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Beware, vaping e-cigarettes around children is adversely impacting their lung health
  1. Ana Lucia Fuentes1,2,
  2. Laura E Crotty Alexander1,2
  1. 1 Medicine, University of California San Diego, La Jolla, California, USA
  2. 2 Medicine, VA San Diego Healthcare System, San Diego, California, USA
  1. Correspondence to Dr Laura E Crotty Alexander, Medicine, University of California San Diego, San Diego, California, USA; lca{at}

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Electronic cigarettes (e-cigarettes) are hand-held devices that heat and aerosolise liquids that commonly consist of propylene glycol, glycerol, chemical flavourants and nicotine (or tetrahydrocannabinol).1 These devices were initially marketed as a lower risk nicotine replacement, but increasing evidence points to the contrary. Even more concerning is that marketing has targeted the vulnerable adolescent population, with 78% of middle school and high school students exposed to at least one e-cigarette advertisement between 2014 and 2016.2 Of interest is how these marketing strategies likely contributed to the misinformation surrounding e-cigarettes. Pepper et al explored adolescents’ understanding of e-cigarettes and found concerning misperceptions about nicotine and e-liquids among participants.3 They found that 62% of non-nicotine vapers and 49% of nicotine vapers thought nicotine in e-liquids was made artificially rather than from tobacco. This could indicate that there is a misperception that some forms of nicotine are safer than others. Additionally, they found that adolescents who believed they were using e-cigarettes without nicotine had poorer overall knowledge of e-cigarettes, potentially leading to confusion of what compounds they are actually vaping.

Some may be comforted by studies that argue that nicotine use has not increased with the rise of vaping. For example, Miech et al found that more high school students reported vaping ‘just flavouring’ rather than nicotine.4 However, it is important to note that the nicotine content reported on product labels and what is chemically measured can vary widely. Nicotine has been detected in multiple products labelled as ‘zero nicotine’, with studies showing as much as 23.9 mg/mL of nicotine found in ‘nicotine-free’ e-cigarettes.5 This means that users may be unaware of what they are truly vaping and thus are at risk of unwittingly becoming nicotine addicts. Additionally, Marynak et al found that 99% of e-cigarette product sales in 2015 contained nicotine, leading to the conclusion that consumers (including youths and adolescents) are most likely using nicotine-containing products.6

Unfortunately, there has been a dramatic increase in e-cigarette use in adolescents and young adults.7 e-Cigarette use increased 900% among high school students from 2011 to 2015.8 Vaping devices are now the most commonly used tobacco product among youth in the USA.8 It is difficult to prove how much the aggressive marketing strategies used by the tobacco industry contributed to this rapid rise in e-cigarette use, but one company, JUUL, recently lost a $40 million lawsuit in North Carolina due to the impact of their deceptive marketing practices on teenage use of their high nicotine-containing e-devices. It is regrettable that any e-cigarettes were marketed as ‘safer’ before enough data existed to make that determination.

Fortunately, we now have solid evidence regarding the negative health impacts of e-cigarette use. Because of this, the US Food and Drug Administration has increased regulation of flavoured cartridge-based e-cigarettes and raised the age of tobacco sales to 21.9 Although it is exciting and comforting to know that e-cigarettes are finally being regulated by the appropriate bodies, it remains disappointing that products can enter and remain on the market until they are proven unsafe rather than being proven safe prior to being sold to children and adults.

While the evidence concerning the negative health impacts of vaping is growing daily, there is a paucity of data regarding the health effects of secondhand nicotine vaping (SHNV) exposure. This absence of evidence emboldens vapers to use e-cigarettes around friends, family and acquaintances with abandon. Like e-cigarettes, it seems SHNV exposure needs to be proven unsafe prior to action being taken to protect the public. Fortunately, in this issue of Thorax, Islam et al report data demonstrating increased bronchitic symptoms and shortness of breath in those exposed to secondhand e-cigarette aerosols.10

In contrast to SHNV exposure, there is significant evidence about the health risks associated with secondhand cigarette smoke. This has led to widespread campaigns banning cigarette smoking from public places. Unfortunately, this has not translated to SHNV exposure. In fact, studies have shown that parents were more likely to have smoke-free than vape-free home policies, which supports the perception that SHNV exposure is less harmful.11

Because of this perception and the potential for harm, the findings reported by Islam et al are of critical importance. While association is not causation, this study is the first to describe the negative effects of SHNV exposure on respiratory symptoms. More work needs to be done to prove that this exposure directly causes harm. Ultimately, this is a public health concern that—if not addressed—has the potential to negatively affect our population, including those who are most vulnerable.

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Ethics approval

This study does not involve human participants.



  • Twitter @crottyalexander

  • Contributors ALF and LECA co-wrote, edited and approved the manuscript.

  • Funding LECA’s salary was supported in part by a VA Merit Award (1I01BX004767; PI LCA), NIH NHLBI R01 (HL147326; PI LCA) and TRDRP High Impact Pilot Award grant number (T30IP0965; PI LCA).

  • Competing interests None declared.

  • Provenance and peer review Commissioned; externally peer reviewed.

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