Electronic Cigarettes/Vaping

What are electronic cigarettes?

Electronic cigarettes (or e-cigarettes) are electronic devices that heat a liquid solution to produce an aerosol that is then inhaled. The solution usually contains nicotine, a humectant, and flavoring chemicals. E-cigarettes come in many shapes and forms and also go by many different names, including e-cigs, vapes, vape pens, e-hookahs, mods, and electronic nicotine delivery systems (ENDS). JUUL, one of the most common brands of e-cigarettes, looks like a USB drive. Vaping is the term that's most often used for smoking e-cigarettes. E-cigarettes can also be used to deliver marijuana and other drugs like methamphetamine.  

Prevalence of use

Since the introduction of e-cigarettes into the American marketplace in 2006, there has been a dramatic increase in their use, especially among youth populations. In 2011, 1.5% of middle and high school students reported using e-cigarettes compared to 27.5% in 2019. E-cigarette users tend to be younger, more educated, and of a higher socioeconomic status compared to conventional cigarette smokers. 


Health effects

Although e-cigarette aerosol contains fewer toxins than regular cigarettes, vaping is not harmless. E-cigarettes are marketed to adults as a smoking cessation aid, but they are not FDA approved nor is there sufficient evidence to prove their effectiveness. Additionally, e-cigarettes are not safe for kids, teens, and young adults. They are associated with the following adverse effects.

  • Nicotine use
    • Highly addictive
    • Can harm brain development in adolescents and young adults 
  • Aerosol exposure
    • Contains fewer harmful chemicals than conventional cigarettes but still contains carcinogens and other respiratory irritants
    • Linked to cases of severe lung illness and injury
  • Defective devices
    • Reports of burns, explosive injuries, and chemical injuries
  • Endothelial dysfunction, oxidative stress, DNA damage




E-cigarette or vaping product use associated lung injury (EVALI)

EVALI was first recognized in 2019. As of Feb 2020, there have been more than 2800 cases and 60 deaths. Around 80% of cases have occurred in people under age 35 and the youngest death was reported in a 15-year old. 

Since EVALI is a new phenomenon, its pathogenesis is not well understood. It is an acute lung injury with findings of fibrinous pneumonitis, diffuse alveolar damage, and/or pneumonia

The majority of cases have been linked to vaping tetrahydrocannabinol (THC) and/or vitamin E acetate. Many of the e-cigarettes and products used were obtained from illicit or informal sources.

The clinical features include:

  • Shortness of breath
  • Cough
  • Hemoptysis
  • Chest pain
  • Fever and chills
  • Nausea
  • Vomiting
  • Diarrhea
  • Abdominal pain

​On chest x-ray, >80% have findings of hazy or consolidative opacities.  It is important to rule out community-acquired pneumonia as this is much more common than EVALI. 

Public health initiatives

E-cigarettes were aggressively marketed to children and teenagers with kid-friendly flavors and packaging designed to look like popular snacks (see image below).   

food lookalike_0.pnghttps://www.fda.gov/tobacco-products/ctp-newsroom/e-liquids-misleadingly-labeled-or-advertised-food-products

As rates of youth e-cigarette use have skyrocketed, state and federal organizations have enacted stricter regulations to make it harder for kids to have access to these prodcuts. The FDA has banned flavored e-cigarettes and forced companies to stop advertising to children. 

As pediatricians, it is our role to screen for e-cigarette use, counsel against its use, and provide resources to aid in smoking cessation. 


Farber, H. J. (2020). New Understanding of the Health Hazards of Electronic Cigarettes and Vaping. Pediatrics in Review, 41(3), 152–154. https://doi.org/10.1542/pir.2019-0269

Hollingsworth, H. E-cigarette or vaping product use associated lung injury (EVALI).  G Finlay (Ed.), UpToDate. Updated March 9, 2020. https://www.uptodate.com

Rigotti, NA and Kalkhoran, S. Vaping and e-cigarettes. L Kunins (Ed.), UpToDate. Updated February 24, 2020. https://www.uptodate.com

Walley, S. C., Wilson, K. M., Winickoff, J. P., & Groner, J. (2019). A Public Health Crisis: Electronic Cigarettes, Vape, and JUUL. Pediatrics, 143(6). https://doi.org/10.1542/peds.2018-2741