Recent reports of a cluster of lung diseases associated with electronic cigarette use have led many to start questioning the safety of “vaping”. In fact, vaping’s safety always has been questionable. Electronic cigarettes heat a liquid that usually contains the drug nicotine as well as chemicals that are “generally recognized as safe” when eaten but not when inhaled. These chemicals include propylene glycol and vegetable glycerin that is derived from vegetable oil. Once heated, the liquid becomes an aerosol or “vapor” that is inhaled. That vapor contains all of the chemicals in the liquid and also may contain others produced by the heating process.

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For the past seven years, a steady stream of scientific studies has uncovered potential health risks associated with vaping. These risks include nicotine dependence, airway injury, and cardiovascular disease. Now we must add debilitating lung disease to that list. Lipoid pneumonia is one such disease, probably caused by inhalation of oil-containing vapor: the body’s immune response to oil in the lungs involves inflammation that can be fatal. Oil can enter electronic cigarette liquids either unintentionally as a contaminant or intentionally, such as when vaping substances other than nicotine, like marijuana. Intentional or not, the possibility of oil in electronic cigarette liquids highlights the need for immediate, strong regulation of these products.

Importantly, the types of lung injury reported today are not new. The first case of electronic cigarette-associated lipoid pneumonia was reported in the medical literature in 2012. Between 2013 and 2018 there were another six reported cases of pneumonia-like diseases in electronic cigarette users. The message from the current cluster of diseases and this accumulated scientific evidence is clear: electronic cigarette use has the potential to cause dependence, disease and, very rarely (so far), death. Anyone who has avoided smoking tobacco cigarettes because of health concerns has every reason to avoid using electronic cigarettes for the same reasons. If you are a non-smoker or a former smoker who is using electronic cigarettes today, the best way to protect your lung health is to stop using them now and never to smoke or vape again.

The images of the CT scans are shown looking through the body from feet. In these CT scans, there are patchy densities or cloud-like areas throughout both lungs which are seen with unusual pneumonias, lung fluid or lung inflammation. Photograph: Intermountain Healthcare

But what about current cigarette smokers? Despite the fact that electronic cigarettes are not approved in the US as a smoking cessation medication, electronic cigarette manufacturers, advocates, and even some public health groups recommend these products to help smokers quit. Aside from anecdote, the best scientific evidence supporting this idea comes from a recent study that shows that if an electronic cigarette is used along with behavioral therapy, it may help some (but not all) smokers quit tobacco cigarettes completely.

That encouraging result shows great potential and deserves further scientific study. Of course, electronic cigarettes are sold at convenience stores, gas stations, and “vape shops” where behavioral therapy is not available. Moreover, not all electronic cigarettes are equal when it comes to delivering the nicotine that smokers need to suppress tobacco cravings: some deliver no nicotine at all while others deliver more nicotine than a tobacco cigarette. In this context – with no systematic therapy options and uncertain nicotine delivery – there is perhaps no surprise in the observation that the majority of published population-level research from the US shows that electronic cigarettes enable continued tobacco cigarette smoking and not cessation.

Smokers in the US can use a variety of FDA-approved smoking cessation medications that are demonstrably effective at increasing the chances of quitting successfully, particularly when used in conjunction with behavioral therapy. One important advantage of these medications is that their production is tightly regulated. In contrast, electronic cigarettes undergo relatively little regulation. As the current cluster of lung diseases indicates, without regulation and quality control, a product that may seem safe today could be dangerously contaminated tomorrow.

Until these products are regulated effectively, proven safe, and shown to be effective as smoking cessation aids, there is little reason for tobacco cigarette smokers to use them. One exception might be when a smoker has tried every FDA-approved medication without success. In that instance, a nicotine-delivering electronic cigarette may play a short-term role so long as it is used in conjunction with an evidenced-based behavioral therapy regimen designed first to eliminate smoking and then to eliminate vaping. All successes and failures of this approach should be reported in the scientific literature.

The facts are these: electronic cigarettes are a highly variable group of products that may or may not deliver nicotine, may or may not help smokers quit, sometimes is associated with deadly pneumonia-like illness, and always exposes users’ lungs to chemicals that pose unknown long-term health risks. From a public health perspective, they have no role as a recreational product. Absent regulatory approval as a safe and effective medication, the only role for nicotine-delivering electronic cigarettes in smoking cessation is as a short-term tool of last resort within an evidence-based behavioral therapy regimen.