988–10008|issn=1660-4601|pmc=4555324 |pmid=26308021|doi=10.3390/ijerph120809988|doi-access=free}}{{CC-notice|cc=by4|url=http://www.mdpi.com/1660-4601/12/8/9988/htm|author(s)=Christian Giroud, Mariangela de Cesare, Aurélie Berthet, Vincent Varlet, Nicolas Concha-Lozano, and Bernard Favrat}}</ref>

British American Tobacco, through their subsidiary Nicoventures, licensed a nicotine delivery system based on existing asthma ] technology from UK-based healthcare company ].<ref>{{cite news |title=BAT unit to market nicotine inhaler|publisher=Tobacco Journal International |url=http://www.tobaccojournal.com/BAT_unit_to_market__innovative__nicotine_inhaler.50583.0.html |date=7 June 2011}}</ref> In September 2014 a product based on this named Voke obtained approval from the United Kingdom's Medicines and Healthcare Products Regulatory Agency.<ref name=Odell2014>{{cite news |url=http://www.ft.com/cms/s/0/ecff7448-3a86-11e4-bd08-00144feabdc0.html|title=British American Tobacco nicotine inhaler wins regulatory approval|author=Mark Odell|work=Financial Times|date=12 September 2014}}</ref>

In 2011, ] bought the rights to a nicotine pyruvate technology developed by Jed Rose at Duke University.<ref>{{cite news |author=Michael Felberbaum |date=26 May 2011 |url= https://www.boston.com/business/articles/2011/05/26/philip_morris_intl_buys_rights_to_nicotine_system/ |title=Philip Morris Int'l buys rights to nicotine system|work=]|agency=Associated Press}}</ref> The technology is based on the chemical reaction between ] and nicotine, which produces an inhalable nicotine pyruvate vapor.<ref>{{cite web |date=27 February 2010 |url=http://esciencenews.com/articles/2010/02/27/new.smoking.cessation.therapy.proves.promising |title=New smoking cessation therapy proves promising |website=Esciencenews}}</ref> Philip Morris Products S.A. created a different kind e-cigarette named P3L.{{sfnp|National Academies of Sciences, Engineering, and Medicine|2018|loc=Nicotine Salts |p=96}} The device is supplied with a cartridge that contains nicotine and lactic acid in different cavities.{{sfnp|National Academies of Sciences, Engineering, and Medicine|2018|loc=Nicotine Salts |p=96}} When turned on and heated, the nicotine salt called nicotine lactate forms an aerosol.{{sfnp|National Academies of Sciences, Engineering, and Medicine|2018|loc=Nicotine Salts |p=96}}

]
The ] is a heated tobacco product marketed by Philip Morris International.<ref name=Uranaka2016>{{cite news|url=https://huffingtonpost.com/entry/iqos-e-cigarette_us_56fa8639e4b0a372181af0c4|title=Big Tobacco Is Starting To Cash In On Vaping|author1=Taiga Uranaka|author2=Ritsuko Shimizu|work=HuffPost|agency=Reuters|date=29 March 2016}}</ref> It heats tobacco at a lower temperature than traditional cigarettes.<ref name=LiSaad2018>{{cite journal|last1=Li|first1=Gerard|last2=Saad|first2=Sonia|last3=Oliver|first3=Brian|last4=Chen|first4=Hui|title=Heat or Burn? Impacts of Intrauterine Tobacco Smoke and E-Cigarette Vapor Exposure on the Offspring's Health Outcome|journal=Toxics|volume=6|issue=3|year=2018|pages=43|issn=2305-6304|doi=10.3390/toxics6030043|pmc=6160993|pmid=30071638|doi-access=free}}{{CC-notice|cc=by4|url=https://www.mdpi.com/2305-6304/6/3/43/htm|author(s)=Gerard Li, Sonia Saad, Brian G. Oliver, and Hui Chen}}</ref> The tobacco sticks reach a temperature up to 350&nbsp;°C.<ref>{{cite news |url=http://www.salon.com/2014/06/26/philip_morris_intl_to_sell_marlboro_heatsticks/|title=Philip Morris Int'l to sell Marlboro Heatsticks|author=Michael Felberbaum|publisher=Salon Media Group |agency=Associated Press|date=26 June 2014|access-date=2 June 2019|archive-date=28 June 2014|archive-url=https://web.archive.org/web/20140628134323/http://www.salon.com/2014/06/26/philip_morris_intl_to_sell_marlboro_heatsticks/|url-status=dead}}</ref> It sold first in Japan since November 2014.<ref name=TabuchiKiyohara2016>{{cite journal|last1=Tabuchi|first1=Takahiro|last2=Kiyohara|first2=Kosuke |last3=Hoshino|first3=Takahiro|last4=Bekki|first4=Kanae|last5=Inaba|first5=Yohei|last6=Kunugita |first6=Naoki|title=Awareness and use of electronic cigarettes and heat-not-burn tobacco products in Japan|journal=Addiction|volume=111|issue=4|year=2016|pages=706–713|issn=0965-2140|doi=10.1111/add.13231 |pmid=26566956}}</ref> In December 2016, the United Tobacco Vapor Group's (UTVG) stated that they have been given a patent for their vaporizing component system.<ref name=Yahoo2016/> qmos from UTVG does not contain a wick or sponge and the number of components is 5 compared to 20 for traditional e-cigarettes.<ref name=Yahoo2016>{{cite news|url=https://finance.yahoo.com/news/vaporizing-technology-qmos-set-revolutionize-140000566.html|title=New Vaporizing Technology, qmos, set to Revolutionize Vaping and E-Cigarette Industries|publisher=]|agency=]|date=2 December 2016}}</ref>

] has developed vaporizers that heats the leaves of tobacco to deliver nicotine in a vapor.<ref>{{cite news|url=https://www.bloomberg.com/bw/articles/2013-11-21/plooms-e-cigarettes-vaporizers-use-real-tobacco|title=Ploom's E-Cigarettes and Vaporizers Use Real Tobacco|author=Brad Stone|work=]|date=21 November 2013}}</ref><ref>{{cite news|author=Melissa Vonder Haar|work=CSP Magazine|date=11 March 2015|url=http://www.cspnet.com/category-news/tobacco/articles/pax-labs-ceo-teases-fundamentally-different-e-cigarette|title=PAX Labs CEO Teases 'Fundamentally Different' E-Cigarette |archive-url=https://web.archive.org/web/20160419214721/http://www.cspnet.com/category-news/tobacco/articles/pax-labs-ceo-teases-fundamentally-different-e-cigarette |archive-date=19 April 2016|url-status=dead}}</ref> In June 2015, they introduced ], a type of e-cigarette which delivers 10 times as much nicotine as other e-cigarettes, equivalent to an actual cigarette puff.<ref name=Yakowicz2015>{{cite news|url=http://www.inc.com/will-yakowicz/pax-labs-vaporizer-company-raises-47-million.html|title=This Silicon Valley Company Just Raised $47 Million to Smoke Cigarette Makers|author=Will Yakowicz |work=]|date=10 June 2015}}</ref> Juul was spun off from Pax Labs in June 2017 and is now available by the independent company Juul Labs.<ref>{{cite news |url=https://techcrunch.com/2018/02/08/pax-labs-brings-on-bharat-vasan-as-new-ceo/|last1=Crook |first1=Jordan|title=PAX Labs brings on Bharat Vasan as new CEO|work=]|date=8 February 2018}}</ref> The eTron 3T from Vapor Tobacco Manufacturing, launched in December 2014,<ref name=Tuinstra2014/> employs a patented, aqueous system whereby the tobacco is extracted into water.<ref name="O'Connell2013">{{cite web|last1=O'Connell|first1=Thomas|title=US8479747B2 - Method for preparing tobacco extract for electronic smoking devices|url=https://patents.google.com/patent/US8479747 |website=Google Patents|date=9 July 2013}}</ref> The e-liquid contains ] tobacco, organic glycerin, and water.<ref name=Tuinstra2014>{{cite news|last1=Tuinstra|first1=Taco |url=http://www.tobaccoreporter.com/2014/12/certified-organic-e-liquids-being-launched-by-vtm/ |title=Certified organic e-liquids being launched by VTM |work=Tobacco Reporter|date=16 December 2014}}</ref>

In December 2013, ] launched Ploom in Japan.<ref name=Tuinstra2016>{{cite news|url=http://www.tobaccoreporter.com/2016/01/jt-announces-launch-of-next-generation-ploom/|title=JT announces launch of next-generation Ploom|first=Taco |last=Tuinstra|work=Tobacco Reporter|date=26 January 2016}}</ref> In January 2016, they launched Ploom TECH<ref name=Rossel2016>{{cite news|url=http://www.tobaccoreporter.com/2016/07/blending-nature-and-technology/|title=Blending nature and technology|first=Stefanie |last=Rossel|work=Tobacco Reporter|date=1 July 2016}}</ref> that produces a vapor from a heated liquid that moves through a capsule of granulated tobacco leaves.<ref name=Chambers2017>{{cite news|url=https://www.bloomberg.com/news/articles/2017-02-03/japan-tobacco-sees-no-quick-fix-for-heat-not-burn-shortage|title=Japan Tobacco Sees No Quick Fix for Heat-Not-Burn Shortage|first=Sam |last=Chambers|work=Bloomberg News|date=3 February 2017}}</ref> In 2016, British American Tobacco (BAT) released its own version of the heat but not burn technology called glo in Japan<ref>{{cite news |url=http://www.japantimes.co.jp/news/2017/03/22/business/corporate-business/bat-finds-strong-japan-demand-glo-smokeless-tobacco-device/|title=BAT finds strong Japan demand for its Glo smokeless tobacco device|work=The Japan Times|agency=Reuters|date=22 March 2017}}</ref> and Switzerland.<ref>{{cite news|url=https://www.nytimes.com/reuters/2017/04/26/business/26reuters-brit-am-tobacco-agm.html?_r=0|title=British American Says 2017 Trading in Line With Expectations|work=The New York Times|agency=Reuters|date=26 April 2017}}</ref> It uses tobacco sticks rather than nicotine liquid,<ref name=Uranaka2017>{{cite news|url=https://www.reuters.com/article/us-brit-am-tobacco-smokeless-idUSKBN18Q0EB|title=British American Tobacco will expand sales of its "glo" tobacco-heating device to Tokyo and Osaka from July|last1=Uranaka|first1=Taiga|last2=Sarkar|first2=Himani|publisher=Reuters |date=30 May 2017}}</ref> and does not directly heat or burn tobacco.<ref name=ANI2016>{{cite news |url=http://www.india.com/buzz/now-safer-e-cigarette-with-tobacco-flavour-less-harmful-smoke-1010152/ |title=Now, 'safer' e-cigarette with tobacco flavour, less harmful smoke|author=ANI|publisher=]|agency=India WebPortal Private Limited|date=6 March 2016}}</ref> Heated tobacco products were first introduced in 1988, but were not a commercial success.<ref name=Caputi2016>{{cite journal|last1=Caputi|first1=TL|title=Heat-not-burn tobacco products are about to reach their boiling point.|journal=Tobacco Control|volume=26|issue=5|pages=609–610|date=24 August 2016|pmid=27558827 |s2cid=46170776|doi=10.1136/tobaccocontrol-2016-053264}}</ref>

BLOW started selling e-hookahs, an electronic version of the ] in 2014.<ref>{{cite news |url=http://www.nbcsandiego.com/news/local/E-Hookah-vape-cigarette-smoke-243042311.html|title='E-Hookah' Debuts in San Diego Amid Critics|author=Candice Nguyen|publisher=NBCUniversal|date=1 February 2014}}</ref> The handle of each hose for the e-hookah contains a heating element and a liquid, which produces vapor.<ref name=Ochs2014>{{cite news |url=http://www.pcworld.com/article/2099480/blow-hookah-no-fire-no-charcoal-just-vapor-and-lasers.html|title=Blow Hookah: No fire, no charcoal, just vapor and lasers |author=Susie Ochs|work=] |agency=TechHive |date=20 February 2014|access-date=2 June 2019 |archive-url=https://web.archive.org/web/20170318200026/http://www.pcworld.com/article/2099480/blow-hookah-no-fire-no-charcoal-just-vapor-and-lasers.html|archive-date=18 March 2017|url-status=dead}}</ref> ], based in Toronto, Canada, invented a 3D printed adapter to turn a traditional hookah into an e-hookah.<ref name=Thimmesch2014>{{cite news |url=https://3dprint.com/17857/3d-printed-hookah/|title=Canadian Doctor Promotes a 3D Printed Adapter for Converting Hookahs to E-Hookahs |author=Debra Thimmesch|publisher=3DPrint.com|agency=3DR Holdings|date=7 October 2014}}</ref> It is used instead of the ceramic bowl that contains ].<ref name=3DPI2014/> Rather than the tobacco, users can insert e-cigarettes.<ref name=3DPI2014>{{cite news |url=https://3dprintingindustry.com/news/3dpi-tv-3d-printed-e-hookah-adapter-help-smokers-27401/ |title=3DPI.TV – 3D Printed e-Hookah Adapter Could Help Smokers|publisher=3DPI.TV|agency=3D Printing Industry|date=20 May 2014}}</ref>

== Cannabis vaping ==
{{Further|CBD cigarette}}
Some vape pens, generally not referred to as "e-cigarettes", contain ] derivatives instead of nicotine and tobacco derivatives. Some cannabis pens, known as "dab pens", contain cannabis extracted using butane as solvent ("butane hash oil"). Other vaporizers contain e-liquid made with pure THC, and they generally resemble conventional e-cigarettes. A 2020 study shows that one third of teenagers engaged in conventional, tobacco vaping also engage in THC vaping.<ref name="THC vaping article">{{cite journal |last1=Chadi |first1=Nicholas |last2=Minato |first2=Claudia |last3=Stanwick |first3=Richard |title=Cannabis vaping: Understanding the health risks of a rapidly emerging trend |journal=Paediatrics & Child Health |pages=S16–S20 |doi=10.1093/pch/pxaa016 |date=June 2020|volume=25 |issue=Suppl 1 |pmid=33390752 |pmc=7757764 }}</ref>

KanaVape is an e-cigarette containing ] (CBD) and no ].<ref>{{cite news |url=http://www.vice.com/en_se/read/kanavape-antonin-cohen-interview-france-cannabis-e-cigarette-legal-876 |author=Gaspard Glanz|author-link=Gaspard Glanz |title=France's First Cannabis E-Cigarette Is Completely Legal|publisher=Vice|date=17 December 2014}}</ref> Several companies including Canada's Eagle Energy Vapor are selling ]-based e-cigarettes instead of containing nicotine.<ref name=Ma2015>{{cite news|author=Alexandra Ma|date=11 August 2015|title=This Is What It's Like To Vape Caffeine |work=HuffPost |url=https://huffingtonpost.com/entry/eagle-energy-vapor-caffeine_55c8c514e4b0f1cbf1e5a202}}</ref>

==See also==
*]

==Notes==
{{Reflist|group=note}}


==References== ==References==
{{Reflist|30em}} {{Reflist}}

==Bibliography==
* {{cite web|last1=McNeill|first1=A|last2=Brose|first2=LS|last3=Calder|first3=R|last4=Bauld|first4=L |last5=Robson|first5=D|title=Evidence review of e-cigarettes and heated tobacco products 2018 |url=https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/684963/Evidence_review_of_e-cigarettes_and_heated_tobacco_products_2018.pdf|location=UK|website=Public Health England|pages=1–243|date=February 2018|ref={{harvid|McNeill|2018}}}}
* {{cite book|editor-last1=Stratton |editor-first1=Kathleen |editor-last2=Kwan |editor-first2=Leslie Y. |editor-last3=Eaton |editor-first3=David L. |title=Public Health Consequences of E-Cigarettes |author=((])) |publisher=] |place=Washington, DC |date=January 2018 |doi=10.17226/24952 |pmid=29894118 |isbn=978-0-309-46834-3 |collaboration=Committee on the Review of the Health Effects of Electronic Nicotine Delivery Systems |url=https://nap.nationalacademies.org/read/24952/chapter/1#vii |access-date=15 January 2023}}
* {{cite web|last1=Wilder|first1=Natalie|last2=Daley|first2=Claire|last3=Sugarman|first3=Jane |last4=Partridge|first4=James|title=Nicotine without smoke: Tobacco harm reduction |url=https://www.rcplondon.ac.uk/projects/outputs/nicotine-without-smoke-tobacco-harm-reduction-0 |location=UK|website=Royal College of Physicians|pages=1–191|date=April 2016|ref={{harvid|Wilder|2016}}}}
* {{cite web|last1=McNeill|first1=A|last2=Brose|first2=LS|last3=Calder|first3=R|last4=Hitchman|first4=SC |last5=Hajek|first5=P|last6=McRobbie|first6=H|title=E-cigarettes: an evidence update |url=https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/454516/Ecigarettes_an_evidence_update_A_report_commissioned_by_Public_Health_England.pdf|location=UK|website=Public Health England |pages=1–113 |date=August 2015|ref={{harvid|McNeill|2015}}}}
* {{cite web|title=State Health Officer's Report on E-Cigarettes: A Community Health Threat |website=]|agency=] |pages=1–21|date=January 2015 |url=https://www.cdph.ca.gov/Programs/CCDPHP/DCDIC/CTCB/CDPH%20Document%20Library/Policy/ElectronicSmokingDevices/StateHealthEcigReport.pdf |ref={{harvid|Chapman|2015}}}}{{PD-notice}}
* {{cite web|url=http://apps.who.int/gb/fctc/PDF/cop6/FCTC_COP6_10-en.pdf|title=Electronic nicotine delivery systems|website=World Health Organization|pages=1–13|date=21 July 2014|ref={{harvid|WHO|2014}}}}
* {{cite web|author1=Linda Bauld|author2=Kathryn Angus|author3=Marisa de Andrade|date=May 2014 |url=https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/311491/Ecigarette_uptake_and_marketing.pdf|title=E-cigarette uptake and marketing|location=UK|website=Public Health England |pages=1–19|ref={{harvid|Bauld|2014}}}}
* {{cite book|url=https://stacks.cdc.gov/view/cdc/21569/Share|title=The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General|publisher=] |pmid=24455788 |author1=National Center for Chronic Disease Prevention Health Promotion (US) Office on Smoking Health|pages=1–943|year=2014|ref={{harvid|SGUS|2014}}}}


==External links== ==External links==
* {{commonscat-inline|Electronic cigarettes}} * {{Commons category-inline|Electronic cigarettes}}


{{Electronic cigarettes}}
{{Cigarettes}}
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Latest revision as of 23:18, 6 December 2024

Device that vaporizes a liquid nicotine solution for inhalation "Vape" redirects here. For the Argentine reconnaissance vehicle, see VAPE. Not to be confused with Heated tobacco product or Vaporizer (inhalation device).

Photo of device
A first-generation e-cigarette that resembles a tobacco cigarette, with a battery portion that can be disconnected and recharged using the USB power charger
Photo of devices
Various types of e-cigarettes from 2015, including a disposable e-cigarette, a rechargeable e-cigarette, a medium-size tank device, large-size tank devices, an e-cigar, and an e-pipe

An electronic cigarette (e-cigarette), commonly called a vape, is a device that simulates tobacco smoking. It consists of an atomizer, a power source such as a battery, and a container such as a cartridge or tank. Instead of smoke, the user inhales vapor. As such, using an e-cigarette is often called "vaping". The atomizer is a heating element that vaporizes a liquid solution called e-liquid, which quickly cools into an aerosol of tiny droplets, vapor and air. The vapor mainly comprises propylene glycol and/or glycerin, usually with nicotine and flavoring. Its exact composition varies, and depends on several things including user behavior.

E-cigarettes are activated by taking a puff or pressing a button. Some look like traditional cigarettes, and most kinds are reusable.

Nicotine is highly addictive. Users become physically and psychologically dependent. Scientists do not know how harmful e-cigarettes are over the long-term because it is hard to separate the effects of vaping from the effects of smoking when so many people both vape and smoke. E-cigarettes have not been used widely enough or for long enough to be sure.

Vaping is likely far less harmful than smoking, but still harmful. E-cigarette vapor contains far fewer toxins than cigarette smoke, and at much lower concentrations. The vapor contains traces of harmful substances not found in cigarette smoke. E-cigarettes containing nicotine are more effective than nicotine replacement therapy (NRT) for smoking cessation. However, e-cigarettes have not been subject to the same rigorous testing that most nicotine replacement therapy products have, and health warnings may encourage a smoker to quit vaping.

Construction

Main article: Construction of electronic cigarettes
The first image is displaying an exploded view of an e-cigarette with a transparent clearomizer and changeable dual-coil head.
An exploded view of a typical e-cigarette design with transparent atomizer (labeled clearomizer in diagram) and changeable dual-coil head.

An electronic cigarette consists of an atomizer, a power source such as a battery, and a container for e-liquid such as a cartridge or tank.

E-cigarettes have evolved over time, and the different designs are classified in generations. First-generation e-cigarettes tend to look like traditional cigarettes and are called "cigalikes". Second-generation devices are larger and look less like traditional cigarettes. Third-generation devices include mechanical mods and variable voltage devices. The fourth-generation includes sub-ohm tanks (meaning they have electrical resistance of less than 1 ohm) and temperature control. There are also pod mod devices that use protonated nicotine, rather than free-base nicotine found in earlier generations, providing higher nicotine yields.

E-liquid

The mixture used in vapor products such as e-cigarettes is called e-liquid. E-liquid formulations vary widely. A typical e-liquid is composed of propylene glycol and glycerin (95%) and a combination of flavorings, nicotine, and other additives (5%). The flavorings may be natural, artificial, or organic. Over 80 harmful chemicals such as formaldehyde and metallic nanoparticles have been found in e-liquids at trace quantities. There are many e-liquid manufacturers, and more than 15,000 flavors.

Many countries regulate what e-liquids can contain. In the US, there are Food and Drug Administration (FDA) compulsory manufacturing standards and American E-liquid Manufacturing Standards Association (AEMSA) recommended manufacturing standards. European Union standards are published in the EU Tobacco Products Directive.

Coils

In 2019 a study found that the metal coils of e-cigarettes can leach metal into the e-liquid leading to permanent lung damage in some cases. Research has shown that higher voltages generate more heat and release more toxic substances into the e-liquid. Vaping cannabis usually involves higher temperatures than nicotine.

Use

Popularity

Estimated trends in the global number of vapers

Since entering the market around 2003, e-cigarette use has risen rapidly. In 2011 there were about 7 million adult e-cigarette users globally, increasing to 68 million in 2020 compared with 1.1 billion cigarette smokers. There was a further rise to 82 million e-cigarette users in 2021. This increase has been attributed to targeted marketing, lower cost compared to conventional cigarettes, and the better safety profile of e-cigarettes compared to tobacco. E-cigarette use is highest in China, the US, and Europe, with China having the most users.

Motivation

Reasons for initiating e-cigarette use in the European Union, in a 2018 Eurobarometer poll

There are varied reasons for e-cigarette use. Most users are trying to quit smoking, but a large proportion of use is recreational or as an attempt to get around smoke-free laws. Many people vape because they believe vaping is safer than smoking. The wide choice of flavors and lower price compared to cigarettes are also important factors.

Other motivations include reduced odor and fewer stains. E-cigarettes also appeal to technophiles who enjoy customizing their devices.

Gateway theory

The gateway hypothesis is the idea that using less harmful drugs can lead to more harmful ones. Evidence shows that many users who begin by vaping will go on to also smoke traditional cigarettes. People with mental illnesses, who as a group are more susceptible to nicotine addiction, are at particularly high risk of dual use.

However, an association between vaping and subsequent smoking does not necessarily imply a causal gateway effect. Instead, people may have underlying characteristics that predispose them to both activities. There is a genetic association between smoking, vaping, gambling, promiscuity and other risk-taking behaviors. Young people with poor executive functioning use e-cigarettes, cigarettes, and alcohol at higher rates than their peers. E-cigarette users are also more likely to use both cannabis and unprescribed Adderall or Ritalin. Longitudinal studies of e-cigarettes and smoking have been criticized for failing to adequately control for these and other confounding factors.

Smoking rates have continually declined as e-cigarettes have grown in popularity, especially among young people, suggesting that there is little evidence for a gateway effect at the population level. This observation has been criticized, however, for ignoring the effect of anti-smoking interventions.

Young adult and teen use

Worldwide, increasing numbers of young people are vaping. With access to e-cigarettes, young people's tobacco use has dropped by about 75%.

Most young e-cigarette users have never smoked, but there is a substantial minority who both vape and smoke. Many young people who would not smoke are vaping. Young people who smoke tobacco or marijuana, or who drink alcohol, are much more likely to vape. Among young people who have tried vaping, most used a flavored product the first time.

Vaping correlates with smoking among young people, even in those who would otherwise be unlikely to smoke. Experimenting with vaping encourages young people to continue smoking. A 2015 study found minors had little resistance to buying e-cigarettes online. Teenagers may not admit to using e-cigarettes, but use, for instance, a hookah pen. As a result, self-reporting may be lower in surveys.

More recent studies show a trend of an increasing proportion of young people who use e-cigarettes. In 2018, 20% of high school students were using e-cigarettes. In 2020, however, this number increased to 50% of high school students reported to have used e-cigarettes. Similarly, in Canada, there has been trend showing 29% of young people reporting to have used e-cigarettes in 2017, increasing to 37% in 2018.

Health effects

Main article: Health effects of electronic cigarettes

The health risks of e-cigarettes are not known for certain, but the risk of serious adverse events is thought to be low, and e-cigarettes are likely safer than combusted tobacco products. However, this does not mean that e-cigarettes are harmless. E-cigarette use is associated with increased risk of chronic obstructive pulmonary disease, asthma, chronic bronchitis, and emphysema. Those who use e-cigarettes daily have higher risk than those who use them occasionally. According to the National Academies of Sciences, Engineering, and Medicine, "Laboratory tests of e-cigarette ingredients, in vitro toxicological tests, and short-term human studies suggest that e-cigarettes are likely to be far less harmful than combustible tobacco cigarettes." Randomized controlled trials provide "high-certainty" evidence that e-cigarettes containing nicotine are more effective than nicotine replacement therapy for discontinuing tobacco smoking, and moderate‐certainty evidence that they are more effective than e-cigarettes free of nicotine.

Some of the most common but less serious adverse effects include abdominal pain, headache, blurry vision, throat and mouth irritation, vomiting, nausea, and coughing. Nicotine is addictive and harmful to fetuses, children, and young people. In 2019 and 2020, an outbreak of severe vaping lung illness in the US was strongly linked to vitamin E acetate by the CDC. While it is still widely debated which particular component of vape liquid is the cause of illness, vitamin E acetate, specifically, has been identified as a potential culprit in vape-related illnesses. There was likely more than one cause of the outbreak.

E-cigarettes produce similar levels of particulates to tobacco cigarettes. There is "only limited evidence showing adverse respiratory and cardiovascular effects in humans", with the authors of a 2020 review calling for more long-term studies on the subject. E-cigarettes increase the risk of asthma by 40% and chronic obstructive pulmonary disease by 50% compared to not using nicotine at all.

Pregnancy

The British Royal College of Midwives states: "While vaping devices such as electronic cigarettes (e-cigs) do contain some toxins, they are at far lower levels than found in tobacco smoke. If a pregnant woman who has been smoking chooses to use an e-cig and it helps her to quit smoking and stay smokefree, she should be supported to do so." Based on the available evidence on e-cigarette safety, there was also "no reason to believe that use of an e-cig has any adverse effect on breastfeeding." The statement went on to say, "vaping should continue, if it is helpful to quitting smoking and staying smokefree". The UK National Health Service says: "If using an e-cigarette helps you to stop smoking, it is much safer for you and your baby than continuing to smoke." Many women who vape continue to do so during pregnancy because of the perceived safety of e-cigarettes compared to tobacco.

United States

In one of the few studies identified, a 2015 survey of 316 pregnant women in a Maryland clinic found that the majority had heard of e-cigarettes, 13% had used them, and 0.6% were current daily users. These findings are of concern because the dose of nicotine delivered by e-cigarettes can be as high or higher than that delivered by traditional cigarettes.

Data from two states in the Pregnancy Risk Assessment System (PRAMS) show that in 2015—roughly the mid-point of the study period—10.8% of the sample used e-cigarettes in the three months prior to the pregnancy while 7.0%, 5.8%, and 1.4% used these products at the time of the pregnancy, in the first trimester, and at birth respectively. According to National Health Interview Survey (NHIS) data from 2014 to 2017, 38.9% of pregnant smokers used e-cigarettes compared to only 13.5% of non-pregnant, reproductive age women smokers. A health economic study found that passing an e-cigarette minimum legal sale age law in the United States increased teenage prenatal smoking by 0.6 percentage points and had no effect on birth outcomes. Nevertheless, additional research needs to be done on the health effects of electronic cigarette use during pregnancy.

According to the CDC, E-cigarettes are not safe during pregnancy. "Although the aerosol of e-cigarettes generally has fewer harmful substances than cigarette smoke, e-cigarettes and other products containing nicotine are not safe to use during pregnancy. Nicotine is a health danger for pregnant women and developing babies and can damage a developing baby's brain and lungs. Also, some of the flavorings used in e-cigarettes may be harmful to a developing baby."

A popular vaporizer named Juul was widely used by American young people until 2022, when the FDA banned its products from sale. Close to 80% of respondents in a 2017 Truth Initiative study aged 15–24 reported using Juul also used the device in the last 30 days. In the 2010s, US teenagers used the verb "Juuling" to describe vaping, and Juuling was the subject of widespread memes on social media.

Harm reduction

Switching from tobacco to vaping may reduce weight gain after smoking cessation, increase exercise tolerance, reduce exposure to toxic chemicals, and reduce risk of death. Vaping may reduce shortness of breath, reduce coughing, reduce spitting, and reduce sore throat compared to tobacco.
Effects of vaping, compared to tobacco smoking

Harm reduction refers to any reduction in harm from a prior level. Harm minimization strives to reduce harms to the lowest achievable level. When a person does not want to quit nicotine, harm minimization means striving to eliminate tobacco exposure by replacing it with vaping. E-cigarettes can reduce smokers' exposure to carcinogens and other toxic chemicals found in tobacco.

Tobacco harm reduction has been a controversial area of tobacco control. Health advocates have been slow to support a harm reduction method out of concern that tobacco companies cannot be trusted to sell products that will lower the risks associated with tobacco use. A large number of smokers want to reduce harm from smoking by using e-cigarettes. The argument for harm reduction does not take into account the adverse effects of nicotine. There cannot be a defensible reason for harm reduction in children who are vaping with a base of nicotine. Quitting smoking is the most effective strategy to tobacco harm reduction.

Tobacco smoke contains 100 known carcinogens and 900 potentially cancer-causing chemicals, but e-cigarette vapor contains less of the potential carcinogens than found in tobacco smoke. A study in 2015 using a third-generation device found levels of formaldehyde were greater than with cigarette smoke when adjusted to a maximum power setting. E-cigarettes cannot be considered safe because there is no safe level for carcinogens. Due to their similarity to traditional cigarettes, e-cigarettes could play a valuable role in tobacco harm reduction. The public health community remains divided concerning the appropriateness of endorsing a device whose safety and efficacy for smoking cessation remain unclear. Overall, the available evidence supports the cautionary implementation of harm reduction interventions aimed at promoting e-cigarettes as attractive and competitive alternatives to cigarette smoking, while taking measures to protect vulnerable groups and individuals.

The core concern is that smokers who could have quit entirely will develop an alternative nicotine addiction. Dual use may be an increased risk to a smoker who continues to use even a minimal amount of traditional cigarettes, rather than quitting. Because of the convenience of e-cigarettes, it may further increase the risk of addiction. The promotion of vaping as a harm reduction aid is premature, while a 2011 review found they appear to have the potential to lower tobacco-related death and disease. Evidence to substantiate the potential of vaping to lower tobacco-related death and disease is unknown. The health benefits of reducing cigarette use while vaping is unclear. E-cigarettes could have an influential role in tobacco harm reduction. The authors warned against the potential harm of excessive regulation and advised health professionals to consider advising smokers who are reluctant to quit by other methods to switch to e-cigarettes as a safer alternative to smoking.

A 2014 review recommended that regulations for e-cigarettes could be similar to those for dietary supplements or cosmetic products to not limit their potential for harm reduction. A 2012 review found e-cigarettes could considerably reduce traditional cigarettes use and they likely could be used as a lower risk replacement for traditional cigarettes, but there is not enough data on their safety and efficacy to draw definite conclusions. There is no research available on vaping for reducing harm in high-risk groups such as people with mental disorders.

A 2014 PHE report concluded that hazards associated with products currently on the market are probably low, and apparently much lower than smoking. However, harms could be reduced further through reasonable product standards. The British Medical Association encourages health professionals to recommend conventional nicotine replacement therapies, but for patients unwilling to use or continue using such methods, health professionals may present e-cigarettes as a lower-risk option than tobacco smoking.

The American Association of Public Health Physicians (AAPHP) suggests those who are unwilling to quit tobacco smoking or unable to quit with medical advice and pharmaceutical methods should consider other nicotine-containing products such as e-cigarettes and smokeless tobacco for long-term use instead of smoking. A 2014 WHO report concluded that some smokers will switch completely to e-cigarettes from traditional tobacco but a "sizeable" number will use both. This report found that such "dual-use" of e-cigarettes and tobacco "will have much smaller beneficial effects on overall survival compared with quitting smoking completely."

Smoking cessation

Whether e-cigarettes help people quit smoking is debated. Limited evidence suggests that e-cigarettes likely do help people to stop smoking when used in clinical settings. However, more smokers become dual users than succeed in complete abstinence. Outside clinical settings, vaping does not greatly change the odds of quitting smoking.

A small number of studies have looked at whether using e-cigarettes reduces the number of cigarettes smokers consume. E-cigarette use may decrease the number of cigarettes smoked, but smoking just one to four cigarettes daily greatly increases the risk of cardiovascular disease compared to not smoking. The extent to which decreasing cigarette smoking with vaping leads to quitting is unknown.

It is unclear whether e-cigarettes are only helpful for particular types of smokers. Vaping with nicotine may reduce tobacco use among daily smokers. Whether vaping is effective for quitting smoking may depend on whether it was used as part of an effort to quit.

One of the challenges in studying e-cigarettes is that there are hundreds of brands and models of e-cigarettes sold that vary in the design and operation of the devices and composition of the liquid, and the technology continues to change. E-cigarettes have not been subjected to the same type of efficacy testing as nicotine replacement products. There are also social concerns - use of e-cigarettes may normalize tobacco use and prolong cigarette use for people who could have quit instead, or it could put extra pressure on smokers to stop cigarette smoking because e-cigarettes are a more socially acceptable alternative. The evidence indicates smokers are more frequently able to completely quit smoking using tank devices compared to cigalikes, which may be due to their more efficient nicotine delivery. One study supports the claim that smokers are more likely to use e-cigarettes as a nicotine replacement product to aid in smoking cessation than other pharmaceutical products.

There is low quality evidence that vaping assists smokers to quit smoking in the long-term compared with nicotine-free vaping. Nicotine-containing e-cigarettes were associated with greater effectiveness for quitting smoking than e-cigarettes without nicotine. A 2013 study in smokers who were not trying to quit, found that vaping, with or without nicotine decreased the number of cigarettes consumed. E-cigarettes without nicotine may reduce tobacco cravings because of the smoking-related physical stimuli.

A 2015 meta-analysis on clinical trials found that e-cigarettes containing nicotine are more effective than nicotine-free ones for quitting smoking. They compared their finding that nicotine-containing e-cigarettes helped 20% of people quit with the results from other studies that found nicotine replacement products helps 10% of people quit. A 2016 review found low quality evidence of a trend towards benefit of e-cigarettes with nicotine for smoking cessation. In terms of whether flavored e-cigarettes assisted quitting smoking, the evidence is inconclusive. Tentative evidence indicates that health warnings on vaping products may influence users to give up vaping.

As of 2020, the efficacy and safety of vaping for quitting smoking during pregnancy was unknown. No research is available to provide details on the efficacy of vaping for quitting smoking during pregnancy. There is robust evidence that vaping is not effective for quitting smoking among adolescents. In view of the shortage of evidence, vaping is not recommend for cancer patients, although for all patients vaping is likely less dangerous than smoking cigarettes. The effectiveness of vaping for quitting smoking among vulnerable groups is uncertain.

Safety

Main article: Health effects of electronic cigarettes Further information: Composition of electronic cigarette aerosol

There is no consensus on the risks of e-cigarette use. There is little data about their safety, and a considerable variety of liquids are used as carriers, and thus are present in the aerosol delivered to the user. Reviews of the safety of e-cigarettes have reached quite different conclusions. A 2014 WHO report cautioned about potential risks of using e-cigarettes. Regulated US FDA products such as nicotine inhalers may be safer than e-cigarettes, but e-cigarettes are generally seen as safer than combusted tobacco products such as cigarettes and cigars.

The risk of early death is anticipated to be similar to that of smokeless tobacco. Since vapor does not contain tobacco and does not involve combustion, users may avoid several harmful constituents usually found in tobacco smoke, such as ash, tar, and carbon monoxide. However, e-cigarette use with or without nicotine cannot be considered risk-free because the long-term effects of e-cigarette use are unknown.

Possible side effects of nicotine include increased clotting tendency, atherosclerosis, enlargement of the aorta, bronchospasm, muscular tremor and pain, gastrointestinal nausea, dry mouth, dyspepsia, diarrhea, heartburn, peptic ulcer, cancer, lightheadedness, headache, sleep disturbances, abnormal dreams, irritability, dizziness, blood restriction, increased or decreased heart rate, increased blood pressure, tachycardia, more (or less) arrhythmias, coronary artery constriction, coronary artery disease, high insulin, insulin resistance, and risks to the child later in life during pregnancy include type 2 diabetes, obesity, hypertension, neurobehavioral defects, respiratory dysfunction, and infertility.
Possible side effects of nicotine

The cytotoxicity of e-liquids varies, and contamination with various chemicals have been detected in the liquid. Metal parts of e-cigarettes in contact with the e-liquid can contaminate it with metal particles. Many chemicals including carbonyl compounds such as formaldehyde can inadvertently be produced when the nichrome wire (heating element) that touches the e-liquid is heated and chemically reacted with the liquid. Normal usage of e-cigarettes, and reduced voltage (3.0 V) devices generate very low levels of formaldehyde.

The later-generation and "tank-style" e-cigarettes with a higher voltage (5.0 V) may generate equal or higher levels of formaldehyde compared to smoking. A 2015 report by Public Health England found that high levels of formaldehyde only occurred in overheated "dry-puffing". Users detect the "dry puff" (also known as a "dry hit") and avoid it, and they concluded that "There is no indication that EC users are exposed to dangerous levels of aldehydes." However, e-cigarette users may "learn" to overcome the unpleasant taste due to elevated aldehyde formation, when the nicotine craving is high enough.

Another common chemical found in e-cigarettes is ketene. When it enters the lungs after inhaled, this chemical causes damage to the cellular structure of lung tissue causing the cells to not function at maximum capacity and not absorb gasses as readily. This can cause shortness of breath which can lead to other health conditions such as tachycardia and respiratory failure. E-cigarette users who use devices that contain nicotine are exposed to its potentially harmful effects.

Nicotine is associated with cardiovascular disease, possible birth defects, and poisoning. In vitro studies of nicotine have associated it with cancer, but carcinogenicity has not been demonstrated in vivo. There is inadequate research to show that nicotine is associated with cancer in humans. The risk is probably low from the inhalation of propylene glycol and glycerin. No information is available on the long-term effects of the inhalation of flavors.

In October 2021, researchers at Johns Hopkins University reported over 2,000 unknown chemicals in the vape clouds that they tested from Vuse, Juul, Blu and Mi-Salt vape devices.

In 2019–2020, there was an outbreak of vaping-related lung illness in the US and Canada, primarily related to vaping THC with vitamin E acetate.

E-cigarettes create vapor that consists of fine and ultrafine particles of particulate matter, with the majority of particles in the ultrafine range. The vapor have been found to contain propylene glycol, glycerin, nicotine, flavors, small amounts of toxicants, carcinogens, and heavy metals, as well as metal nanoparticles, and other substances. Many carcinogenic compounds have been detected in e-cigarettes, such as N-Nitrosonornicotine (NNN), N-Nitrosoanatabine (NAT), etc., all of which have been proven to be harmful to human health. Exactly what the vapor consists of varies in composition and concentration across and within manufacturers, and depends on the contents of the liquid, the physical and electrical design of the device, and user behavior, among other factors.

E-cigarette vapor potentially contains harmful chemicals not found in tobacco smoke. The majority of toxic chemicals found in cigarette smoke are absent in e-cigarette vapor. E-cigarette vapor contains lower concentrations of potentially toxic chemicals than with cigarette smoke. Those which are present, are mostly below 1% of the corresponding levels permissible by workplace safety standards. But workplace safety standards do not recognize exposure to certain vulnerable groups such as people with medical ailments, children, and infants who may be exposed to second-hand vapor.

Concern exists that some of the mainstream vapor exhaled by e-cigarette users may be inhaled by bystanders, particularly indoors, although e-cigarette pollutant levels are much lower than for cigarettes and likely to pose a much lower risk, if any, compared to cigarettes. E-cigarette use by a parent might lead to inadvertent health risks to offspring. A 2014 review recommended that e-cigarettes should be regulated for consumer safety. There is limited information available on the environmental issues around production, use, and disposal of e-cigarettes that use cartridges. E-cigarettes that are not reusable may contribute to the problem of electronic waste.

Addiction

Further information: Effects of electronic cigarettes on human brain development

Nicotine, a key ingredient in most e-liquids, is well-recognized as one of the most addictive substances, as addictive as heroin and cocaine. Addiction is believed to be a disorder of experience-dependent brain plasticity. The reinforcing effects of nicotine play a significant role in the beginning and continuing use of the drug. First-time nicotine users develop a dependence about 32% of the time. Chronic nicotine use involves both psychological and physical dependence. Nicotine-containing e-cigarette vapor induces addiction-related neurochemical, physiological and behavioral changes. Nicotine affects neurological, neuromuscular, cardiovascular, respiratory, immunological and gastrointestinal systems.

Neuroplasticity within the brain's reward system occurs as a result of long-term nicotine use, leading to nicotine dependence. The neurophysiological activities that are the basis of nicotine dependence are intricate. It includes genetic components, age, gender, and the environment. Nicotine addiction is a disorder which alters different neural systems such as dopaminergic, glutamatergic, GABAergic, serotoninergic, that take part in reacting to nicotine. Long-term nicotine use affects a broad range of genes associated with neurotransmission, signal transduction, and synaptic architecture. The ability to quitting smoking is affected by genetic factors, including genetically based differences in the way nicotine is metabolized.

An image of the human brain. The reinforcing effects of addictive drugs, such as nicotine, are associated with their ability to excite the mesolimbic and dopaminergic systems. How does the nicotine in e-cigarettes affect the brain? Until about age 25, the brain is still growing. Each time a new memory is created or a new skill is learned, stronger connections – or synapses – are built between brain cells. Young people's brains build synapses faster than adult brains. Because addiction is a form of learning, adolescents can get addicted more easily than adults. The nicotine in e-cigarettes and other tobacco products can also prime the adolescent brain for addiction to other drugs such as cocaine.
The reinforcing effects of addictive drugs, such as nicotine, are associated with its ability to excite the mesolimbic and dopaminergic systems.
How does the nicotine in e-cigarettes affect the brain? Until about age 25, the brain is still growing. Each time a new memory is created or a new skill is learned, stronger connections – or synapses – are built between brain cells. Young people's brains build synapses faster than adult brains. Because addiction is a form of learning, adolescents can get addicted more easily than adults. The nicotine in e-cigarettes and other tobacco products can also prime the adolescent brain for addiction to other drugs such as cocaine.

Nicotine is a parasympathomimetic stimulant that binds to and activates nicotinic acetylcholine receptors in the brain, which subsequently causes the release of dopamine and other neurotransmitters, such as norepinephrine, acetylcholine, serotonin, gamma-aminobutyric acid, glutamate, endorphins, and several neuropeptides, including proopiomelanocortin-derived α-MSH and adrenocorticotropic hormone. Corticotropin-releasing factor, Neuropeptide Y, orexins, and norepinephrine are involved in nicotine addiction. Continuous exposure to nicotine can cause an increase in the number of nicotinic receptors, which is believed to be a result of receptor desensitization and subsequent receptor upregulation.

Long-term exposure to nicotine can also result in downregulation of glutamate transporter 1. Long-term nicotine exposure upregulates cortical nicotinic receptors, but it also lowers the activity of the nicotinic receptors in the cortical vasodilation region. These effects are not easily understood. With constant use of nicotine, tolerance occurs at least partially as a result of the development of new nicotinic acetylcholine receptors in the brain.

After several months of nicotine abstinence, the number of receptors go back to normal. The extent to which alterations in the brain caused by nicotine use are reversible is not fully understood. Nicotine also stimulates nicotinic acetylcholine receptors in the adrenal medulla, resulting in increased levels of epinephrine and beta-endorphin. Its physiological effects stem from the stimulation of nicotinic acetylcholine receptors, which are located throughout the central and peripheral nervous systems.

When nicotine intake stops, the upregulated nicotinic acetylcholine receptors induce withdrawal symptoms. These symptoms can include cravings for nicotine, anger, irritability, anxiety, depression, impatience, trouble sleeping, restlessness, hunger, weight gain, and difficulty concentrating. When trying to quit smoking with vaping a base containing nicotine, symptoms of withdrawal can include irritability, restlessness, poor concentration, anxiety, depression, and hunger. The changes in the brain cause a nicotine user to feel abnormal when not using nicotine. In order to feel normal, the user has to keep his or her body supplied with nicotine. E-cigarettes may reduce cigarette craving and withdrawal symptoms.

It is not clear whether e-cigarette use will decrease or increase overall nicotine addiction, but the nicotine content in e-cigarettes is adequate to sustain nicotine dependence. Chronic nicotine use causes a broad range of neuroplastic adaptations, making quitting hard to accomplish. A 2015 study found that users vaping non-nicotine e-liquid exhibited signs of dependence. Experienced users tend to take longer puffs which may result in higher nicotine intake. It is difficult to assess the impact of nicotine dependence from e-cigarette use because of the wide range of e-cigarette products. The addiction potential of e-cigarettes may have risen because as they have progressed, they have delivered nicotine better.

A 2015 American Academy of Pediatrics (AAP) policy statement stressed "the potential for these products to addict a new generation of youth to nicotine and reverse more than 50 years of public health gains in tobacco control." The World Health Organization (WHO) is concerned about starting nicotine use among non-smokers, and the National Institute on Drug Abuse said e-cigarettes could maintain nicotine addiction in those who are attempting to quit. The limited available data suggests that the likelihood of excessive use of e-cigarettes is smaller than traditional cigarettes. No long-term studies have been done on the effectiveness of e-cigarettes in treating tobacco addiction, but some evidence suggests that dual use of e-cigarettes and traditional cigarettes may be associated with greater nicotine dependence.

There is concern that children may progress from vaping to smoking. Adolescents are likely to underestimate nicotine's addictiveness. Vulnerability to the brain-modifying effects of nicotine, along with youthful experimentation with e-cigarettes, could lead to a lifelong addiction. A long-term nicotine addiction from using a vape may result in using other tobacco products. The majority of addiction to nicotine starts during youth and young adulthood. Adolescents are more likely to become nicotine dependent than adults.

The adolescent brain seems to be particularly sensitive to neuroplasticity as a result of nicotine. Minimal exposure could be enough to produce neuroplastic alterations in the very sensitive adolescent brain. A 2014 review found that in studies up to a third of young people who have not tried a traditional cigarette have used e-cigarettes. The degree to which teens are using e-cigarettes in ways the manufacturers did not intend, such as increasing the nicotine delivery, is unknown, as is the extent to which e-cigarette use may lead to addiction or substance dependence in young people.

Positions

Main article: Positions of medical organizations on electronic cigarettes

Because of overlap with tobacco laws and medical drug policies, e-cigarette legislation is being debated in many countries. The revised EU Tobacco Products Directive came into effect in May 2016, providing stricter regulations for e-cigarettes. In February 2010 the US District Court ruled against the FDA's seizure of E-Cigarettes as a "drug-device" and in December 2010 the US Court of Appeals confirmed them to be tobacco products which were by then subject to regulation under the 2009 FSPTC Act. In August 2016, the US FDA extended its regulatory power to include e-cigarettes, cigars, and "all other tobacco products". Large tobacco companies have greatly increased their marketing efforts.

The scientific community in US and Europe are primarily concerned with their possible effect on public health. There is concern among public health experts that e-cigarettes could renormalize smoking, weaken measures to control tobacco, and serve as a gateway for smoking among young people. The public health community is divided over whether to support e-cigarettes, because their safety and efficacy for quitting smoking is unclear. Many in the public health community acknowledge the potential for their quitting smoking and decreasing harm benefits, but there remains a concern over their long-term safety and potential for a new era of users to get addicted to nicotine and then tobacco. There is concern among tobacco control academics and advocates that prevalent universal vaping "will bring its own distinct but as yet unknown health risks in the same way tobacco smoking did, as a result of chronic exposure", among other things.

Medical organizations differ in their views about the health implications of vaping. There is general agreement that e-cigarettes expose users to fewer toxicants than tobacco cigarettes. Some healthcare groups and policy makers have hesitated to recommend e-cigarettes for quitting smoking, because of limited evidence of effectiveness and safety. Some have advocated bans on e-cigarette sales and others have suggested that e-cigarettes may be regulated as tobacco products but with less nicotine content or be regulated as a medicinal product.

A 2019 World Health Organization (WHO) report found that the scientific evidence "does not support the tobacco industry's claim that these products are less harmful relative to conventional tobacco products" and that there is insufficient evidence to support vaping as a smoking cessation tool. Healthcare organizations in the UK (including the Royal College of Physicians and Public Health England) have encouraged smokers to switch to e-cigarettes or other nicotine replacements if they cannot quit, as this would potentially save millions of lives. The American Cancer Society, American Heart Association, and the surgeon general of the United States have cautioned that accumulating evidence indicates e-cigarettes may have negative effects on the heart and lungs and should not be used to quit smoking without sufficient evidence that they are safe and effective.

In 2016, the US Food and Drug Administration (US FDA) stated that "Although ENDS may potentially provide cessation benefits to individual smokers, no ENDS have been approved as effective cessation aids." In 2019 the European Respiratory Society stated that "The long-term effects of ECIG use are unknown, and there is therefore no evidence that ECIGs are safer than tobacco in the long term" and that "he tobacco harm reduction strategy is based on well-meaning but incorrect or undocumented claims or assumptions." Following hundreds of possible cases of severe lung illness and five confirmed deaths associated with vaping in the US, the Centers for Disease Control and Prevention stated on 6 September 2019 that people should consider not using vaping products while their investigation is ongoing.

History

It is commonly stated that the modern e-cigarette was invented in 2003 by Chinese pharmacist Hon Lik, but tobacco companies had been developing nicotine aerosol generation devices since as early as 1963.

Early prototypes and barriers to entry: 1920s–1990s

In 1927, Joseph Robinson applied for a patent for an electronic vaporizer to be used with medicinal compounds. The patent was approved in 1930 but the device was never marketed. In 1930, the United States Patent and Trademark Office reported a patent stating, "for holding medicinal compounds which are electrically or otherwise heated to produce vapors for inhalation." In 1934 and 1936, further similar patents were applied for.

The earliest e-cigarette can be traced to American Herbert A. Gilbert. In 1963, Gilbert applied for a patent for "a smokeless non-tobacco cigarette" that involved "replacing burning tobacco and paper with heated, moist, flavored air". This device produced flavored steam without nicotine. The patent was granted in 1965. Gilbert's invention was ahead of its time. However, it received little attention and was never commercialized because smoking was still fashionable at that time. Gilbert said in 2013 that today's electric cigarettes follow the basic design set forth in his original patent.

The Favor cigarette, introduced in 1986 by public company Advanced Tobacco Products, was another early noncombustible product promoted as an alternative nicotine-containing tobacco product. Favor was conceptualized by Phil Ray, one of the founders of Datapoint Corporation and inventors of the microprocessor. Development started in 1979 by Phil Ray and Norman Jacobson. Favor was a "plastic, smoke-free product shaped and colored like a conventional cigarette that contained a filter paper soaked with liquid nicotine so users could draw a small dose by inhaling. There was no electricity, combustion, or smoke; it delivered only nicotine."

Favor cigarettes were sold in California and several Southwestern states, marketed as "an alternative to smokers, and only to smokers, to use where smoking is unacceptable or prohibited." In 1987, the FDA exercised jurisdiction over products analogous to E-Cigarettes. Advanced Tobacco Products never challenged the Warning Letter and ceased all distribution of Favor. Ray's wife Brenda Coffee coined the term vaping. Philip Morris' division NuMark, launched in 2013 the MarkTen e-cigarette that Philip Morris had been working on since 1990.

Modern electronic cigarette: 2000s

Despite these earlier efforts, Hon Lik, a Chinese pharmacist and inventor, who worked as a research pharmacist for a company producing ginseng products, is frequently credited with the invention of the modern e-cigarette. Hon quit smoking after his father, also a heavy smoker, died of lung cancer. In 2001, he thought of using a high frequency, piezoelectric ultrasound-emitting element to vaporize a pressurized jet of liquid containing nicotine. This design creates a smoke-like vapor. Hon said that using resistance heating obtained better results and the difficulty was to scale down the device to a small enough size. Hon's invention was intended to be an alternative to smoking. Hon Lik sees the e-cigarette as comparable to the "digital camera taking over from the analogue camera." Ultimately, Hon Lik did not quit smoking. He is now a dual user, both smoking and vaping.

Ruyan first-generation electronic cigar.
The Ruyan e-cigar was first launched in China in 2004.

Hon Lik registered a patent for the modern e-cigarette design in 2003. Hon is credited with developing the first commercially successful electronic cigarette. The e-cigarette was first introduced to the Chinese domestic market in 2004. Many versions made their way to the US, sold mostly over the Internet by small marketing firms. E-cigarettes entered the European market and the US market in 2006 and 2007. The company that Hon worked for, Golden Dragon Holdings, registered an international patent in November 2007. The company changed its name to Ruyan (如烟, literally "like smoke") later the same month, and started exporting its products.

Many US and Chinese e-cigarette makers copied his designs illegally, so Hon has not received much financial reward for his invention (although some US manufacturers have compensated him through out-of-court settlements). Ruyan later changed its company name to Dragonite International Limited. As of 2014, most e-cigarettes used a battery-powered heating element rather than the earlier ultrasonic technology design.

Initially, their performance did not meet the expectations of users. The e-cigarette continued to evolve from the first-generation three-part device. In 2007, British entrepreneurs Umer and Tariq Sheikh invented the cartomizer. This is a mechanism that integrates the heating coil into the liquid chamber. They launched this new device in the UK in 2008 under their Gamucci brand and the design is now widely adopted by most "cigalike" brands. Other users tinkered with various parts to produce more satisfactory homemade devices, and the hobby of "modding" was born. The first mod to replace the e-cigarette's case to accommodate a longer-lasting battery, dubbed the "screwdriver", was developed by Ted and Matt Rogers in 2008. Other enthusiasts built their own mods to improve functionality or aesthetics. When pictures of mods appeared at online vaping forums many people wanted them, so some mod makers produced more for sale.

In 2008, a consumer created an e-cigarette called the screwdriver. The device generated a lot of interest back then, as it let the user to vape for hours at one time. The invention led to demand for customizable e-cigarettes, prompting manufacturers to produce devices with interchangeable components that could be selected by the user. In 2009, Joyetech developed the eGo series which offered the power of the screwdriver model and a user-activated switch to a wide market. The clearomizer was invented in 2009. Originating from the cartomizer design, it contained the wicking material, an e-liquid chamber, and an atomizer coil within a single clear component. The clearomizer allows the user to monitor the liquid level in the device. Soon after the clearomizer reached the market, replaceable atomizer coils and variable voltage batteries were introduced. Clearomizers and eGo batteries became the best-selling customizable e-cigarette components in early 2012.

International growth: 2010s – present

Large tobacco companies have acquired some of the e-cigarette companies.
Tobacco company Subsidiary company Electronic cigarette
Imperial Tobacco Fontem Ventures and Dragonite Puritane blu eCigs
British American Tobacco CN Creative and Nicoventures Vype
R. J. Reynolds Tobacco Company R. J. Reynolds Vapor Company Vuse
Altria Nu Mark, LLC MarkTen, Green Smoke
Acquired a 35% stake in Juul Labs.
Japan Tobacco International Ploom E-lites Logic

International tobacco companies dismissed e-cigarettes as a fad at first. However, recognizing the development of a potential new market sector that could render traditional tobacco products obsolete, they began to produce and market their own brands of e-cigarettes and acquire existing e-cigarette companies. They bought the largest e-cigarette companies. blu eCigs, a prominent US e-cigarette manufacturer, was acquired by Lorillard Inc. for $135 million in April 2012.

British American Tobacco was the first tobacco business to sell e-cigarettes in the UK. They launched the e-cigarette Vype in July 2013, while Imperial Tobacco's Fontem Ventures acquired the intellectual property owned by Hon Lik through Dragonite International Limited for $US 75 million in 2013 and launched Puritane in partnership with Boots UK. On 1 October 2013 Lorillard Inc. acquired another e-cigarette company, this time the UK based company SKYCIG. SKY was rebranded as blu.

Various e-cigarettes from 2018. From left to right: Phix, Juno, Von Erl, Juul

On 3 February 2014, Altria Group, Inc. acquired popular e-cigarette brand Green Smoke for $110 million. The deal was finalized in April 2014 for $110 million with $20 million in incentive payments. Altria also markets its own e-cigarette, the MarkTen, while Reynolds American has entered the sector with its Vuse product. Philip Morris, the world's largest tobacco company, purchased UK's Nicocigs in June 2014. On 30 April 2015, Japan Tobacco bought the US Logic e-cigarette brand. Japan Tobacco also bought the UK E-Lites brand in June 2014. On 15 July 2014, Lorillard sold blu to Imperial Tobacco as part of a deal for $7.1 billion. As of 2018, 95% of e-cigarettes were made in China.

In the UK, where most vaping uses refillable sets and e-liquid, there is now support from the National Health Service, and other medical bodies now embrace the use of e-cigarettes as a viable way to quit smoking. This has contributed to record numbers of people vaping, with estimated 3.6 million in 2019, 3.2 million in 2020, rising to 3.6 million in 2021. Current vapers being 2.2 million as of 2024.

Society and culture

"Vaper" redirects here. Not to be confused with Vapor.

Consumers have shown passionate support for e-cigarettes that other nicotine replacement products did not receive. They have a mass appeal that could challenge combustible tobacco's market position.

By 2013, a subculture had emerged calling itself "the vaping community". Members often see e-cigarettes as a safer alternative to smoking, and some view it as a hobby. The online forum E-Cig-Reviews.com was one of the first major communities. It and other online forums, such as UKVaper.org, were where the hobby of modding started. There are also groups on Facebook and Reddit. Online forums based around modding have grown in the vaping community.

Vapers embrace activities associated with e-cigarettes and sometimes evangelise for them. E-cigarette companies have a substantial online presence, and there are many individual vapers who blog and tweet about e-cigarette related products. A 2014 Postgraduate Medical Journal editorial said vapers "also engage in grossly offensive online attacks on anyone who has the temerity to suggest that ENDS are anything other than an innovation that can save thousands of lives with no risks".

Contempt for Big Tobacco is part of vaping culture. A 2014 review stated that tobacco and e-cigarette companies interact with consumers for their policy agenda. The companies use websites, social media, and marketing to get consumers involved in opposing bills that include e-cigarettes in smoke-free laws. This is similar to tobacco industry activity going back to the 1980s. These approaches were used in Europe to minimize the EU Tobacco Products Directive in October 2013. Grassroots lobbying also influenced the Tobacco Products Directive decision. Tobacco companies have worked with organizations conceived to promote e-cigarette use, and these organizations have worked to hamper legislation intended at restricting e-cigarette use.

E-cigarette user blowing a large cloud of aerosol (vapor). This activity is known as cloud-chasing.
E-cigarette user blowing a cloud of aerosol (vapor). The activity is known as cloud-chasing.

Large gatherings of vapers, called vape meets, take place around the US. They focus on e-cigarette devices, accessories, and the lifestyle that accompanies them. Vapefest, which started in 2010, is an annual show hosted by different cities. People attending these meetings are usually enthusiasts that use specialized, community-made products not found in convenience stores or gas stations. These products are mostly available online or in dedicated "vape" storefronts where mainstream e-cigarettes brands from the tobacco industry and larger e-cig manufacturers are not as popular. Some vape shops have a vape bar where patrons can test out different e-liquids and socialize. The Electronic Cigarette Convention in North America which started in 2013, is an annual show where companies and consumers meet up.

A subclass of vapers configure their atomizers to produce large amounts of vapor by using low-resistance heating coils. This practice is called "cloud-chasing". By using a coil with very low resistance, the batteries are stressed to a potentially unsafe extent. This could present a risk of dangerous battery failures. As vaping comes under increased scrutiny, some members of the vaping community have voiced their concerns about cloud-chasing, stating the practice gives vapers a bad reputation when doing it in public. The Oxford Dictionaries' word of the year for 2014 was "vape".

Regulation

Main articles: Regulation of electronic cigarettes and List of vaping bans in the United States

Regulation of e-cigarettes varies across countries and states, ranging from no regulation to banning them entirely. For instance, e-cigarettes containing nicotine are illegal in Japan, forcing the market to use heated tobacco products for cigarette alternatives. Others have introduced strict restrictions and some have licensed devices as medicines such as in the UK. However, as of February 2018, there is no e-cigarette device that has been given a medical license that is commercially sold or available by prescription in the UK. As of 2015, around two thirds of major nations have regulated e-cigarettes in some way.

Because of the potential relationship with tobacco laws and medical drug policies, e-cigarette legislation is being debated in many countries. The companies that make e-cigarettes have been pushing for laws that support their interests. In 2016 the US Department of Transportation banned the use of e-cigarettes on commercial flights. This regulation applies to all flights to and from the US. In 2018, the Royal College of Physicians asked that a balance is found in regulations over e-cigarettes that ensure product safety while encouraging smokers to use them instead of tobacco, as well as keep an eye on any effects contrary to the control agencies for tobacco.

The legal status of e-cigarettes is currently pending in many countries. Many countries such as Brazil, Singapore, Uruguay, and India have banned e-cigarettes. Canada-wide in 2014, they were technically illegal to sell, as no nicotine-containing e-cigarettes are not regulated by Health Canada, but this is generally unenforced and they are commonly available for sale Canada-wide. In 2016, Health Canada announced plans to regulate vaping products. In the US and the UK, the use and sale to adults of e-cigarettes are legal. The revised EU Tobacco Products Directive came into effect in May 2016, providing stricter regulations for e-cigarettes. It limits e-cigarette advertising in print, on television and radio, along with reducing the level of nicotine in liquids and reducing the flavors used. It does not ban vaping in public places. It requires the purchaser for e-cigarettes to be at least 18 and does not permit buying them for anyone less than 18 years of age. The updated Tobacco Products Directive has been disputed by tobacco lobbyists whose businesses could be impacted by these revisions.

As of 8 August 2016, the US FDA extended its regulatory power to include e-cigarettes, e-liquid and all related products. Under this ruling the FDA will evaluate certain issues, including ingredients, product features and health risks, as well their appeal to minors and non-users. The FDA rule also bans access to minors. A photo ID is now required to buy e-cigarettes, and their sale in all-ages vending machines is not permitted in the US. As of August 2017, regulatory compliance deadlines relating to premarket review requirements for most e-cigarette and e-liquid products have been extended from November 2017 to 8 August 2022, which attracted a lawsuit filed by the American Heart Association, American Academy of Pediatrics, the Campaign for Tobacco-Free Kids, and other plaintiffs.

In May 2016, the US FDA used its authority under the Family Smoking Prevention and Tobacco Control Act to deem e-cigarette devices and e-liquids to be tobacco products, which meant it intended to regulate the marketing, labelling, and manufacture of devices and liquids; vape shops that mix e-liquids or make or modify devices were considered manufacturing sites that needed to register with US FDA and comply with good manufacturing practice regulation. E-cigarette and tobacco companies have recruited lobbyists in an effort to prevent the US FDA from evaluating e-cigarette products or banning existing products already on the market.

In February 2014, the European Parliament passed regulations requiring standardization and quality control for liquids and vaporizers, disclosure of ingredients in liquids, and child-proofing and tamper-proofing for liquid packaging. In April 2014 the US FDA published proposed regulations for e-cigarettes. In the US some states tax e-cigarettes as tobacco products, and some state and regional governments have broadened their indoor smoking bans to include e-cigarettes. As of April 2017, 12 US states and 615 localities had prohibited the use of e-cigarettes in venues in which traditional cigarette smoking was prohibited. In 2015, at least 48 states and 2 territories had banned e-cigarette sales to minors.

In November 2020, the New Zealand government passed a vaping regulation that requires vape stores to register as specialist vape retailers before they can sell e-cigarettes, the wider range of flavoured e-liquids, and other related vaping products. Vaping products are required to be notified by the government before they can be sold to ensure that the products are following safety requirements and ingredients in liquids do not contain prohibited substances.

E-cigarettes containing nicotine have been listed as drug delivery devices in a number of countries, and the marketing of such products has been restricted or put on hold until safety and efficacy clinical trials are conclusive. Since they do not contain tobacco, television advertising in the US is not restricted. Some countries have regulated e-cigarettes as a medical product even though they have not approved them as a smoking cessation aid. A 2014 review stated the emerging phenomenon of e-cigarettes has raised concerns in the health community, governments, and the general public and recommended that e-cigarettes should be regulated to protect consumers. It added, "heavy regulation by restricting access to e-cigarettes would just encourage continuing use of much unhealthier tobacco smoking." A 2014 review said regulation of the e-cigarette should be considered on the basis of reported adverse health effects.

Criticism of vaping bans

Critics of vaping bans state that vaping is a much safer alternative to smoking tobacco products and that vaping bans incentivize people to return to smoking cigarettes. For example, critics cite the British Journal of Family Medicine in August 2015 which stated, "E-cigarettes are 95% safer than traditional smoking." Additionally, San Francisco's chief economist, Ted Egan, when discussing the San Francisco vaping ban stated the city's ban on e-cigarette sales will increase smoking as vapers switch to combustible cigarettes. Critics of smoking bans stress the absurdity of criminalizing the sale of a safer alternative to tobacco while tobacco continues to be legal. Prominent proponents of smoking bans are not in favor of criminalizing tobacco either, but rather allowing consumers to have the choice to choose whatever products they desire.

In 2022, after two years of review, the Food and Drug Administration (FDA) denied Juul's application to keep its tobacco and menthol flavored vaping products on the market. Critics of this denial note that research published in Nicotine and Tobacco Research found that smokers who transitioned to Juuls in North America were significantly more likely to switch to vaping than those in the United Kingdom who only had access to lower-strength nicotine products. This happens as the Biden administration seeks to mandate low-nicotine cigarettes which, critics note, is not what makes cigarettes dangerous. They also note that vaping does not contain many of the components that make smoking dangerous such as the combustion process and certain chemicals that are present in cigarettes that are not present in vape products.

Product liability

Multiple reports from the U.S. Fire Administration conclude that electronic cigarettes have been combusting and injuring people and surrounding areas. The composition of a cigarette is the cause of this, as the cartridges that are meant to contain the liquid mixture are in such close proximity to the battery. A research report by the U.S. Fire Administration supports this, stating that, "Unlike mobile phones, some e-cigarette lithium-ion batteries within e-cigarettes offer no protection to stop the coil overheating".

In 2015, the U.S. Fire Administration noted in their report that electronic cigarettes are not created by Big Tobacco or other tobacco companies, but by independent factories that have little quality control. Because of this low quality control when made, electronic cigarettes have led to incidents in which people are hurt, or in which the surrounding area is damaged.

Marketing

Main article: Electronic cigarette and e-cigarette liquid marketing

They are marketed to men, women, and children as being safer than traditional cigarettes. They are also marketed to non-smokers. E-cigarette marketing is common. There are growing concerns that e-cigarette advertising campaigns unjustifiably focus on young adults, adolescents, and women. Large tobacco companies have greatly increased their marketing efforts. This marketing trend may expand the use of e-cigarettes and contribute to re-glamorizing smoking. Some companies may use e-cigarette advertising to advocate smoking, deliberately, or inadvertently, is an area of concern. A 2014 review said, "the e-cigarette companies have been rapidly expanding using aggressive marketing messages similar to those used to promote cigarettes in the 1950s and 1960s."

E-cigarette companies are using methods that were once used by the tobacco industry to persuade young people to start using cigarettes. E-cigarettes are promoted to a certain extent to forge a vaping culture that entices non-smokers. Themes in e-cigarette marketing, including sexual content and customer satisfaction, are parallel to themes and techniques that are appealing to young people and young adults in traditional cigarette advertising and promotion. A 2017 review found "The tobacco industry sees a future where ENDS accompany and perpetuate, rather than supplant, tobacco use, especially targeting the youth." E-cigarettes and nicotine are regularly promoted as safe and even healthy in the media and on brand websites, which is an area of concern.

While advertising of tobacco products is banned in most countries, television and radio e-cigarette advertising in several countries may be indirectly encouraging traditional cigarette use. E-cigarette advertisements are also in magazines, newspapers, online, and in retail stores. Between 2010 and 2014, e-cigarettes were second only to cigarettes as the top advertised product in magazines. As cigarette companies have acquired the largest e-cigarette brands, they currently benefit from a dual market of smokers and e-cigarette users while simultaneously presenting themselves as agents of harm reduction. This raises concerns about the appropriateness of endorsing a product that directly profits the tobacco industry. There is no evidence that the cigarette brands are selling e-cigarettes as part of a plan to phase out traditional cigarettes, despite some stating to want to cooperate in "harm reduction". E-cigarette advertising for using e-cigarettes as a quitting tool have been seen in the US, UK, and China, which have not been supported by regulatory bodies.

In the US, six large e-cigarette businesses spent $59.3 million on promoting e-cigarettes in 2013. In the US and Canada, over $2 million is spent yearly on promoting e-cigarettes online. E-cigarette websites often made unscientific health statements in 2012. The ease to get past the age verification system at e-cigarette company websites allows underage individuals to access and be exposed to marketing. Around half of e-cigarette company websites have a minimum age notice that prohibited underage individuals from entering.

Celebrity endorsements are used to encourage e-cigarette use. A 2012 national US television advertising campaign for e-cigarettes starred Stephen Dorff exhaling a "thick flume" of what the advertisement describes as "vapor, not tobacco smoke", exhorting smokers with the message "We are all adults here, it's time to take our freedom back." Opponents of the tobacco industry state that the Blu advertisement, in a context of longstanding prohibition of tobacco advertising on television, seems to have resorted to advertising tactics that got former generations of people in the US addicted to traditional cigarettes. Cynthia Hallett of Americans for Non-Smokers' Rights described the US advertising campaign as attempting to "re-establish a norm that smoking is okay, that smoking is glamorous and acceptable".

University of Pennsylvania communications professor Joseph Cappella stated that the setting of the advertisement near an ocean was meant to suggest an association of clean air with the nicotine product. In 2012 and 2013, e-cigarette companies advertised to a large television audience in the US which included 24 million young people. The channels to which e-cigarette advertising reached the largest numbers of young people (ages 12–17) were AMC, Country Music Television, Comedy Central, WGN America, TV Land, and VH1.

Displaying a diagram of e-cigarette use among youth is rising as e-cigarette advertising increases.
From 2011 to 2014, e-cigarette use among young people in the US was rising as e-cigarette advertising increased.

Since at least 2007, e-cigarettes have been heavily promoted across media outlets globally. They are vigorously advertised, mostly through the Internet, as a safe substitute to traditional cigarettes, among other things. E-cigarette companies promote their e-cigarette products on Facebook, Instagram, YouTube, and Twitter. They are promoted on YouTube by movies with sexual material and music icons, who encourage minors to "take their freedom back." They have partnered with a number of sports and music icons to promote their products. Tobacco companies intensely market e-cigarettes to young people, with industry strategies including cartoon characters and candy flavors. Fruit flavored e-liquid is the most commonly marketed e-liquid flavor on social media.

E-cigarette companies commonly promote that their products contain only water, nicotine, glycerin, propylene glycol, and flavoring but this assertion is misleading as researchers have found differing amounts of heavy metals in the vapor, including chromium, nickel, tin, silver, cadmium, mercury, and aluminum. The widespread assertion that e-cigarettes emit "only water vapor" is not true because the evidence demonstrates e-cigarette vapor contains possibly harmful chemicals such as nicotine, carbonyls, metals, and volatile organic compounds, in addition to particulate matter. Massive advertising included the assertion that they would present little risk to non-users. However, "disadvantages and side effects have been reported in many articles, and the unfavorable effects of its secondhand vapor have been demonstrated in many studies", and evidence indicates that use of e-cigarettes degrades indoor air quality.

Many e-cigarette companies market their products as a smoking cessation aid without evidence of effectiveness. E-cigarette marketing has been found to make unsubstantiated health statements (e.g., that they help one quit smoking) including statements about improving psychiatric symptoms, which may be particularly appealing to smokers with mental illness. E-cigarette marketing advocate weight control and emphasize use of nicotine with many flavors. These marketing angles could particularly entice overweight people, young people, and vulnerable groups. Some e-cigarette companies state that their products are green without supporting evidence which may be purely to increase their sales.

Economics

The number of e-cigarettes sold increased every year from 2003 to 2014. In 2015 a slowdown in the growth in usage occurred in the US. As of January 2018, the growth in usage in the UK has slowed down since 2013. As of 2014, there were at least 466 e-cigarette brands. Worldwide e-cigarette sales in 2014 were around US$7 billion. Worldwide e-cigarette sales in 2019 were about $19.3 billion. E-cigarette sales could exceed traditional cigarette sales by 2023. Approximately 30–50% of total e-cigarettes sales are handled on the internet. Established tobacco companies have a significant share of the e-cigarette market.

As of 2018, 95% of e-cigarette devices were made in China, mainly in Shenzhen. Chinese companies' market share of e-liquid is low. In 2014, online and offline sales started to increase. Since combustible cigarettes are relatively inexpensive in China a lower price may not be a large factor in marketing vaping products over there.

In 2015, 80% of all e-cigarette sales in convenience stores in the US were products made by tobacco companies. According to Nielsen Holdings, convenience store e-cigarette sales in the US went down for the first time during the four-week period ending on 10 May 2014. Wells Fargo analyst Bonnie Herzog attributes this decline to a shift in consumers' behavior, buying more specialized devices or what she calls "vapors-tanks-mods (VTMs)" that are not tracked by Nielsen. Wells Fargo estimated that VTMs accounted for 57% of the 3.5 billion dollar market in the US for vapor products in 2015.

In 2014, dollar sales of customizable e-cigarettes and e-liquid surpassed sales of cigalikes in the US, even though, overall, customizables are a less expensive vaping option. In 2014, the Smoke-Free Alternatives Trade Association estimated that there were 35,000 vape shops in the US, more than triple the number a year earlier. However the 2015 slowdown in market growth affected VTMs as well.

Large tobacco retailers are leading the cigalike market. "We saw the market's sudden recognition that the cigarette industry seems to be in serious trouble, disrupted by the rise of vaping," Mad Money's Jim Cramer stated April 2018. "Over the course of three short days, the tobacco stocks were bent, they were spindled and they were mutilated by the realization that electronic cigarettes have become a serious threat to the old-school cigarette makers," he added. In 2019, a vaping industry organization released a report stating that a possible US ban on e-cigarettes flavors can potentially effect greater than 150,000 jobs around the US.

The leading seller in the e-cigarette market in the US is the Juul e-cigarette, which was introduced in June 2015. As of August 2018, Juul accounts for over 72% of the US e-cigarette market monitored by Nielsen, and its closest competitor—RJ Reynolds' Vuse—makes up less than 10% of the market. Juul rose to popularity quickly, growing by 700% in 2016 alone. On 17 July 2018 Reynolds announced it will debut in August 2018 a pod mod type device similar Juul. The popularity of the Juul pod system has led to a flood of other pod devices hitting the market.

In Canada, e-cigarettes had an estimated value of 140 million CAD in 2015. There are numerous e-cigarette retail shops in Canada. A 2014 audit of retailers in four Canadian cities found that 94% of grocery stores, convenience stores, and tobacconist shops which sold e-cigarettes sold nicotine-free varieties only, while all vape shops stocked at least one nicotine-containing product.

By 2015, the e-cigarette market had only reached a twentieth of the size of the tobacco market in the UK. In the UK in 2015 the "most prominent brands of cigalikes" were owned by tobacco companies, however, with the exception of one model, all the tank types came from "non-tobacco industry companies". Yet some tobacco industry products, while using prefilled cartridges, resemble tank models.

France's e-cigarette market was estimated by Groupe Xerfi to be 130 million in 2015. Additionally, France's e-liquid market was estimated at €265 million. In December 2015, there were 2,400 vape shops in France, 400 fewer than in March of the same year. Industry organization Fivape said the reduction was due to consolidation, not to reduced demand.

In Vietnam, the e-cigarette market is growing rapidly, with the use rate increasing 18 times from 2015 to 2020. The use rate of e-cigarettes in adolescents aged 13–15 is 3.5%, up 1.6% from 2019. According to estimates by the World Health Organization (WHO), the global economic losses caused by tobacco each year are $1.4 trillion. Economic losses caused by tobacco are estimated to account for 1% of GDP. The Vietnamese government is making efforts to control the e-cigarette market. However, here are still many challenges to be addressed, such as consumer's lack of understanding of the harm of e-cigarettes, unclear legal regulations, and fierce competition from imported e-cigarette products.

Environmental impact

Main article: Environmental impact of electronic cigarettes
A discarded e-cigarette next to a traditional cigarette in a car park
A discarded e-cigarette next to a traditional cigarette in a car park

Compared to traditional cigarettes, reusable e-cigarettes do not create waste and potential litter from every use in the form of discarded cigarette butts. Traditional cigarettes tend to end up in the ocean where they cause pollution, though once discarded they undergo biodegradation and photodegradation. Although some brands have begun recycling services for their e-cigarette cartridges and batteries, the prevalence of recycling is unknown.

E-cigarettes that are not reusable contribute to the problem of electronic waste, which can create a hazard for people and other organisms. If improperly disposed of, they can release heavy metals, nicotine, and other chemicals from batteries and unused e-liquid. A July 2018–April 2019 garbology study found e-cigarette products composed 19% of the waste from all traditional and electronic tobacco and cannabis products collected at 12 public high schools in Northern California.

Councils in England and Wales are pushing for a 2024 ban on single-use vapes due to environmental and health risks, as 1.3 million are thrown away weekly. Recycling challenges, waste issues, and fire hazards are cited. Concerns about youth vaping are also raised. The UK Vaping Industry Association defends disposables as quitting aids but warns of potential black market products if banned.

Related technologies

Other devices to deliver inhaled nicotine have been developed. They aim to mimic the ritual and behavioral aspects of traditional cigarettes.

British American Tobacco, through their subsidiary Nicoventures, licensed a nicotine delivery system based on existing asthma inhaler technology from UK-based healthcare company Kind Consumer. In September 2014 a product based on this named Voke obtained approval from the United Kingdom's Medicines and Healthcare Products Regulatory Agency.

In 2011, Philip Morris International bought the rights to a nicotine pyruvate technology developed by Jed Rose at Duke University. The technology is based on the chemical reaction between pyruvic acid and nicotine, which produces an inhalable nicotine pyruvate vapor. Philip Morris Products S.A. created a different kind e-cigarette named P3L. The device is supplied with a cartridge that contains nicotine and lactic acid in different cavities. When turned on and heated, the nicotine salt called nicotine lactate forms an aerosol.

Philip Morris International's iQOS device with charger and tobacco stick.
Philip Morris International's IQOS device with charger and tobacco stick

The IQOS is a heated tobacco product marketed by Philip Morris International. It heats tobacco at a lower temperature than traditional cigarettes. The tobacco sticks reach a temperature up to 350 °C. It sold first in Japan since November 2014. In December 2016, the United Tobacco Vapor Group's (UTVG) stated that they have been given a patent for their vaporizing component system. qmos from UTVG does not contain a wick or sponge and the number of components is 5 compared to 20 for traditional e-cigarettes.

Pax Labs has developed vaporizers that heats the leaves of tobacco to deliver nicotine in a vapor. In June 2015, they introduced Juul, a type of e-cigarette which delivers 10 times as much nicotine as other e-cigarettes, equivalent to an actual cigarette puff. Juul was spun off from Pax Labs in June 2017 and is now available by the independent company Juul Labs. The eTron 3T from Vapor Tobacco Manufacturing, launched in December 2014, employs a patented, aqueous system whereby the tobacco is extracted into water. The e-liquid contains organic tobacco, organic glycerin, and water.

In December 2013, Japan Tobacco launched Ploom in Japan. In January 2016, they launched Ploom TECH that produces a vapor from a heated liquid that moves through a capsule of granulated tobacco leaves. In 2016, British American Tobacco (BAT) released its own version of the heat but not burn technology called glo in Japan and Switzerland. It uses tobacco sticks rather than nicotine liquid, and does not directly heat or burn tobacco. Heated tobacco products were first introduced in 1988, but were not a commercial success.

BLOW started selling e-hookahs, an electronic version of the hookah in 2014. The handle of each hose for the e-hookah contains a heating element and a liquid, which produces vapor. Gopal Bhatnagar, based in Toronto, Canada, invented a 3D printed adapter to turn a traditional hookah into an e-hookah. It is used instead of the ceramic bowl that contains shisha tobacco. Rather than the tobacco, users can insert e-cigarettes.

Cannabis vaping

Further information: CBD cigarette

Some vape pens, generally not referred to as "e-cigarettes", contain cannabis derivatives instead of nicotine and tobacco derivatives. Some cannabis pens, known as "dab pens", contain cannabis extracted using butane as solvent ("butane hash oil"). Other vaporizers contain e-liquid made with pure THC, and they generally resemble conventional e-cigarettes. A 2020 study shows that one third of teenagers engaged in conventional, tobacco vaping also engage in THC vaping.

KanaVape is an e-cigarette containing cannabidiol (CBD) and no THC. Several companies including Canada's Eagle Energy Vapor are selling caffeine-based e-cigarettes instead of containing nicotine.

See also

Notes

  1. Also known as an e-cig, vaporizer, vape pen, hookah pen, e-pipe, or, formally, electronic nicotine delivery system (ENDS).
  2. A 2014 review found "In addition to the uniqueness of the liquid compositions in each brand, inconsistency of both the device performance properties and the data collection methodologies used by researchers contribute to the observed variation in constituent levels and to the range of particle size distributions among products."
  3. "Most ENDS consist of a rechargeable, battery-operated heating element and a replaceable or refillable cartridge for the e-liquid. An atomizer heats the liquid in the cartridge to convert it into an aerosol, which is then inhaled by the user. Most of these products are rechargeable, but some are disposable."
  4. "Once again, there is a strong potential for confounding, such that comparisons of dual users with smokers who do not use e-cigarettes will not yield meaningful causal estimates"
  5. A 2019 review concluded that, "no long term vaping toxicological/safety studies have been done in humans; without these data, saying with certainty that e-cigarettes are safer than combustible cigarettes is impossible."
  6. Two of the authors of this study received funding from Pfizer, which manufactures nicotine replacement therapy products.
  7. Since 2016 the US Food and Drug Administration (US FDA) regulated e-cigarettes under the classification of tobacco products and labeled them as electronic nicotine delivery systems. A 2018 report commissioned by the US FDA decided to use the term e-cigarettes, indicating that for some use e-liquids containing no nicotine.
  8. "The ACS does not recommend the use of e-cigarettes as a cessation method. No e-cigarette has been approved by the Food and Drug Administration (FDA) as a safe and effective cessation product. The long-term risks of exclusive use of e-cigarettes are not fully known but evidence is accumulating that e-cigarette use has negative effects on the cardiovascular system and lungs. Without immediate measures to stop epidemic use of these products, the long-term adverse health effects will increase."
  9. "Companies should not be able to claim that e-cigarettes are a cessation aid unless they are approved by the FDA for that purpose...There is not yet enough evidence for clinicians to counsel their patients who are using combustible tobacco products to use e-cigarettes as a primary cessation aid. The association will continue to monitor the evidence concerning e-cigarettes as cessation devices to determine whether they might be integrated into comprehensive cessation strategies. For patients with existing cardiovascular disease and stroke, or at risk of a cardiovascular disease event, intensive cessation counseling should be offered as soon as possible."
  10. Alteria no longer sells e-cigarettes.

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Bibliography

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