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The Evidence of Electronic Cigarette Risks Is Catching Up With Public Perception

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March 29, 2019

Stanton A. Glantz, PhD1

The Evidence of Electronic Cigarette Risks Is Catching Up With Public Perception

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The advent of electronic cigarettes (e-cigarettes), devices that deliver a nicotine aerosol to the lungs by heating a nicotine-containing liquid rather than burning tobacco, has triggered an intense debate over their value for reducing the harm tobacco products cause. The optimists see e-cigarettes delivering nicotine without all the combustion byproducts of conventional cigarettes,1 whereas others point out that e-cigarettes still deliver an aerosol of ultrafine particles and other toxicants that carry substantial health risks.2


A key to realizing the optimists’ vision for e-cigarettes is smokers switching completely from cigarettes to e-cigarettes. Because perceived risks play an important role in selecting tobacco products, Huang and colleagues3 examined how perceptions of the risk of e-cigarettes compared with cigarettes have changed from 2012 to 2017 using 2 national surveys, the Tobacco Products and Risk Perceptions Surveys they conducted and the Health Information National Trends Surveys (HINTS). They found that the fraction of respondents who believed that e-cigarettes were less harmful than cigarettes decreased from approximately 45% in 2012 to approximately 35% in 2017, whereas the fraction who thought they were about the same increased to approximately 45%. (These estimates combine the 2 surveys. The estimates of “about the same” in 2012 were very different in the 2 surveys, so are not listed here; the other results were more similar.) The fractions who thought e-cigarettes were more dangerous than cigarettes increased but remained low, at less than 10%.


Huang and colleagues3 express concern that as fewer people view e-cigarettes as less harmful than cigarettes, fewer will be interested in switching from combustible cigarettes to e-cigarettes. Based on the evidence available in 2017, the National Academies of Science, Engineering, and Medicine concluded that “e-cigarettes pose less risk to an individual than combustible tobacco cigarettes.”4(p11) The report emphasized that at the time, no studies on the long-term health effects of e-cigarettes had been performed, which they recognized as a limitation. However, the data are catching up with public perception.


Since the report was completed, evidence has started to emerge that e-cigarette users are at increased risk of myocardial infarction,5-7 stroke,6 and chronic obstructive pulmonary disease and other respiratory diseases,8-10 controlling for smoking and other demographic and risk factors. Some of these risks approach those of smoking cigarettes. There is also emerging evidence that e-cigarettes deregulate biologically significant genes associated with cancer.11 Equally important, the risks of e-cigarette use are in addition to any risks of cigarette smoking, which means that dual users (people who continue to smoke cigarettes while using e-cigarettes) have higher risks of heart and lung disease than people who just smoke. This finding is particularly important because, contrary to the hopes of the e-cigarette optimists, about two-thirds of adult e-cigarette users are dual users (ie, continue to smoke).


In addition, although 1 randomized clinical trial12 has shown that e-cigarettes improve cessation when used as part of a clinically supervised smoking cessation program that includes intensive counseling, as used in the population as a whole as a mass-marketed consumer product, e-cigarettes are associated with reduced odds of cessation.13 In addition, 80% of former cigarette smokers were continuing to use e-cigarettes 6 month later. Although not a direct health effect (in the same way that exposure to e-cigarette aerosol triggers pathophysiological processes that increase the risk of heart and lung disease), this effect of depressing smoking cessation in the population as a whole is another risk of using e-cigarettes.


Increased perceived risks of e-cigarettes is also an important element for curbing their use by youth. Youth who believe that e-cigarettes are not harmful or are less harmful than cigarettes are more likely to use e-cigarettes than youth with more negative views of e-cigarettes.14 In terms of overall public health effects, this explosion of youth use swamps any potential harm reduction that may accompany adults switching from cigarettes to e-cigarettes.15 From this perspective, the declining public perception that e-cigarettes are less harmful than cigarettes is a good thing that may turn out to be where the scientific consensus lands as the new evidence on the harms of e-cigarettes continues to accumulate.



1.  Abrams  DB, Glasser  AM, Pearson  JL, Villanti  AC, Collins  LK, Niaura  RS.  Harm minimization and tobacco control: reframing societal views of nicotine use to rapidly save lives.  Annu Rev Public Health. 2018;39(1):193-213. doi:10.1146/annurev-publhealth-040617-013849PubMedGoogle ScholarCrossref

2.  Glantz  SA, Bareham  DW.  E-cigarettes: use, effects on smoking, risks, and policy implications.  Annu Rev Public Health. 2018;39:215-235. doi:10.1146/annurev-publhealth-040617-013757PubMedGoogle ScholarCrossref

3.  Huang  J, Feng  B, Weaver  SR, Pechacek  TF, Slovic  P, Eriksen  MP.  Changing perceptions of harm of e-cigarette vs cigarette use among adults in 2 US national surveys from 2012 to 2017.  JAMA Netw Open. 2019;2(3):e191047. doi:10.1001/jamanetworkopen.2019.1047ArticleGoogle Scholar

4.  National Academies of Sciences, Engineering, and Medicine.  Public Health Consequences of e-Cigarettes. Washington, DC: National Academies Press; 2018. doi:10.17226/24952

5.  Alzahrani  T, Pena  I, Temesgen  N, Glantz  SA.  Association between electronic cigarette use and myocardial infarction.  Am J Prev Med. 2018;55(4):455-461. doi:10.1016/j.amepre.2018.05.004PubMedGoogle ScholarCrossref

6.  Ndunda  PM, Muutu  TM. Electronic cigarette use is associated with a higher risk of stroke. International Stroke Conference 2019 Oral Abstracts. Stroke. 2019;50(suppl 1):abstract 9. https://www.ahajournals.org/doi/10.1161/str.50.suppl_1.9. Accessed February 8, 2019. 

7.  Bhatta  D, Glantz  SA. Electronic cigarette use and myocardial infarction among adults in the United States Population Assessment of Tobacco and Health. Paper presented at: Society for Research on Nicotine and Tobacco Annual Meeting; February 20-23, 2019; San Francisco, CA. Abstract P0S4-99. https://cdn.ymaws.com/www.srnt.org/resource/resmgr/SRNT19_Abstracts.pdf. Accessed February 26, 2019. 

8.  Perez  M, Atuegwu  N, Mead  E, Oncken  C, Mortensen  E. E-cigarette use is associated with emphysema, chronic bronchitis and COPD (A6245). American Thoracic Society Session D22: Cutting Edge Research in Smoking Cessation and E-cigarettes. http://www.abstractsonline.com/pp8/#!/4499/presentation/19432. Published May 23, 2018. Accessed February 9, 2019. 

9.  Wills  TA, Pagano  I, Williams  RJ, Tam  EK.  E-cigarette use and respiratory disorder in an adult sample.  Drug Alcohol Depend. 2019;194:363-370. doi:10.1016/j.drugalcdep.2018.10.004PubMedGoogle ScholarCrossref

10.  Bhatta  D, Glantz  SA. Electronic cigarette use is associated with respiratory disease among adults in the United States Population Assessment of Tobacco and Health: a longitudinal analysis. Paper presented at: Society for Research on Nicotine and Tobacco Annual Meeting; February 22-23, 2019; San Francisco, CA. Abstract P0S2-146. https://cdn.ymaws.com/www.srnt.org/resource/resmgr/SRNT19_Abstracts.pdf. Accessed February 26, 2019. 

11.  Tommasi  S, Caliri  AW, Caceres  A,  et al.  Deregulation of biologically significant genes and associated molecular pathways in the oral epithelium of electronic cigarette users.  Int J Mol Sci. 2019;20(3):738. doi:10.3390/ijms20030738PubMedGoogle ScholarCrossref

12.  Hajek  P, Phillips-Waller  A, Przulj  D,  et al.  A randomized trial of e-cigarettes versus nicotine-replacement therapy.  N Engl J Med. 2019;380(7):629-637. doi:10.1056/NEJMoa1808779PubMedGoogle Scholar

13.  Kalkhoran  S, Glantz  SA.  E-cigarettes and smoking cessation in real-world and clinical settings: a systematic review and meta-analysis.  Lancet Respir Med. 2016;4(2):116-128. doi:10.1016/S2213-2600(15)00521-4PubMedGoogle ScholarCrossref

14.  Gorukanti  A, Delucchi  K, Ling  P, Fisher-Travis  R, Halpern-Felsher  B.  Adolescents’ attitudes towards e-cigarette ingredients, safety, addictive properties, social norms, and regulation.  Prev Med. 2017;94:65-71. doi:10.1016/j.ypmed.2016.10.019PubMedGoogle ScholarCrossref

15.  Soneji  SS, Sung  HY, Primack  BA, Pierce  JP, Sargent  JD.  Quantifying population-level health benefits and harms of e-cigarette use in the United States.  PLoS One. 2018;13(3):e0193328. doi:10.1371/journal.pone.0193328PubMedGoogle ScholarCrossref

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