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Electronic cigarette

An electronic cigarette is a battery-powered device that heats a liquid solution, typically containing nicotine derived from tobacco, propylene glycol, vegetable glycerin, flavorings, and other chemicals, to generate an aerosol that users inhale through a mouthpiece.^[1]^[2]^[3] These devices, also called e-cigarettes, vapes, or electronic nicotine delivery systems, mimic the act of smoking traditional cigarettes but produce vapor rather than combustion byproducts.^[4] Invented in 2003 by Chinese pharmacist Hon Lik, who sought an alternative to combustible tobacco after heavy smoking and the loss of his father to lung cancer, the modern e-cigarette patented a system using piezoelectric ultrasound to vaporize the liquid.^[5]^[6] E-cigarettes vary in design from cigarette-like disposables to customizable mods with refillable tanks and adjustable power sources, enabling users to control vapor production and nicotine delivery.^[7] Global market revenue reached approximately USD 13.4 billion in 2024, with projections for continued growth driven by device sales and evolving consumer preferences, though usage among U.S. youth has declined to 5.9% in 2024 from higher peaks, amid regulatory efforts targeting flavored products.^[8]^[9] While empirical studies indicate e-cigarette aerosols expose users to fewer and lower levels of toxicants than cigarette smoke, supporting their role in harm reduction for adult smokers attempting to quit, long-term health data remain limited, with evidence of nicotine addiction risks, respiratory irritation, and cardiovascular effects, particularly concerning for non-smokers and adolescents.^[10]^[11] Controversies persist over their potential as a gateway to smoking versus a net public health benefit, with peer-reviewed analyses emphasizing reduced harm relative to tobacco combustion but cautioning against initiation among youth due to dependency and unknown chronic outcomes.^[12]^[13]

Technology and Components

Device Design and Operation

Electronic cigarettes are battery-powered devices that heat a liquid solution, known as e-liquid, to generate an inhalable aerosol without combustion. The modern electronic cigarette was invented in 2003 by Chinese pharmacist Hon Lik, who developed it as a potential smoking cessation tool following his father's death from lung cancer caused by smoking.^[14] Early prototypes utilized piezoelectric ultrasound to nebulize the liquid, but subsequent designs adopted resistive heating elements for vaporization.^[15] Core components typically include a rechargeable lithium-ion battery that supplies power, an atomizer consisting of a heating coil wrapped around a wick, a reservoir such as a cartridge or tank to hold the e-liquid, and a mouthpiece for inhalation.^[4] The atomizer's coil, often made of materials like kanthal or stainless steel, draws e-liquid via capillary action from the wick, which is usually composed of cotton or silica.^[16] Circuitry within the device incorporates a sensor—either airflow-based or pressure-activated—and sometimes a microcontroller to regulate voltage, wattage, and safety features like short-circuit protection.^[17] Operation begins when the user inhales through the mouthpiece, triggering the airflow sensor to complete the circuit and activate the battery, which delivers electricity to the coil at temperatures typically ranging from 180–250°C (356–482°F).^[18] This rapid heating causes the e-liquid—primarily a mixture of propylene glycol, vegetable glycerin, nicotine, and flavorings—to evaporate into an aerosol comprising fine droplets and vapor.^[4] The user then inhales the aerosol, which delivers nicotine to the lungs; some devices feature a manual button for activation instead of or in addition to automatic puff detection.^[16] Unlike combustible cigarettes, this process produces no smoke, ash, or combustion byproducts such as tar or carbon monoxide, though the aerosol may contain trace thermal degradation products depending on operating conditions.^[19] Device designs vary in form factor, from cigarette-like disposables to modular systems with adjustable power outputs, but the fundamental mechanism relies on electrical resistance heating to aerosolize the liquid rather than burning it.^[15] Battery capacities commonly range from 100–3000 mAh, influencing usage duration, while coil resistances are measured in ohms (e.g., 0.1–2.0 Ω) to control heat intensity and vapor production.^[20] Safety features in regulated devices include overheat and dry-hit prevention to mitigate risks from wick burnout or liquid depletion.^[7]

E-liquids and Ingredients

E-liquids, also known as vape juice, consist of a mixture primarily comprising solvents, nicotine, and flavoring agents that are heated to produce an inhalable aerosol. The base solvents are typically propylene glycol (PG) and vegetable glycerin (VG), which serve as carriers for other components and generate vapor upon heating. PG, a colorless, odorless liquid, provides throat hit and aids in flavor delivery, while VG, derived from vegetable oils, contributes to denser vapor clouds and smoother inhalation.^[2]^[21] In analyzed samples, e-liquids averaged 57 g/100 g PG, 37 g/100 g glycerol, and smaller amounts of other glycols.^[21] Nicotine, when present, is usually extracted from tobacco plants or produced synthetically, with concentrations ranging from 0 mg/mL in nicotine-free variants to as high as 50 mg/mL in some products, though regulated markets limit strengths (e.g., up to 20 mg/mL in the EU since 2016).^[2]^[22] It dissolves readily in PG/VG mixtures, influencing user satisfaction and addiction potential akin to traditional tobacco but without combustion byproducts.^[23] Flavorings, often food-grade compounds deemed generally recognized as safe (GRAS) for oral consumption, include vanillin, ethyl maltol, and fruit or tobacco mimics, comprising up to several percent of the e-liquid by volume.^[24] These additives enhance appeal but may form reactive carbonyls or irritants when heated, with in vitro studies indicating potential cytotoxicity for certain flavors like cinnamon or banana derivatives, though human inhalation data remains limited and concentrations vary by product.^[25]^[26] Additional minor ingredients can include water for viscosity adjustment, ethanol as a solvent, triacetin for smoothness, and sweeteners like sucralose to balance flavors without significant caramelization.^[24] Quality varies due to limited pre-market oversight in some regions, potentially introducing impurities like heavy metals from manufacturing, but pharmaceutical-grade PG/VG predominate in regulated formulations.^[25] Overall, e-liquid composition prioritizes aerosol formation over the tar and carcinogens in combusted tobacco, though solvent inhalation induces mucociliary effects in animal models at high exposures.^[27]

Hardware Variations and Advancements

Electronic cigarettes have evolved through distinct generations of hardware, beginning with simple, cigarette-mimicking designs and progressing to sophisticated, customizable systems. First-generation devices, known as cigalikes, emerged commercially around 2003–2007, patented by Chinese pharmacist Hon Lik and marketed by Ruyan; these featured a small rechargeable battery, a pre-filled cartridge holding ≤1 mL of e-liquid, and an atomizer that produced limited vapor with a glowing LED tip simulating a burning cigarette end.^[14] Their compact, disposable or two-part design prioritized familiarity for smokers but offered short battery life and low power output, restricting nicotine delivery and vapor production.^[14] Second-generation hardware, often termed vape pens, appeared in the early 2010s, introducing larger batteries and refillable tank systems that replaced cartridges, allowing users to customize e-liquid flavors and nicotine strengths while improving aerosol generation and battery longevity.^[14] These pen-shaped devices added manual activation buttons and basic airflow adjustments, marking a shift toward greater user control and efficiency over the fixed setups of cigalikes.^[28] Third-generation devices, including advanced personal vaporizers (APVs) and box mods, gained prominence from the mid-2010s, featuring high-capacity removable batteries (often 18650 cells), digital displays, and variable wattage or voltage controls ranging up to 200+ watts for enhanced power and vapor volume.^[29] Key advancements included sub-ohm atomizers (coils with resistance <1 ohm), which enable higher current flow and denser clouds via increased heat, and temperature control (TC) modes that use materials like nickel or titanium to regulate coil temperature, preventing dry hits and flavor degradation.^[28] Rebuildable atomizers, such as dripping atomizers (RDAs) and tank atomizers (RTAs), allow users to manually construct coils from wire (e.g., kanthal or stainless steel) and wicks (often organic cotton), offering customization for flavor and vapor preferences among enthusiasts while reducing long-term costs.^[29] Fourth-generation pod systems, popularized by JUUL's 2015 launch, adopted compact, USB-like forms with pre-filled or refillable pods (typically 0.7–2 mL capacity), draw-activated firing (no button), and compatibility with nicotine salts for smoother high-nicotine delivery, emphasizing portability and discretion over power.^[14] These closed-system variants contrasted with open systems like mods by prioritizing simplicity and leak resistance, though they limited customization. Recent fifth-generation advancements incorporate smart features such as Bluetooth connectivity for app-based puff tracking, AI-driven nicotine monitoring, and auto-adjusting sensors, alongside innovations like mesh coils for even heating and extended lifespan, and ceramic or advanced polymer materials to minimize residue buildup.^[28]^[29] Overall, hardware progression has emphasized safety enhancements (e.g., short-circuit protection in regulated mods), modularity (interchangeable components), and efficiency, with open systems suiting advanced users and closed systems appealing to beginners, though regulatory pressures have influenced design toward reduced emissions and youth-resistant features in later models.^[14]

Usage and Adoption

Global Prevalence and Trends

Electronic cigarette use has expanded rapidly on a global scale, with estimates placing the number of vapers at over 100 million individuals as of 2024.^[30] ^[31] The World Health Organization reports at least 86 million adult users, predominantly in high-income countries, alongside at least 15 million adolescents aged 13-15 years who use e-cigarettes.^[30] Independent estimates from the Global State of Tobacco Harm Reduction suggest 114 million vapers worldwide in 2023, reflecting accelerated adoption.^[32] Prevalence trends indicate steady growth since the early 2010s, driven by product accessibility and marketing in developed markets. In 2021, approximately 82 million people vaped globally, up from 68 million in 2020.^[33] ^[34] This upward trajectory equates to about 1.9% of the global population engaging in vaping by recent counts, with high-income nations accounting for over two-thirds of users.^[31] Among youth, meta-analyses report current e-cigarette use at around 4.8-5% and ever-use at 16.8-17% across global adolescent populations, with males exhibiting higher rates than females.^[35] ^[36] Regional variations highlight concentration in Europe, North America, and parts of Asia, where regulatory environments and cultural factors influence uptake. While tobacco smoking prevalence has declined globally—from 1.38 billion users in 2000 to 1.2 billion in 2024—e-cigarette adoption has partially offset this by attracting former smokers and, in some cases, non-smokers.^[30] Emerging data for 2025 suggest continued expansion amid debates over long-term health impacts and policy responses, though stringent regulations in regions like the European Union and United States have moderated youth initiation in recent years.^[37]^[38]

User Demographics and Motivations

In the United States, current e-cigarette use among adults is highest among those aged 18-24 years, with approximately 18% prevalence reported in 2021 data from the Behavioral Risk Factor Surveillance System.^[39] Usage declines with age thereafter, though it remains notable among current and former smokers across adult demographics.^[40] Men report higher rates of current e-cigarette use than women, consistent with patterns in combustible tobacco consumption.^[40] Among ever-users of e-cigarettes (17.1% of U.S. adults in 2022), current use stands at 4.3%, with the majority having a history of cigarette smoking; non-smokers and former smokers exhibit far lower adoption rates (0.3% and 0.6%, respectively, in a 2024 European cohort).^[41]^[42] E-cigarette adoption is predominantly among current smokers or recent quitters, with dual use (concurrent e-cigarette and cigarette consumption) characterizing over half of adult vapers in multiple surveys.^[43] Never-smokers represent a small fraction of regular users, often limited to younger cohorts influenced by social factors rather than nicotine dependence.^[42] Youth usage has declined to 5.9% among U.S. middle and high school students in 2024, down from 7.7% in 2023, though frequent use persists among a subset (38.4% of current youth users vaping on 20+ days in the past month).^[38] ![Reasons for initiating e-cigarette use (EU 2018)](./assets/Reasons_for_initiating_e-cigarette_use_EU_2018 Primary motivations for adult e-cigarette use center on smoking cessation or reduction, with 34.2% of dual users citing reduced combustible cigarette intake as a key driver in a 2022 survey of smokers.^[44] Other common reasons include perceived health benefits over smoking, enjoyment of device use, and social acceptability, though convenience alone correlates with lower usage frequency.^[43] Among those quitting vaping, health concerns (74%) and cost savings (45%) predominate, underscoring instrumental rather than recreational intent for many.^[45] For young adults, intrinsic factors like quitting smoking or favoring vaping's sensory profile over cigarettes sustain continued use, while extrinsic social influences play a lesser role.^[46] Mental health coping emerges as a endorsed reason in 39.6% of cases tied to higher frequency, potentially reflecting self-medication for stress or anxiety amid nicotine's pharmacological effects.^[47]

Patterns of Dual Use and Switching

Dual use refers to the concurrent consumption of electronic cigarettes and combustible tobacco cigarettes, often as a transitional behavior among smokers attempting to reduce or quit smoking. In the United States, approximately 29.4% of adults who used e-cigarettes in 2021 also smoked combustible cigarettes, representing a subset of current smokers who incorporate vaping into their nicotine intake. ^[40] Prevalence of dual use varies by demographics, with higher rates observed among younger adults; for instance, in a 2022 study of U.S. adults, dual use was reported at 41.1% for ages 18–29 and 36.8% for ages 30–39, compared to 15.6% for ages 40–49. ^[48] Globally, dual use patterns show that among e-cigarette users, the proportion concurrently smoking has declined over time, from 54.6% in 2016 to lower figures in recent years, reflecting market maturation and increased adoption for cessation purposes. ^[49] Longitudinal trends indicate a gradual reduction in dual use intensity. In South Korea, the proportion of smokers engaging in dual use decreased from 19.8% in 2013 to 16.4% in 2019, with prolonged dual use (lasting over a year) among dual users falling from 40.0% to 27.4% in the same period, suggesting many transition toward exclusive vaping or abstinence. ^[50] In England, where e-cigarettes are promoted for harm reduction, dual use affected about 5% of adults as of 2024, with patterns shifting from frequent smoking to predominant vaping; the most common dual use profile across 2016–2023 was daily cigarette smoking combined with daily vaping (49.0%), though this evolved toward less cigarette dependence as disposable pod devices proliferated. ^[51] ^[52] U.S. data from the Population Assessment of Tobacco and Health (PATH) study similarly show increasing transitions from dual use to exclusive e-cigarette use, rising from 9.5% per year in earlier waves to 20.0% by recent assessments, driven by factors like nicotine delivery efficiency. ^[53] Switching from dual use to exclusive e-cigarette use or complete cessation is supported by clinical evidence, though outcomes vary. A 2019 randomized controlled trial in the United Kingdom found that e-cigarettes achieved a 18.0% one-year abstinence rate among smokers (verified by cotinine levels), compared to 9.9% for nicotine replacement therapy, with many participants progressing from dual use to exclusive vaping before quitting entirely. ^[54] In England’s Smoking Toolkit Study, adults who initiated e-cigarette use while smoking showed repeated point-prevalence switching away from cigarettes, with 69.5% of those switched at 12 months maintaining abstinence from smoking over the subsequent year as of 2025 data. ^[55] However, not all dual users successfully switch; some analyses indicate dual users are less likely to achieve sustained cessation than exclusive smokers, potentially due to sustained nicotine dependence or behavioral reinforcement from combustible tobacco, with reversion to smoking observed in subsets tracked longitudinally. ^[56] Empirical data emphasize that while dual use sustains higher exposure to tobacco toxins than exclusive vaping, it often serves as an intermediate step, with success rates improving alongside advancements in e-cigarette technology and user education. ^[57]

Health Effects

Harm Reduction for Smokers

Electronic cigarettes facilitate harm reduction for smokers by delivering nicotine via aerosolization without the combustion products inherent in traditional tobacco smoking, such as tar, carbon monoxide, and numerous carcinogens. Public Health England has estimated that e-cigarettes are approximately 95% less harmful than smoking, based on assessments of toxicant exposure levels, a figure derived from independent reviews commissioned in 2015 and supported by subsequent evidence on reduced harmful chemical yields. ^[58] ^[59] This reduction stems from the absence of pyrolysis and the lower concentrations of volatile organic compounds, heavy metals, and polycyclic aromatic hydrocarbons in e-cigarette emissions compared to cigarette smoke. ^[60] Systematic reviews of randomized controlled trials indicate that nicotine-containing e-cigarettes outperform nicotine replacement therapy (NRT) in promoting smoking cessation among smokers motivated to quit. The 2024 Cochrane review, analyzing data from multiple trials, found high-certainty evidence that e-cigarettes with nicotine increase six-month quit rates compared to NRT, with a relative risk of 1.63 (95% CI 1.30 to 2.05), and moderate-certainty evidence of superiority over no intervention or behavioral support alone. ^[61] ^[62] For smokers unable or unwilling to quit entirely, complete switching to e-cigarettes has been associated with substantial decreases in biomarkers of exposure to tobacco-specific nitrosamines and other toxins, approaching levels seen in non-smokers. ^[10] Observational and intervention studies on smokers who switch to exclusive e-cigarette use report improvements in respiratory symptoms and objective health markers. A 2024 analysis of switching patterns showed moderate increases in the resolution of wheeze and cough compared to continued smoking, alongside reductions in phlegm production. ^[63] Short-term trials, including one published in 2024, demonstrated that adding e-cigarettes to counseling enhanced cessation rates without elevating adverse health events over six months, supporting their role as a transitional tool. ^[64] However, while acute harms appear mitigated, population-level data suggest incomplete alignment in risk reduction for all smoking-related diseases, such as certain cardiovascular outcomes, underscoring the need for long-term monitoring. ^[57] These findings position e-cigarettes as a viable harm reduction strategy for adult smokers, provided they prioritize complete substitution over dual use.^[65]

Risks to Non-Smokers and Youth Initiation

Secondhand exposure to e-cigarette aerosol, while containing nicotine and fewer toxicants than combustible cigarette smoke, poses lower overall risks to non-smokers compared to secondhand smoke, with studies indicating 90-95% reductions in harmful chemicals and particulate matter.^[66] Children exposed to secondhand vapor absorb significantly less nicotine than from secondhand smoke, as evidenced by biomarker measurements showing higher cotinine levels from smoke exposure.^[67] However, aerosol may still cause acute symptoms like eye, nose, and throat irritation or reduced respiratory function in short-term exposure scenarios, particularly in enclosed spaces.^[68] Prospective data link secondhand aerosol to increased risks of bronchitic symptoms and shortness of breath, though these effects are milder and less consistent than those from tobacco smoke.^[69] For non-smoking youth, the primary concern stems from direct initiation of e-cigarette use, which delivers nicotine—a substance known to disrupt adolescent brain development by altering circuits involved in attention, learning, impulse control, and reward processing, with effects persisting into adulthood.^[70]^[71] Nicotine exposure during this period heightens addiction vulnerability, as youth brains show heightened responsiveness to nicotine's reinforcing effects compared to adults, potentially priming pathways for other substance dependencies.^[72] In the United States, current e-cigarette use among middle and high school students stood at 5.9% in 2024, affecting approximately 1.63 million youth, down from peaks near 20% in 2019 but still indicating widespread experimentation driven by flavored products and social influences.^[73]^[38] The extent to which youth e-cigarette initiation serves as a gateway to combustible cigarette smoking remains debated, with longitudinal studies showing associations—such as 3-4 times higher odds of subsequent smoking among baseline vapers—but often failing to establish causation after accounting for confounders like prior risk behaviors or common liability to nicotine experimentation.^[74]^[75] A systematic review of prospective cohorts highlighted consistent links to smoking initiation in 28 studies, yet critics note that reverse causation (e.g., youth predisposed to smoking trying e-cigarettes first) and shared genetic/environmental factors explain much of the correlation, with no clear evidence of e-cigarettes uniquely driving uptake in non-prone individuals.^[76]^[77] Empirical data from nicotine-containing versus nicotine-free e-cigarette trials further suggest that nicotine itself amplifies progression risks, underscoring the need to restrict youth access to prevent addiction onset rather than assuming inevitable tobacco escalation.^[78] Tobacco control literature, often from institutions skeptical of harm reduction, emphasizes gateway risks, but independent analyses reveal these claims overstate causality amid declining overall youth tobacco use.^[79]

Comparative Toxicology to Combustible Tobacco

Electronic cigarette aerosols lack the combustion process inherent to combustible tobacco cigarettes, resulting in the absence of pyrolysis and combustion byproducts such as tar, carbon monoxide, and polycyclic aromatic hydrocarbons (PAHs), which are major contributors to tobacco-related toxicity.^[80] In contrast to cigarette smoke, which contains over 7,000 chemicals including at least 70 known carcinogens, e-cigarette aerosols primarily consist of propylene glycol, vegetable glycerin, nicotine, and flavorants, with far fewer identified toxicants overall.^[81] Quantitative analyses indicate that levels of targeted toxicants in e-cigarette aerosols are 68.5% to over 99% lower than in cigarette smoke for compounds like formaldehyde, acetaldehyde, and acrolein.^[82] Cigarette smoke delivers high concentrations of tobacco-specific nitrosamines (TSNAs), heavy metals, and volatile organic compounds (VOCs) through incomplete combustion, whereas e-cigarette aerosols exhibit substantially reduced emissions of these substances due to the heating rather than burning mechanism.^[83] For instance, TSNA levels in e-cigarette aerosols are typically 90-99% lower than in cigarette smoke, and carbonyl compounds like formaldehyde arise from thermal degradation of e-liquids but at concentrations 10-100 times below those in smoke under standard puffing regimens.^[84] Metals such as nickel and chromium can leach from e-cigarette coils, yet their aerosol concentrations remain orders of magnitude lower than in cigarette smoke, where they originate from tobacco filler and combustion.^[85] In vitro toxicological assessments, including cytotoxicity and genotoxicity tests on human lung cells, demonstrate that e-cigarette aerosols induce significantly less oxidative stress, inflammation, and DNA damage compared to cigarette smoke equivalents.^[86] A comparative analysis using 3D human airway models confirmed no cytotoxicity or impaired barrier function from e-cigarette exposures at levels matching smoker puff topography, unlike the pronounced effects from tobacco smoke.^[86] These findings align with chemical emission data showing e-cigarette aerosols to be compositionally simpler and less hazardous, though aerosol complexity increases with higher device power or degraded components, potentially elevating certain aldehydes.^[84] Despite these reductions, e-cigarette aerosols are not devoid of risk, containing nicotine and select harmful chemicals like diacetyl in some flavors, but epidemiological and biomarker studies in users corroborate lower systemic exposure to carcinogens and toxins relative to smokers.^[85] For example, urinary levels of NNAL (a TSNA metabolite) in exclusive vapers are 70-95% lower than in combustible cigarette smokers.^[87] Independent reviews emphasize that while absolute safety is unproven, the toxicological profile supports e-cigarettes as a lower-risk alternative for adult smokers, predicated on reduced but non-zero emissions of respiratory irritants and potential mutagens.^[80] Long-term human data remain limited, but short-term clinical trials show diminished endothelial dysfunction and inflammatory markers in switchers compared to continued smokers.^[88]

Emerging Long-Term Data and Uncertainties

A 2025 population-based analysis linked exclusive electronic cigarette use to increased odds of chronic obstructive pulmonary disease (COPD) and hypertension compared to non-use, drawing from U.S. health survey data spanning multiple years.^[89] Similarly, longitudinal cohort data indicate that e-cigarette initiation among youth correlates with heightened risks of subsequent cigarette smoking, substance use, asthma exacerbations, injuries, and mental health issues, though causation remains debated due to confounding factors like pre-existing vulnerabilities.^[79] These findings emerge from observational studies tracking users over 2–5 years, highlighting acute-to-intermediate respiratory and cardiovascular perturbations, including elevated heart rate and blood pressure post-inhalation.^[65] Animal models of chronic e-cigarette aerosol exposure, simulating years of human use, demonstrate less severe cardiovascular and respiratory impairment than combustible cigarettes, with reduced inflammation and fibrosis but detectable endothelial dysfunction and renal alterations.^[90] Human cohort evidence supports harm reduction for complete switchers from smoking, showing attenuated progression of smoking-attributable diseases, yet dual use—common in 20–40% of users—may accelerate lung cancer risk through additive oxidative stress.^[91] A systematic review of longitudinal and cross-sectional data found no significant cancer incidence elevation from e-cigarette use alone in most cases, attributing discrepancies to methodological variances like self-reported exposure.^[92] Key uncertainties stem from the technology's recency, with adoption surging post-2010, limiting data beyond a decade for never-smokers or youth.^[93] Potential long-term risks include nicotine-driven dependence trajectories, chronic bronchial irritation without combustion byproducts, and subtle vascular remodeling, as evidenced by arterial stiffness markers in early cohorts.^[94] Gastrointestinal and hepatic effects, such as microbiome disruption and fibrosis, appear in preclinical extensions but lack robust human confirmation.^[95] While e-cigarettes exhibit lower toxicant profiles than tobacco smoke, variability in device potency, e-liquid formulations, and user behaviors confounds projections, underscoring the need for extended prospective trials decoupled from institutional emphases on acute harms.^[57]^[96]

Controversies and Scientific Debates

Gateway Hypothesis Evaluation

The gateway hypothesis posits that electronic cigarette use among non-smoking youth causally leads to initiation of combustible tobacco cigarette smoking, potentially through nicotine dependence, behavioral normalization of inhalation devices, or progression to more harmful substances.^[97] This claim has been advanced in numerous observational studies showing associations, with adjusted odds ratios for subsequent smoking among baseline e-cigarette users ranging from 1.41 to 8.30 in longitudinal analyses of adolescent never-smokers.^[77] For instance, a 2025 systematic review of 99 individual-level studies identified consistent positive links between vaping and later smoking progression, though it rated the evidence as very low certainty due to pervasive biases.^[98]^[99] Critiques emphasize that such associations do not establish causation, attributing them instead to the common liability hypothesis, where youth predisposed to nicotine experimentation—due to genetic risk-taking traits, peer influences, or socioeconomic factors—are more likely to try both products regardless of order.^[97]^[100] Longitudinal designs often fail to fully control for over 30 potential confounders, such as prior susceptibility to smoking or unreported early tobacco exposure, and exclude dual users at baseline, limiting generalizability to only 5.3% of overall cigarette initiations.^[77] A 2023 analysis of 22 sub-cohorts highlighted methodological flaws, including short follow-up periods (6–24 months) and overgeneralization of sub-group risks to populations, concluding that causal claims contradict broader evidence.^[77] Population-level trends further undermine the hypothesis: youth combustible smoking rates have accelerated in decline since e-cigarette availability increased, with U.S. high school smoking dropping from 15.8% in 2011 to 1.9% by 2023, even as vaping peaked and then stabilized.^[75]^[101] A 2023 Queen Mary University of London study, described as the most comprehensive to date, found no evidence that e-cigarettes promote smoking uptake at a societal scale, suggesting displacement effects where vaping substitutes for cigarettes among at-risk youth.^[102] Similarly, a 2024 evaluation favored common liability over gateway causation, noting that misinterpreting associations risks policies that could elevate smoking by restricting less harmful alternatives.^[97] Overall, while e-cigarette use correlates with elevated smoking risk among susceptible youth, rigorous causal evidence for a gateway effect remains weak, confounded by selection biases and contradicted by aggregate data showing decoupled trends in vaping and smoking prevalence.^[98] Studies from tobacco control-oriented sources often amplify gateway interpretations despite these limitations, whereas harm reduction analyses prioritize confounding and population outcomes.^[103] Further randomized or quasi-experimental research is needed to disentangle directionality, but current data do not support prohibiting e-cigarettes on gateway grounds alone.^[104]

Youth Vaping Epidemic Claims

Claims of a youth vaping "epidemic" gained prominence in the United States around 2018–2019, when the U.S. Food and Drug Administration (FDA) and Centers for Disease Control and Prevention (CDC) highlighted sharp increases in e-cigarette use among middle and high school students, attributing the rise primarily to flavored, pod-based devices like Juul.^[105] According to the National Youth Tobacco Survey (NYTS), past-30-day e-cigarette use among these students peaked at approximately 20% in 2019, with high school prevalence reaching 27.5% that year, prompting public health officials to declare it a crisis due to concerns over nicotine addiction and potential gateway effects to combustible tobacco.^[106] These claims emphasized that e-cigarettes had become the most used tobacco product among youth since 2014, surpassing traditional cigarettes, and warned of long-term risks including brain development impairment from nicotine exposure.^[37] ^[73] However, subsequent NYTS data reveal a sustained decline in youth e-cigarette use following regulatory interventions such as flavor restrictions, marketing curbs, and enforcement against unauthorized products. Past-30-day prevalence fell to 7.7% in 2023 and further to 5.9% in 2024 across middle and high school students, representing about 1.6 million users and marking the lowest level in over a decade, with roughly 500,000 fewer youth vapers compared to the prior year.^[107] ^[108] High school use specifically dropped from 10% in 2023 to 7.8% in 2024, while middle school rates declined from 5.9% to 3.5%.^[109] This trajectory contrasts with the "epidemic" framing, as overall youth tobacco use reached a 25-year low of 7.8% in 2024, driven largely by e-cigarette reductions, and current cigarette smoking among youth hit 1.4%—far below historical peaks.^[110] ^[111] Critiques of the epidemic narrative argue that it overstates the scale and novelty of the issue relative to past youth smoking trends, where cigarette prevalence exceeded 30% among high schoolers in the 1990s and earlier decades, leading to far greater documented morbidity and mortality.^[112] For instance, cigarette smoking rates declined from 17.1% in 2002 to 1.4% by 2024, a steeper drop post-e-cigarette emergence, suggesting vaping may have displaced rather than amplified overall nicotine uptake among non-smokers.^[113] Independent analyses note the absence of acute, widespread health outcomes directly attributable to youth e-cigarette use, unlike combustible tobacco, and question the causal evidence for gateway effects given the parallel collapse in youth smoking initiation.^[112] ^[114] Public health agencies like the CDC, while data providers, have been accused of alarmism to justify broad restrictions, potentially overlooking e-cigarettes' role in reducing combustible tobacco harm among experimenting youth.^[112] Despite ongoing daily use among about 30% of youth vapers in 2024, the lack of epidemic-level disease incidence and the post-peak stabilization underscore that claims may reflect temporary spikes amplified by institutional biases toward anti-nicotine policies rather than enduring causal threats.^[115]

Flavor Restrictions and Behavioral Outcomes

In various jurisdictions, restrictions on flavored electronic cigarettes have been enacted primarily to diminish their appeal to non-smokers, particularly youth, by prohibiting non-tobacco flavors such as fruit, candy, and menthol in e-liquids. For instance, Massachusetts implemented a comprehensive flavored tobacco ban effective June 1, 2020, which included e-cigarettes and led to an 88.91% reduction in total e-cigarette unit sales in the state compared to pre-ban levels. Similarly, California's flavored tobacco ban, enacted in December 2022, resulted in significant declines in e-cigarette sales, with overall tobacco product sales dropping by approximately 10% in the year following implementation. In the European Union, the Tobacco Products Directive (TPD) of 2016 banned characterizing flavors in cigarettes and restricted them in e-cigarettes, contributing to reported decreases in youth e-cigarette experimentation.^[116]^[117]^[118] Empirical data indicate these policies correlate with reduced e-cigarette initiation and use among adolescents and young adults. In states with flavor bans, e-cigarette use among youth aged 18-24 declined significantly relative to states without such restrictions, with one analysis showing sustained reductions in Massachusetts post-2020. A systematic review of global flavor restrictions found significant decreases in youth electronic nicotine product (ENP) use, attributing this to lowered product attractiveness. However, these reductions are not uniform; in high-retailer-density areas, youth access persisted through alternative channels, suggesting enforcement challenges limit overall efficacy.^[119]^[120]^[118] Among adult smokers, flavor restrictions have shown mixed behavioral outcomes, often hindering harm reduction efforts. Studies reveal that bans are associated with slower declines in combustible cigarette smoking, with states implementing e-cigarette flavor policies experiencing unintended increases in cigarette use prevalence—up to a 2.2% rise in daily smoking rates from 2018 to 2023 compared to non-ban states. In California, while e-cigarette sales fell, cigarette sales also declined modestly, but young adult (18-24) vapers reported higher rates of switching back to or initiating cigarette use post-ban, potentially due to reduced appeal of tobacco-only flavors for cessation. Experimental evidence further suggests that flavor bans elevate the likelihood of consumers turning to illicit markets for banned products, inflating black market activity without proportionally boosting quit rates.^[119]^[121]^[122] Critically, while youth vaping reductions are documented, the net public health impact remains debated due to substitution effects. Comprehensive analyses of U.S. state-level data post-flavor bans indicate no significant overall reduction in tobacco product use among adults 21 and older, with dual use patterns persisting or shifting toward more harmful cigarettes. In Massachusetts, local surveys post-2020 ban found no decrease in e-cigarette consumption in urban areas like Greater Boston, implying behavioral adaptation via unregulated sources. These outcomes underscore that flavor restrictions may curb novel uptake but risk undermining switching from combustible tobacco, where empirical substitution models predict net harm if black market proliferation or cigarette relapse exceeds vaping declines.^[123]^[124]^[125]

Historical Development

Early Prototypes (1920s–1990s)

In 1927, American inventor Joseph Robinson filed a patent for an "electric vaporizer" designed to produce inhalable vapors from medicinal compounds without combustion, which some sources identify as an early conceptual precursor to the electronic cigarette.^[126] The device featured a storage unit for liquids, a heating element to generate mist, and a mouthpiece for inhalation, explicitly avoiding tobacco burning to eliminate smoke and ash.^[127] The patent was granted in 1930 but was never commercialized, likely due to technological limitations in battery power, material durability, and lack of market interest in nicotine delivery alternatives at the time.^[128] Subsequent decades saw sporadic patent filings for similar non-combustible inhalation devices, though none achieved practical implementation. These early efforts reflected a recognition of combustion's health drawbacks—such as tar and carbon monoxide production—but lacked the engineering feasibility for widespread adoption amid dominant traditional tobacco industry interests.^[127] A more defined prototype emerged in 1963 when Herbert A. Gilbert, an Ohio-based engineer, filed for a "smokeless non-tobacco cigarette" patent, granted in 1965, which closely resembled modern e-cigarette principles by vaporizing flavored, nicotine-free liquids through a piezoelectric ultrasonic method or heating element.^[129] Gilbert's device included a plastic tube with a battery-powered heater to produce inhalable mist mimicking smoke, aimed at providing a safer smoking simulation without tobacco or combustion byproducts; he constructed a working prototype and sought partnerships with tobacco firms like Philip Morris.^[130] Despite demonstrations, companies declined commercialization, citing insufficient demand for non-nicotine alternatives and entrenched cigarette market dominance, leaving the invention dormant through the 1970s and 1980s.^[131] From the 1970s to 1990s, isolated experiments continued, such as battery-operated inhalers for nicotine or pharmaceuticals, but systemic barriers including regulatory hurdles, high development costs, and skepticism toward unproven alternatives prevented viable prototypes from advancing beyond patents.^[127] These efforts underscored causal challenges in aerosol delivery—requiring stable vaporization without degradation or toxicity—but yielded no mass-produced devices until the early 2000s.^[130]

Modern Commercialization (2000s–2010s)

The first commercially viable electronic cigarette was developed by Chinese pharmacist Hon Lik, who patented a piezoelectric ultrasound device for aerosolizing nicotine solution in 2003 while working for Golden Dragon Holdings. In May 2004, the company—renamed Ruyan—launched its initial e-cigar product in China, marketed as a healthier alternative to combustible tobacco for smokers seeking to quit or reduce consumption. These early devices featured a basic atomizer, battery, and nicotine cartridge, producing vapor without combustion, and were initially sold domestically with limited export.^[132]^[127] International commercialization accelerated in 2006, with e-cigarettes entering European markets in April and the U.S. in August via imports from China, primarily through small vendors and online sales. Early U.S. brands like NJOY (founded 2007) and Smoking Everywhere emerged, facing regulatory scrutiny; the FDA attempted to classify them as unapproved drugs in 2009, leading to import blocks, but a 2010 federal appeals court ruling allowed regulation as tobacco products absent therapeutic claims. This enabled market persistence, with independent firms driving innovation in refillable cartomizers and variable-voltage batteries by the early 2010s.^[127]^[128]^[133] Global sales reflected rapid expansion, growing from an estimated $20 million in 2008 to $7 billion by 2014, fueled by smoker adoption and device improvements like clearomizers for better flavor delivery. In the U.S., disposable e-cigarette unit sales rose from negligible levels in 2010 to nearly $100 million in the second quarter of 2013 alone. Tobacco companies began entering the sector around 2012 with investments and launches (e.g., Lorillard's Blu in 2012), though independents dominated early growth; pod-based systems like JUUL, introduced in 2015, captured significant share by 2019 through discreet design and high-nicotine salts, contributing to youth appeal concerns amid overall market scaling.^[134]^[133]^[135]

Recent Evolution and Market Shifts (2020s)

The global e-cigarette market expanded significantly in the early 2020s, with revenue reaching approximately US$27.2 billion projected for 2025, reflecting an annual growth rate of around 3.69% through 2030.^[136] In the United States, the market was valued at USD 6.04 billion in 2025, with modest growth anticipated to USD 6.59 billion by 2030 at a CAGR of about 1.8%.^[137] This growth occurred amid heightened regulatory scrutiny, including the U.S. Food and Drug Administration's (FDA) premarket tobacco product application (PMTA) process, which began issuing marketing denial orders for many flavored products starting in 2021, limiting authorized options primarily to tobacco-flavored varieties.^[138] Disposable e-cigarettes emerged as the dominant segment, driving much of the market surge. From February 2020 to May 2025, U.S. disposable e-cigarette unit sales increased by 202.5%, from 4.1 million to 12.3 million units monthly, capturing a larger share due to their affordability, convenience, and appeal of flavored options despite restrictions.^[139] The global disposable market grew from USD 5.7 billion in 2021 to a projected USD 14.8 billion by 2030, fueled by larger-capacity devices containing high nicotine levels, often exceeding those in traditional cigarettes.^[140] Brands like Elf Bar and similar imports proliferated, filling voids left by pod systems such as Juul, whose market position weakened following FDA enforcement actions and lawsuits over youth marketing in 2019-2020.^[141] Regulatory developments reshaped market dynamics globally. In the U.S., FDA's PMTA denials for thousands of applications by 2024 constrained legal sales, prompting industry challenges in courts, including a 2025 Supreme Court affirmation of denials for flavored products like those from Triton.^[142] Internationally, flavor bans in the European Union and countries like Australia intensified by 2023-2025, alongside bans on disposables in places such as the UK and parts of Asia, yet overall vaping prevalence rose, with an estimated 68 million users worldwide in 2020.^[143] These measures aimed to curb youth uptake but correlated with shifts toward unregulated or black-market channels, while authorized products innovated in nicotine delivery, such as synthetic nicotine formulations to evade some restrictions.^[144] Market consolidation and innovation marked further evolution, with traditional tobacco firms like Philip Morris International advancing heated tobacco alternatives alongside e-cigarettes, contributing to broader nicotine product diversification.^[145] Despite tightened policies, e-cigarette sales climbed during 2020-2022, including amid the COVID-19 pandemic, underscoring persistent consumer demand for smoking alternatives.^[146] Projections indicate continued expansion, albeit tempered by enforcement, with the global market potentially reaching USD 47.5 billion by 2028.^[147]

Regulation and Policy

International Frameworks

The World Health Organization's Framework Convention on Tobacco Control (FCTC), adopted in May 2003 and entering into force on February 27, 2005, serves as the cornerstone international treaty for tobacco control, ratified by 183 parties representing over 90% of the global population.^[148] Although the FCTC predates the commercialization of modern electronic cigarettes and does not explicitly reference them, its provisions on tobacco product regulation—such as Articles 9 and 10 requiring disclosure of ingredients and emissions, and broader demands for demand reduction measures—have been interpreted by the WHO and many parties to encompass e-cigarettes as novel nicotine delivery systems akin to tobacco products.^[149] ^[150] This application remains contested, as e-cigarettes lack tobacco combustion, potentially distinguishing them from traditional cigarettes under the treaty's causal focus on smoke-related harms, though WHO guidance urges comprehensive restrictions including advertising bans, packaging warnings, and taxation aligned with FCTC obligations.^[151] The WHO has issued targeted recommendations on e-cigarettes outside the FCTC, emphasizing their classification as tobacco products where feasible and advocating for stringent controls to mitigate youth uptake and health risks, including a 2014 report urging parties to implement non-binding measures like sales bans to unproven users and flavor restrictions.^[148] As of 2023, WHO data indicate that 74 countries lack any e-cigarette regulations, while 88 impose no minimum purchase age, highlighting uneven global implementation influenced by FCTC reporting requirements but hampered by the absence of specific enforcement mechanisms for non-combustible products.^[148] At the FCTC's Conference of the Parties (COP10) in February 2024, delegates deferred a binding decision on e-cigarettes and heated tobacco products, opting instead for a working group to assess their integration into the treaty framework, reflecting ongoing debates over harm reduction evidence versus precautionary restrictions.^[152] No dedicated multilateral treaty exists solely for e-cigarettes, leading to reliance on FCTC extensions or ad hoc national adaptations; for instance, at least 34 countries have enacted outright sales bans by 2023, often justified under FCTC-aligned public health rationales, while others regulate via consumer product safety laws to avoid trade disputes under World Trade Organization rules.^[153] ^[154] Proposals for a new FCTC-like convention on novel nicotine products have surfaced to address regulatory gaps, but as of 2025, these remain aspirational amid evidence that divergent approaches—such as minimum age limits and public use bans in 68 countries—yield varying outcomes without unified causal benchmarks for efficacy.^[151] ^[155]

U.S. Federal and State Measures

The U.S. Food and Drug Administration (FDA) gained authority to regulate tobacco products, including electronic nicotine delivery systems (ENDS), through the Family Smoking Prevention and Tobacco Control Act signed into law on June 22, 2009.^[2] This act empowered the FDA to oversee manufacturing, marketing, and distribution but initially excluded ENDS. On May 10, 2016, the FDA issued the Deeming Rule, extending its jurisdiction to ENDS, cigars, and other deemed tobacco products, with regulations taking effect on August 8, 2016.^[156] Under this framework, manufacturers of new ENDS products must submit Premarket Tobacco Product Applications (PMTAs) demonstrating that marketing is appropriate for public health protection, with initial deadlines set for September 9, 2020.^[138] The FDA has issued marketing granted orders (MGOs) for select ENDS, such as certain Vuse Alto pod-based systems in 2021 and 2022, based on evidence of benefits for adult smokers outweighing risks to youth.^[157] However, it has denied thousands of applications, particularly for flavored products; for instance, in August 2021, denials were issued for flavored ENDS citing insufficient evidence and youth appeal risks, and by May 2023, approximately 6,500 flavored products received marketing denial orders (MDOs).^[158] In August 2025, the FDA denied marketing for the blu Disposable Classic Tobacco Flavor, emphasizing inadequate long-term health data.^[159] Additionally, the Preventing Online Sales of E-Cigarettes to Children (POSECCA) Act, enacted in 2020 and amending the Prevent All Cigarette Trafficking (PACT) Act, prohibits the U.S. Postal Service from shipping ENDS to consumers, effective April 2021, to curb youth access via mail.^[160] At the state level, regulations vary widely, with over 20 states imposing restrictions on flavored ENDS sales by mid-2025 to address youth initiation. Massachusetts enacted a comprehensive flavor ban on December 18, 2019, prohibiting sales of flavored tobacco and ENDS except tobacco flavor, upheld despite legal challenges.^[119] Similar permanent bans exist in California (effective December 2022 for non-tobacco flavors), New Jersey, New York, Rhode Island, Utah, and Maryland, often justified by state health departments citing elevated youth usage rates but showing mixed empirical effects on overall tobacco use among adolescents.^[161] ^[121] States like Colorado and Florida maintain licensing and age-verification requirements without full flavor prohibitions as of May 2025, while local jurisdictions in over 418 areas, including Chicago and San Francisco, enforce additional flavored product sales limits.^[162] Many states also mandate excise taxes on ENDS, ranging from 15% of wholesale price in New York to fixed rates per milliliter in others, alongside minimum purchase ages of 21 aligned with federal law since December 2019.^[163]

Impacts on Access and Black Markets

Regulations on electronic cigarettes, including flavor restrictions, excise taxes, and import controls, have significantly curtailed legal access for adult consumers seeking nicotine alternatives, particularly in jurisdictions with stringent policies. In the United States, federal flavor bans implemented in 2020 for cartridge-based systems, coupled with ongoing enforcement against unauthorized imports, have led to widespread shortages of compliant products, prompting many users to seek unregulated sources. Similarly, Australia's 2021 therapeutic goods reforms, which restricted non-prescription nicotine vapes, resulted in fewer than 8,000 legal units sold monthly against an estimated 1.7 million adult users by 2025, creating a supply gap filled predominantly by illicit channels.^[164]^[165] These access barriers have fueled the growth of black and gray markets, where unregulated products evade taxes, safety standards, and age verification. In Australia, over 90% of vapes circulated illegally by 2025, with organized crime exploiting the demand for flavored and disposable devices banned from legal sale. U.S. Customs and Border Protection and the FDA seized over 6 million unauthorized e-cigarettes valued at more than $120 million in 2025 alone, including a record $86.5 million operation targeting imports from China, yet illicit trade persists, comprising an estimated 86% of retail sales according to anti-tobacco analyses. In the UK, seizures of illegal vapes rose to nearly 3 million units worth £21 million between 2020 and 2024, driven by flavor caps and tax hikes. High excise taxes exacerbate this, as evidenced in states with flavor bans experiencing a 2.2% rise in daily smoking rates from 2018 to 2023 compared to non-ban states, suggesting displaced demand.^[166]^[167]^[168] The proliferation of underground markets undermines regulatory intent by introducing risks from untested products potentially containing contaminants or inaccurate nicotine levels, while evading revenue collection and fostering smuggling networks. In Massachusetts, illegal vape seizures surged 21,000% to 279,432 units in 2024, highlighting enforcement challenges amid demand for affordable alternatives. Surveys indicate that tax increases could drive up to one-third of vapers to black markets, mirroring patterns in high-tax regimes like Russia, where doubled excises in 2025 shifted much of the sector underground. This dynamic often reverses harm reduction gains, as restricted legal options push former smokers back to combustible tobacco, with empirical data showing elevated smoking relapse in ban jurisdictions despite aims to deter youth initiation.^[169]^[170]^[171]

Societal and Economic Dimensions

Marketing Strategies and Influences

Electronic cigarette manufacturers have significantly increased marketing expenditures since the early 2010s, with spending rising from $75.7 million in 2013 to $115.3 million in 2014, primarily through digital channels, point-of-sale promotions, and event sponsorships.^[172] Early brands like Njoy and Blu shifted strategies over time, emphasizing health-related messaging in initial phases before pivoting to lifestyle and social themes as regulatory scrutiny intensified.^[173] These efforts often highlight product discretion, flavor variety, and customization, positioning e-cigarettes as modern alternatives to traditional smoking. Industry actors, including those backed by major tobacco firms, have utilized social media platforms for rapid dissemination, with Instagram emerging as a key venue for visual promotions featuring sleek devices and aerosol clouds. A prominent example is JUUL's "Vaporized" campaign launched in 2015, which deployed imagery of models in their 20s in urban, party-like settings to convey themes of socialization, style, and relaxation, distributed across websites, emails, social media, and live events.^[174]^[175] By 2019, JUUL adjusted to a "Make the Switch" adult-focused narrative amid backlash, though prior tactics correlated with elevated youth awareness.^[176] Social media influencers have amplified reach, with 55 e-cigarette promoters in 2020 partnering with over 600 brands on Instagram, often attracting teenage followers through endorsements of flavors and tricks like cloud-chasing.^[177] Tactics such as sponsoring music festivals, offering scholarships, and leveraging user-generated content have been documented by public health monitors, though manufacturers assert primary targeting of adult smokers seeking cessation aids.^[178] Flavor marketing has proven particularly influential, with advertisements for fruit, mint, and dessert profiles enhancing perceived appeal and satisfaction among users, including youth who report suppressing nicotine's harshness via these variants.^[172]^[179] Experimental studies indicate flavored depictions boost youth interest more than tobacco-only ads, contributing to initiation patterns where 90% of young users prefer non-tobacco flavors.^[180]^[181] Nationwide surveys link ad exposure—reaching up to 82% of U.S. youth aged 12-17 by 2015—to higher experimentation rates, though causal attribution remains debated given confounding factors like peer influence and availability.^[182] Public health analyses from advocacy groups like Truth Initiative emphasize youth vulnerability, yet these sources exhibit institutional opposition to nicotine products, potentially amplifying correlations as causation; industry data counters that adult switching drives sustained market growth, with flavors aiding harm reduction for smokers.^[178] Overall, these strategies have correlated with e-cigarette sales surging 47% from 2019 to 2023, predominantly flavored units comprising 80.6% of volume.^[183]

Public Health Policy Debates

Public health policy debates surrounding electronic cigarettes center on their potential as a harm reduction tool for adult smokers versus the risks they pose to youth and non-smokers, including nicotine addiction and possible gateway effects to combustible tobacco use. Proponents of harm reduction argue that e-cigarettes deliver nicotine with substantially fewer toxicants than traditional cigarettes, potentially aiding smoking cessation; for instance, randomized trials have shown e-cigarette use can increase quit rates among smokers compared to nicotine replacement therapies alone.^[184] However, critics, including the World Health Organization (WHO), contend that e-cigarettes are not risk-free, citing evidence of acute lung injuries like EVALI in 2019—primarily linked to illicit THC vaping—and emerging data on cardiovascular and respiratory harms from long-term use, such as increased risks of COPD and hypertension among exclusive vapers.^[148]^[89] The WHO advocates for stringent measures, including flavor bans and marketing restrictions, to curb uptake, viewing e-cigarettes as promoting nicotine dependence rather than net public health gains.^[185] The gateway hypothesis remains contentious, with observational studies showing associations between youth e-cigarette initiation and subsequent cigarette smoking, but causal evidence is weak due to confounding factors like shared risk factors for substance use; detailed analyses have found no robust support for e-cigarettes independently causing progression to tobacco smoking beyond baseline vulnerabilities.^[97]^[75] Despite this, youth vaping rates—peaking at around 28% in 2019—drove policy urgency, prompting U.S. Food and Drug Administration (FDA) actions like the 2020 flavor enforcement against unauthorized products, which correlated with a decline to the lowest youth e-cigarette use in a decade by 2024, with about 1.6 million fewer users.^[186] State-level flavor restrictions have similarly reduced e-cigarette prevalence among youth without boosting cigarette use, though some studies note potential shifts to black market products.^[119] Opponents of broad restrictions argue they undermine adult switching, as evidenced by UK policies allowing regulated e-cigarettes contributing to smoking declines, contrasting with more prohibitive approaches elsewhere.^[187] Long-term effects fuel ongoing contention, as most evidence derives from short-term studies; while e-cigarette aerosols contain fewer carcinogens than smoke, chronic exposure has been linked to endothelial dysfunction and inflammation, potentially elevating heart disease risks, though at levels below combustible tobacco.^[188]^[189] Policy frameworks reflect this uncertainty: the FDA's youth prevention plan emphasizes access barriers and education, while international bodies like the WHO prioritize total deterrence, highlighting tensions between empirical harm comparisons—e.g., Public Health England estimates e-cigarettes as 95% less harmful—and precautionary principles amid incomplete data.^[190] These debates underscore trade-offs, with some experts cautioning against over-reliance on tobacco control paradigms that may undervalue switching benefits for the 1 billion global smokers.^[191]

Economic Scale and Industry Dynamics

The global electronic cigarette market generated approximately US$28.17 billion in revenue in 2023, with projections estimating growth to US$182.84 billion by 2030 at a compound annual growth rate (CAGR) of 30.6%.^[192] Alternative forecasts indicate a more conservative US$27.2 billion in 2025, expanding at a 3.69% CAGR through 2030, reflecting variances in methodologies and regional emphases.^[136] In the United States, industry revenue reached an estimated $3.1 billion by 2030 projections, driven by premarket tobacco product application (PMTA) approvals that establish compliance barriers favoring larger firms.^[193] Major industry participants include traditional tobacco conglomerates such as Philip Morris International (with products like IQOS), Altria Group (via its stake in Juul Labs), British American Tobacco, and Japan Tobacco, which leverage established distribution networks to capture significant portions of the market.^[194] ^[195] These firms dominate through acquisitions and innovation in closed-system devices, contrasting with smaller vape manufacturers focused on open systems and disposables. In the U.S., retail sales data highlight a shift toward disposable products, comprising a growing share amid flavor restrictions, though over 86% of e-cigarette unit sales in recent years involved unauthorized flavors or devices, per FDA enforcement priorities.^[196] This proliferation of non-compliant imports, often from China, underscores supply chain vulnerabilities and regulatory arbitrage.^[139] Industry dynamics are shaped by escalating regulations, including flavor bans and age-verification mandates, which constrain growth in mature markets like the U.S. and EU while spurring innovation in reduced-nicotine formulations and heated tobacco alternatives.^[197] ^[8] Economic contributions extend to job creation in manufacturing, distribution, and retail—estimated to support thousands of positions globally—and tax revenues, with the U.S. sector alone generating about $2.8 billion annually in federal, state, and local taxes as of 2025.^[198] However, black market expansion, fueled by enforcement gaps, erodes legitimate revenues and complicates fiscal impacts, as unauthorized products evade duties and quality controls.^[199] Competition intensifies with technological shifts toward pod systems and longer-lasting batteries, yet persistent public health scrutiny—often amplified by advocacy groups—pressures profitability through litigation and advertising curbs.^[200]

Waste and Lifecycle Analysis

Electronic cigarettes generate waste primarily through disposable devices, pods, and components such as lithium-ion batteries, plastics, and residual e-liquids containing nicotine and heavy metals. In 2023, Americans discarded approximately 5.7 disposable vapes per second, equating to nearly 500,000 devices daily and contributing to substantial e-waste volumes.^[201] ^[202] These devices often end up in landfills or littered environments due to low recycling participation; for instance, only 17% of vapers in the UK reported proper recycling in 2023, mirroring broader e-waste recycling rates below 10%.^[203] ^[204] The composition of e-cigarette waste poses environmental hazards, including non-biodegradable plastics, lithium from batteries (with about 10,000 kilograms entering UK landfills annually), and leachates that release toxins like heavy metals and nicotine into soil and waterways.^[205] Studies indicate that leachate from discarded disposable e-cigarettes can impair plant growth and soil ecosystems, with ecotoxicological effects observed in controlled exposures.^[206] Among young users, over half dispose of used pods or disposables in regular trash, exacerbating biohazard risks from residual chemicals such as lead and acetaldehyde.^[207] ^[208] Lifecycle assessments of electronic cigarettes remain limited, with available scoping reviews highlighting potential long-term threats from persistent e-waste components compared to traditional cigarettes, which primarily produce biodegradable organic waste alongside non-degradable cellulose acetate filters (estimated at 6.25 trillion littered annually worldwide).^[209] ^[210] Manufacturing e-cigarettes involves resource-intensive processes for batteries and electronics, while use and disposal amplify impacts for single-use models; however, reusable systems may reduce per-unit waste relative to the billions of traditional cigarette filters discarded yearly.^[209] Absent comprehensive comparative data, disposable e-cigarettes represent an emerging burden due to their non-recyclable batteries and lack of standardized disposal infrastructure.^[204] Heated tobacco products (HTPs), such as IQOS introduced by Philip Morris International in 2014, heat tobacco sticks to temperatures around 350°C without combustion, generating an aerosol containing nicotine and other compounds derived from tobacco leaf.^[211] Unlike electronic cigarettes, which vaporize a nicotine-containing liquid, HTPs process actual tobacco material, resulting in emissions of lower levels of harmful chemicals compared to combustible cigarettes but potentially higher than e-cigarette aerosols in certain toxins like carbonyls and polycyclic aromatic hydrocarbons.^[212] Independent analyses indicate HTPs reduce exposure to toxicants by up to 95% relative to cigarettes, though long-term health impacts remain under study.^[213] Nicotine replacement therapies (NRTs), approved by regulators like the FDA since the 1980s, include transdermal patches, gums, lozenges, nasal sprays, and inhalers designed to deliver controlled doses of nicotine to alleviate withdrawal symptoms in smokers attempting cessation.^[214] These pharmaceutical products provide nicotine absorption rates varying by form—patches offer steady release over 16-24 hours, while inhalers mimic hand-to-mouth action—but clinical trials demonstrate e-cigarettes outperform NRTs in achieving sustained abstinence, with one 2019 randomized trial reporting 18% quit rates at one year for e-cigarette users versus 9.9% for NRT users when combined with behavioral support.^[54] A 2022 Cochrane review confirmed high-certainty evidence that nicotine e-cigarettes double the odds of quitting compared to NRTs.^[215] Modern oral nicotine pouches (ONPs), such as Zyn launched in 2014 by Swedish Match, consist of tobacco-free pouches containing nicotine salts, flavorings, and fillers placed between the lip and gum for buccal absorption, delivering nicotine levels up to 50 mg per pouch at rates comparable to smokeless tobacco.^[216] Emerging since the mid-2010s, ONPs have gained popularity as discreet alternatives, with studies suggesting they pose lower risks than combustible or smokeless tobacco products due to absence of tobacco leaf and combustion byproducts, though they still expose users to addictive nicotine and potential oral irritants.^[217] Research positions ONPs within harm reduction frameworks similar to e-cigarettes, potentially serving as substitutes for vaping among youth, but youth initiation raises addiction concerns.^[218]

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E-cigarette brands and social media influencers on Instagram
In 2020, 55 e-cigarette influencers collaborated with over 600 brands on Instagram. Asian and US influencers had more teenage followers. 75% of influencers did ...
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4 marketing tactics e-cigarette companies use to target youth
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CDC shines light on teens' increasing exposure to e-cigarette ads
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The global e-cigarette and vape market is expected to witness a compound annual growth rate of 30.6% from 2023 to 2030 to reach USD 182.84 billion by 2030.
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