An electronic cigarette or e-cigarette[notes 1] is a handheld battery-powered vaporizer that simulates smoking and provides some of the behavioral aspects of smoking, including the hand-to-mouth action of smoking, but without burning tobacco.[76] Using an e-cigarette is known as "vaping" and the user is referred to as a "vaper."[3] Instead of cigarette smoke, the user inhales an aerosol, commonly called vapor.[77] E-cigarettes typically have a heating element that atomizes a liquid solution called e-liquid.[6] E-cigarettes are automatically activated by taking a puff;[78] others turn on manually by pressing a button.[3] Some e-cigarettes look like traditional cigarettes,[79] but they come in many variations.[3] Most versions are reusable, though some are disposable.[80] There are first-generation,[81] second-generation,[82] third-generation,[83] and fourth-generation devices.[84] E-liquids usually contain propylene glycol, glycerin, nicotine, flavorings, additives, and differing amounts of contaminants.[85] E-liquids are also sold without propylene glycol,[86] nicotine,[87] or flavors.[88]
The benefits and the health risks of e-cigarettes are uncertain.[50][89][90] There is tentative evidence they may help people quit smoking,[91] although they have not been proven to be more effective than smoking cessation medicine.[92] There is concern with the possibility that non-smokers and children may start nicotine use with e-cigarettes at a rate higher than anticipated than if they were never created.[93] Following the possibility of nicotine addiction from e-cigarette use, there is concern children may start smoking cigarettes.[93] Youth who use e-cigarettes are more likely to go on to smoke cigarettes.[94][95] Their part in tobacco harm reduction is unclear,[2] while another review found they appear to have the potential to lower tobacco-related death and disease.[96] Regulated US Food and Drug Administration (US FDA) nicotine replacement products may be safer than e-cigarettes,[2] but e-cigarettes are generally seen as safer than combusted tobacco products.[97][98] It is estimated their safety risk to users is similar to that of smokeless tobacco.[99] The long-term effects of e-cigarette use are unknown.[18][100][101] The risk from serious adverse events was reported in 2016 to be low.[45] Less serious adverse effects include abdominal pain, headache, blurry vision,[102] throat and mouth irritation, vomiting, nausea, and coughing.[1] Nicotine itself is associated with some health harms.[103] In 2019, an outbreak of severe lung illness across multiple states in the US was linked to vaping.[104]
E-cigarettes create vapor made of fine and ultrafine particles of particulate matter,[1] which have been found to contain propylene glycol, glycerin, nicotine, flavors, tiny amounts of toxicants,[1] carcinogens,[105] heavy metals, and metal nanoparticles, and other substances.[1] Its exact composition varies across and within manufacturers, and depends on the contents of the liquid, the physical and electrical design of the device, and user behavior, among other factors.[notes 2][77] E-cigarette vapor potentially contains harmful chemicals not found in tobacco smoke.[47] E-cigarette vapor contains fewer toxic chemicals,[1] and lower concentrations of potential toxic chemicals than cigarette smoke.[106] The vapor is probably much less harmful to users and bystanders than cigarette smoke,[105] although concern exists that the exhaled vapor may be inhaled by non-users, particularly indoors.[107]
Since their entrance to the market in 2003,[81] global use has risen exponentially.[107] In a 2014 survey, about 13% of American high school students reported using them at least once in the previous month,[108] and in 2015 around 10% of American adults were users.[109] In the UK, users have increased from 700,000 in 2012 to 2.6 million in 2015.[110] About 60% of UK users are smokers and about 40% are ex-smokers, while use among never-smokers in the UK is negligible.[110] Most still use traditional cigarettes, raising concern that dual use may "delay or deter quitting".[1] Most peoples' reason for using e-cigarettes involve trying to quit smoking, though a large proportion use them recreationally.[78] It is commonly stated that the modern e-cigarette was invented in 2003 by Chinese pharmacist Hon Lik, but tobacco companies have been developing nicotine aerosol generation devices since as early as 1963.[111] As of 2018, 95% of e-cigarettes were made in China.[63] Because of overlap with tobacco laws and medical drug policies, e-cigarette legislation is being debated in many countries.[112] The revised EU Tobacco Products Directive came into effect in May 2016, providing striker regulations for e-cigarettes.[113] As of August 2016, the US FDA extended its regulatory power to include e-cigarettes.[114] Large tobacco companies have greatly increased their marketing efforts.[2] As of 2014, there were 466 brands of e-cigarettes,[115] with global sales of around $7 billion.
Since their introduction to the market in 2003,[81] global usage of e-cigarettes has risen exponentially.[107] By 2013, there were several million users globally.[117] Awareness and use of e-cigarettes greatly increased over the few years leading up to 2014, particularly among young people and women in some parts of the world.[118] A 2013 four-country survey found there was generally greater awareness among white adult smokers compared with non-white ones.[119] Vaping is increasing in the majority of high-income countries.[120] E-cigarette use in the US and Europe is higher than in other countries,[78] except for China which has the greatest number of e-cigarette users.[121] Growth in the US had reportedly slowed in 2015, lowering market forecasts for 2016.[122] Growth in the UK as of January 2018 had reportedly slowed since 2013.[123] The growing frequency of e-cigarette use may be due to heavy promotion in youth-driven media channels, their low cost, and the misbelief that e-cigarettes are safer than traditional cigarettes, according to a 2016 review.[48]
Surveys in 2010 and 2011 suggested that adults with higher incomes were more likely to have heard of e-cigarettes, but those with lower incomes may have been more likely to try them.[124] Most users had a history of smoking regular cigarettes, while results by race were mixed.[124] At least 52% of smokers or ex-smokers have used an e-cigarette.[68] Of smokers who have, less than 15% become everyday e-cigarette users.[91] Though e-cigarette use among those who have never smoked is very low, it continues to rise.[125] Daily vapers are typically recent former smokers.[126] E-cigarettes are commonly used among non-smokers.[127] This includes young adult non-smokers.[127] Vaping is the largest among adults between 18 and 24 years of age, and use is the largest among adults who do not have a high school diploma.[128] Young adults who vape but do not smoke are more than twice as likely to intend to try smoking than their peers who do not vape.[129] A worldwide survey of e-cigarette users conducted in 2014 found that only 3.5% of respondents used liquid without nicotine.[130]
Greater than 10 million people vape daily, as of 2018.[131] Everyday use is common among e-cigarette users.[79] E-cigarette users mostly keep smoking traditional cigarettes.[1] Adults often vape to replace tobacco.[124] Most vapers still use nicotine liquids after stopping smoking for several months.[83] Most e-cigarette users are middle-aged men who also smoke traditional cigarettes, either to help them quit or for recreational use.[78] Older people are more likely to vape for quitting smoking than younger people.[132] Men were found to use higher nicotine doses, compared with women who were vaping.[133] Gender was found to be a predictor of current e-cigarette use with males being significantly more likely to declare having already tried it than females.[134] Among young adults e-cigarette use is not regularly associated with trying to quit smoking.[124] The research indicates that the most common way people try to quit smoking in the UK is with e-cigarettes.[135]
Dual use of e-cigarettes and traditional tobacco is still a definite concern.[50] Dual use of e-cigarettes with cigarettes is the most frequent pattern.[136] One-time e-cigarette use seems to be higher in people with greater levels of educational achievement.[137] Women smokers who are poorer and did not finish high school are more likely to have tried vaping at least once.[138] Vocational school career, lower school performance, being out of school, and studying at a disadvantaged school have been shown to be associated with both e-cigarette ever use and e-cigarette daily use.[134] Vaping is increasing among people with cancer who are frequent smokers.[139]
Gateway theory
In the context of drugs, the gateway hypothesis predicts that the use of less deleterious drugs can lead to a future risk of using more dangerous hard drugs or crime.[140] There is wide concern that vaping may be a "gateway" to smoking.[141] Vaping may also act as a gateway to illicit drug use (recreational use of illegal drugs), is an area of concern.[7] Studies indicate vaping serves as a gateway to traditional cigarettes and cannabis use.[142] Nicotine is a gateway to opioid addiction, as nicotine lowers the threshold for addiction to other agents.[143] Under the common liability model, some have suggested that any favorable relation between vaping and starting smoking is a result of common risk factors.[144] This includes impulsive and sensation seeking personality types or exposure to people who are sympathetic with smoking and relatives.[144] A 2014 review using animal models found that nicotine exposure may increase the likelihood to using other drugs, independent of factors associated with a common liability.[notes 3][146] The gateway theory, in relation to using nicotine, has also been used as a way to propose that using tobacco-free nicotine is probably going to lead to using nicotine via tobacco smoking, and therefore that vaping by non-smokers, and especially by children, may result in smoking independent of other factors associated with starting smoking.[146] Some see the gateway model as a way to illustrate the potential risk-heightening effect of vaping and going on to use combusted tobacco products.[147]
There is concern regarding that the accessibility of e-liquid flavors could lead to using additional tobacco products among non-smokers.[148] It is argued to implement the precautionary principle because vaping by non-smokers may lead to smoking.[149] There is a concern with the possibility that non-smokers as well as children may start nicotine use with e-cigarettes at a rate higher than anticipated than if they were never created.[93] In certain cases, e-cigarettes might increase the likelihood of being exposed to nicotine itself, especially for never-nicotine users who start using nicotine products only as a result of these devices.[80] A 2015 review concluded that "Nicotine acts as a gateway drug on the brain, and this effect is likely to occur whether the exposure is from smoking tobacco, passive tobacco smoke or e-cigarettes."[150] Because those with mental illness are highly predisposed to nicotine addiction, those who try e-cigarettes may be more likely to become dependent, raising concerns about facilitating a transition to combustible tobacco use.[151] Even if an e-cigarette contains no nicotine, the user mimics the actions of smoking.[152] This may renormalize tobacco use in the general public.[152] Normalization of e-cigarette use may lead former cigarette smokers to begin using them, thereby reinstating their nicotine dependence and fostering a return to tobacco use.[153] There is a possible risk of re-normalizing of tobacco use in areas where smoking is banned.[152] Government intervention is recommended to keep children safe from the re-normalizing of tobacco, according to a 2017 review.[75]
The "catalyst model" suggests that vaping may proliferate smoking in minors by sensitizing minors to nicotine with the use of a type of nicotine that is more pleasing and without the negative attributes of regular cigarettes.[154] A 2016 review, based on the catalyst model, "indicate that the perceived health risks, specific product characteristics (such as taste, price and inconspicuous use), and higher levels of acceptance among peers and others potentially make e-cigarettes initially more attractive to adolescents than tobacco cigarettes. Later, increasing familiarity with nicotine could lead to the reevaluation of both electronic and tobacco cigarettes and subsequently to a potential transition to tobacco smoking."[155]
Pregnancy
E-cigarette use was also rising among women, including women of childbearing age as of 2014,[156] but the rate of use during pregnancy is unknown.[85] Many woman still vape during pregnancy because of their perceived safety in comparison with tobacco.[157] In one of the few studies identified, a 2015 survey of 316 pregnant women in a Maryland clinic found that the majority had heard of e-cigarettes, 13% had ever used them, and 0.6% were current daily users.[158] These findings are of concern because the dose of nicotine delivered by e-cigarettes can be as high or higher than that delivered by traditional cigarettes.[158] The rate of e-cigarette use among pregnant adolescents is unknown.[158]
Youth
The prevalence of vaping among adolescents is increasing worldwide.[155] There is substantial variability in vaping in youth worldwide across countries.[161] Over the years leading up to 2017 vaping among adolescents has grown every year since these devices were first introduced to the market.[75] There appears to be an increase of one-time e-cigarette use among young people worldwide.[162] The frequency of vaping in youth is low.[163] The result of youth e-cigarette use leading to smoking is unclear.[129] Most e-cigarette users among youth have never smoked.[129] Many youth who use e-cigarettes also smoke traditional cigarettes.[1] Some youths who have tried an e-cigarette have never used a traditional cigarette; indicating e-cigarettes may be a starting point for nicotine use.[1] Adolescents who would have not been using nicotine products to begin with are vaping.[164] Twice as many youth vaped in 2014 than also used traditional cigarettes.[165] Vaping seems to be a gateway to using traditional cigarettes in adolescents.[166] Youth who use e-cigarettes are more likely to go on to use traditional cigarettes.[94][95] The evidence suggests that young people who vape are also at greater risk for subsequent long-term tobacco use.[167] E-cigarettes are expanding the nicotine market by attracting low-risk youth who would be unlikely to initiate nicotine use with traditional cigarettes.[168] Data from a longitudinal cohort study of children with alcoholic parents found that adolescents (both middle and late adolescence) who used cigarettes, marijuana, or alcohol were significantly more likely to have ever used e-cigarettes.[158] Adolescents were more likely to initiate vaping through flavored e-cigarettes.[133] Among youth who have ever tried an e-cigarette, a majority used a flavored product the first time they tried an e-cigarette.[158] There is a greater likelihood of past or present and later cannabis use among youth and young adults who have vaped
Most youth are not vaping to help them quit tobacco.[124] Adolescent vaping is unlikely to be associated with trying to reduce or quit tobacco.[50] Adolescents who vape but do not smoke are more than twice as likely to intend to try smoking than their peers who do not vape.[129] Vaping is correlated with a higher occurrence of cigarette smoking among adolescents, even in those who otherwise may not have been interested in smoking.[171] Adolescence experimenting with e-cigarettes appears to encourage continued use of traditional cigarettes.[97] A 2015 study found minors had little resistance to buying e-cigarettes online.[47] An emerging concern is that nicotine, fruit flavors, and other e-liquid additives could incite teenagers and children to start using traditional cigarettes.[172] Teenagers may not admit using e-cigarettes, but use, for instance, a hookah pen.[173] As a result, self-reporting may be lower in surveys.[173] Experts suggest that candy-like flavors could lead youths to experiment with vaping.[93] E-cigarette advertisements seen by youth could increase the likelihood among youths to experiment with vaping.[174] A 2016 review found "The reasons for the increasing use of e-cigarettes by minors (persons between 12 and 17 years of age) may include robust marketing and advertising campaigns that showcase celebrities, popular activities, evocative images, and appealing flavors, such as cotton candy."[175] A 2014 survey stated that vapers may have less social and behavioral stigma than cigarette smokers, causing concern that vaping products are enticing youth who may not under other circumstances have used these products.[176] The frequency of vaping is higher in adolescent with asthma than in adolescent who do not have asthma.[177] Boys had experimented more often than girls.[134]
Motivation
There are varied reasons for e-cigarette use.[78] Most users' motivation is related to trying to quit smoking, but a large proportion of use is recreational.[78] Adults cite predominantly three reasons for trying and using e-cigarettes: as an aid to smoking cessation, a belief that they are a safer alternative to traditional cigarettes, and as a way to conveniently get around smoke-free laws.[168] Some users vape for the enjoyment of the activity.[79] Many e-cigarette users use them because they believe they are safer than traditional cigarettes.[130] People who think they pose less risk than cigarette smoking are more likely to vape.[180] A 2017 report found that smokers who previously vaped and quit though continued smoking, 51.5% believed that vaping is less risky than smoking [181] In contrast, 90% of former-smokers who vape believed vaping as less risky than cigarettes.[181] A 2017 report found that a minority of the respondents believed that replacing cigarettes with e-cigarettes would be helpful for their health.[182] Many users vape because they believe it is healthier than smoking for themselves or bystanders.[79] Usually, only a small proportion of users are concerned about the potential adverse health effects.[79] Some people say they want to quit smoking by vaping, but others vape to circumvent smoke-free laws and policies, or to cut back on cigarette smoking.[1] 56% of respondents in a US 2013 survey had tried vaping to quit or reduce their smoking.[89] In the same survey, 26% of respondents would use them in areas where smoking was banned.[89] Continuing dual use among smokers is correlated with trying to cut down on smoking and to get around smoking bans, increased desire to quit smoking, and a decreased smoking dependence.[183] Seniors seem to vape to quit smoking or to get around smoke‐free policies.[157] Concerns over avoiding stains on teeth or odor from smoke on clothes in some cases prompted interest in or use of e-cigarettes.[79] Some e-cigarettes appeal considerably to people curious in technology who want to customize their devices.[184] There appears to be a hereditary component to tobacco use, which probably plays a part in transitioning of e-cigarette use from experimentation to routine use.[6]
It is conceivable that former smokers may be tempted to use nicotine again as a result of e-cigarettes, and possibly start smoking again.[80] E-liquid flavors are enticing to a range of smokers and non-smokers.[148] Non-smoking adults tried e-cigarettes due to curiosity, because a relative was using them, or because they were given one.[7] College students often vape for experimentation.[3] Millions of dollars spent on marketing aimed at smokers suggests e-cigarettes are "newer, healthier, cheaper and easier to use in smoke-free situations, all reasons that e-cigarette users claim motivate their use".[185] Marketing messages echo well-established cigarette themes, including freedom, good taste, romance, sexuality, and sociability as well as messages stating that e-cigarettes are healthy, are useful for smoking cessation, and can be used in smoke free environments.[168] These messages are mirrored in the reasons that adults and youth cite for using e-cigarettes.[168] Exposure to e-cigarette advertising influences people to try them
The belief that e-cigarettes are safer than traditional cigarettes could widen their use among pregnant women.[50] If tobacco businesses persuade women that e-cigarettes are a small risk, non-smoking women of reproductive age might start using them and women smoking during pregnancy might switch to their use or use these devices to reduce smoking, instead of quitting smoking altogether.[85] Traditional cigarette users who have not used e-cigarettes had mixed ideas about their possible satisfaction and around a third thought that e-cigarettes might taste bad.[79] Among current e-cigarette users, e-liquid flavor availability is very appealing.[151] They feel or taste similar to traditional cigarettes, and vapers disagree about whether this is a benefit or a drawback.[79] Some users like that e-cigarettes resembled traditional cigarettes, but others did not.[79] E-cigarettes users' views about saving money from using e-cigarettes compared to traditional cigarettes are inconsistent.[79] The majority of committed e-cigarette users interviewed at an e-cigarette convention found them cheaper than traditional cigarettes.[79]
Some users stopped vaping due to issues with the devices.[79] Dissatisfaction and concerns over safety can discourage ongoing e-cigarette use.[187] Commonly reported issues with using e-cigarettes were that the devices were hard to refill, the cartridges might leak and that altering the dose was hard.[188] Smokers mainly quit vaping because it did not feel similar to traditional cigarettes, did not aid with cravings, and because they wanted to use them only to know what they were like.[183]
Progression
Many users may begin by using a disposable e-cigarette.[163] Users often start with e-cigarettes resembling traditional cigarettes, eventually moving to a later-generation device.[27] Most later-generation e-cigarette users shifted to their present device to get a "more satisfying hit",[27] and users may adjust their devices to provide more vapor for better "throat hits".[138] A 2014 study reported that experienced users preferred rechargeable e-cigarettes over disposable ones.[133] The most commonly used e-cigarettes in the UK are devices with refillable tanks.[189] Most users used either closed systems or open systems, and rarely used both.[133] Women were found to prefer disposable e-cigarettes, and young adults were found to pay more attention to modifiability.[133] Modifiability also was found to increase the probability of initiating e-cigarettes among adolescents.[133]
A 2013 study found that about three-fourths of smokers used a tank system, which allows users to choose flavors and strength to mix their own liquid.[133] Experienced e-cigarette users even ranked the ability to customize as the most important characteristic.[133] Users ranked nicotine strength as an important factor for choosing among various e-cigarettes, though such preference could vary by smoking status, e-cigarette use history, and gender.[133] Non-smokers and inexperienced e-cigarettes users tended to prefer no nicotine or low nicotine e-cigarettes while smokers and experienced e-cigarettes users preferred medium and high nicotine e-cigarettes.[133] There is an abundance of colors, designs, carrying cases, and accessories to accommodate the diversity in personal preferences
The benefits and the health risks of e-cigarettes are uncertain.[50][89][90] There is tentative evidence they may help people quit smoking,[91] although they have not been proven to be more effective than smoking cessation medicine.[92] There is concern with the possibility that non-smokers and children may start nicotine use with e-cigarettes at a rate higher than anticipated than if they were never created.[93] Following the possibility of nicotine addiction from e-cigarette use, there is concern children may start smoking cigarettes.[93] Youth who use e-cigarettes are more likely to go on to smoke cigarettes.[94][95] Their part in tobacco harm reduction is unclear,[2] while another review found they appear to have the potential to lower tobacco-related death and disease.[96] Regulated US Food and Drug Administration (US FDA) nicotine replacement products may be safer than e-cigarettes,[2] but e-cigarettes are generally seen as safer than combusted tobacco products.[97][98] It is estimated their safety risk to users is similar to that of smokeless tobacco.[99] The long-term effects of e-cigarette use are unknown.[18][100][101] The risk from serious adverse events was reported in 2016 to be low.[45] Less serious adverse effects include abdominal pain, headache, blurry vision,[102] throat and mouth irritation, vomiting, nausea, and coughing.[1] Nicotine itself is associated with some health harms.[103] In 2019, an outbreak of severe lung illness across multiple states in the US was linked to vaping.[104]
E-cigarettes create vapor made of fine and ultrafine particles of particulate matter,[1] which have been found to contain propylene glycol, glycerin, nicotine, flavors, tiny amounts of toxicants,[1] carcinogens,[105] heavy metals, and metal nanoparticles, and other substances.[1] Its exact composition varies across and within manufacturers, and depends on the contents of the liquid, the physical and electrical design of the device, and user behavior, among other factors.[notes 2][77] E-cigarette vapor potentially contains harmful chemicals not found in tobacco smoke.[47] E-cigarette vapor contains fewer toxic chemicals,[1] and lower concentrations of potential toxic chemicals than cigarette smoke.[106] The vapor is probably much less harmful to users and bystanders than cigarette smoke,[105] although concern exists that the exhaled vapor may be inhaled by non-users, particularly indoors.[107]
Since their entrance to the market in 2003,[81] global use has risen exponentially.[107] In a 2014 survey, about 13% of American high school students reported using them at least once in the previous month,[108] and in 2015 around 10% of American adults were users.[109] In the UK, users have increased from 700,000 in 2012 to 2.6 million in 2015.[110] About 60% of UK users are smokers and about 40% are ex-smokers, while use among never-smokers in the UK is negligible.[110] Most still use traditional cigarettes, raising concern that dual use may "delay or deter quitting".[1] Most peoples' reason for using e-cigarettes involve trying to quit smoking, though a large proportion use them recreationally.[78] It is commonly stated that the modern e-cigarette was invented in 2003 by Chinese pharmacist Hon Lik, but tobacco companies have been developing nicotine aerosol generation devices since as early as 1963.[111] As of 2018, 95% of e-cigarettes were made in China.[63] Because of overlap with tobacco laws and medical drug policies, e-cigarette legislation is being debated in many countries.[112] The revised EU Tobacco Products Directive came into effect in May 2016, providing striker regulations for e-cigarettes.[113] As of August 2016, the US FDA extended its regulatory power to include e-cigarettes.[114] Large tobacco companies have greatly increased their marketing efforts.[2] As of 2014, there were 466 brands of e-cigarettes,[115] with global sales of around $7 billion.
Since their introduction to the market in 2003,[81] global usage of e-cigarettes has risen exponentially.[107] By 2013, there were several million users globally.[117] Awareness and use of e-cigarettes greatly increased over the few years leading up to 2014, particularly among young people and women in some parts of the world.[118] A 2013 four-country survey found there was generally greater awareness among white adult smokers compared with non-white ones.[119] Vaping is increasing in the majority of high-income countries.[120] E-cigarette use in the US and Europe is higher than in other countries,[78] except for China which has the greatest number of e-cigarette users.[121] Growth in the US had reportedly slowed in 2015, lowering market forecasts for 2016.[122] Growth in the UK as of January 2018 had reportedly slowed since 2013.[123] The growing frequency of e-cigarette use may be due to heavy promotion in youth-driven media channels, their low cost, and the misbelief that e-cigarettes are safer than traditional cigarettes, according to a 2016 review.[48]
Surveys in 2010 and 2011 suggested that adults with higher incomes were more likely to have heard of e-cigarettes, but those with lower incomes may have been more likely to try them.[124] Most users had a history of smoking regular cigarettes, while results by race were mixed.[124] At least 52% of smokers or ex-smokers have used an e-cigarette.[68] Of smokers who have, less than 15% become everyday e-cigarette users.[91] Though e-cigarette use among those who have never smoked is very low, it continues to rise.[125] Daily vapers are typically recent former smokers.[126] E-cigarettes are commonly used among non-smokers.[127] This includes young adult non-smokers.[127] Vaping is the largest among adults between 18 and 24 years of age, and use is the largest among adults who do not have a high school diploma.[128] Young adults who vape but do not smoke are more than twice as likely to intend to try smoking than their peers who do not vape.[129] A worldwide survey of e-cigarette users conducted in 2014 found that only 3.5% of respondents used liquid without nicotine.[130]
Greater than 10 million people vape daily, as of 2018.[131] Everyday use is common among e-cigarette users.[79] E-cigarette users mostly keep smoking traditional cigarettes.[1] Adults often vape to replace tobacco.[124] Most vapers still use nicotine liquids after stopping smoking for several months.[83] Most e-cigarette users are middle-aged men who also smoke traditional cigarettes, either to help them quit or for recreational use.[78] Older people are more likely to vape for quitting smoking than younger people.[132] Men were found to use higher nicotine doses, compared with women who were vaping.[133] Gender was found to be a predictor of current e-cigarette use with males being significantly more likely to declare having already tried it than females.[134] Among young adults e-cigarette use is not regularly associated with trying to quit smoking.[124] The research indicates that the most common way people try to quit smoking in the UK is with e-cigarettes.[135]
Dual use of e-cigarettes and traditional tobacco is still a definite concern.[50] Dual use of e-cigarettes with cigarettes is the most frequent pattern.[136] One-time e-cigarette use seems to be higher in people with greater levels of educational achievement.[137] Women smokers who are poorer and did not finish high school are more likely to have tried vaping at least once.[138] Vocational school career, lower school performance, being out of school, and studying at a disadvantaged school have been shown to be associated with both e-cigarette ever use and e-cigarette daily use.[134] Vaping is increasing among people with cancer who are frequent smokers.[139]
Gateway theory
In the context of drugs, the gateway hypothesis predicts that the use of less deleterious drugs can lead to a future risk of using more dangerous hard drugs or crime.[140] There is wide concern that vaping may be a "gateway" to smoking.[141] Vaping may also act as a gateway to illicit drug use (recreational use of illegal drugs), is an area of concern.[7] Studies indicate vaping serves as a gateway to traditional cigarettes and cannabis use.[142] Nicotine is a gateway to opioid addiction, as nicotine lowers the threshold for addiction to other agents.[143] Under the common liability model, some have suggested that any favorable relation between vaping and starting smoking is a result of common risk factors.[144] This includes impulsive and sensation seeking personality types or exposure to people who are sympathetic with smoking and relatives.[144] A 2014 review using animal models found that nicotine exposure may increase the likelihood to using other drugs, independent of factors associated with a common liability.[notes 3][146] The gateway theory, in relation to using nicotine, has also been used as a way to propose that using tobacco-free nicotine is probably going to lead to using nicotine via tobacco smoking, and therefore that vaping by non-smokers, and especially by children, may result in smoking independent of other factors associated with starting smoking.[146] Some see the gateway model as a way to illustrate the potential risk-heightening effect of vaping and going on to use combusted tobacco products.[147]
There is concern regarding that the accessibility of e-liquid flavors could lead to using additional tobacco products among non-smokers.[148] It is argued to implement the precautionary principle because vaping by non-smokers may lead to smoking.[149] There is a concern with the possibility that non-smokers as well as children may start nicotine use with e-cigarettes at a rate higher than anticipated than if they were never created.[93] In certain cases, e-cigarettes might increase the likelihood of being exposed to nicotine itself, especially for never-nicotine users who start using nicotine products only as a result of these devices.[80] A 2015 review concluded that "Nicotine acts as a gateway drug on the brain, and this effect is likely to occur whether the exposure is from smoking tobacco, passive tobacco smoke or e-cigarettes."[150] Because those with mental illness are highly predisposed to nicotine addiction, those who try e-cigarettes may be more likely to become dependent, raising concerns about facilitating a transition to combustible tobacco use.[151] Even if an e-cigarette contains no nicotine, the user mimics the actions of smoking.[152] This may renormalize tobacco use in the general public.[152] Normalization of e-cigarette use may lead former cigarette smokers to begin using them, thereby reinstating their nicotine dependence and fostering a return to tobacco use.[153] There is a possible risk of re-normalizing of tobacco use in areas where smoking is banned.[152] Government intervention is recommended to keep children safe from the re-normalizing of tobacco, according to a 2017 review.[75]
The "catalyst model" suggests that vaping may proliferate smoking in minors by sensitizing minors to nicotine with the use of a type of nicotine that is more pleasing and without the negative attributes of regular cigarettes.[154] A 2016 review, based on the catalyst model, "indicate that the perceived health risks, specific product characteristics (such as taste, price and inconspicuous use), and higher levels of acceptance among peers and others potentially make e-cigarettes initially more attractive to adolescents than tobacco cigarettes. Later, increasing familiarity with nicotine could lead to the reevaluation of both electronic and tobacco cigarettes and subsequently to a potential transition to tobacco smoking."[155]
Pregnancy
E-cigarette use was also rising among women, including women of childbearing age as of 2014,[156] but the rate of use during pregnancy is unknown.[85] Many woman still vape during pregnancy because of their perceived safety in comparison with tobacco.[157] In one of the few studies identified, a 2015 survey of 316 pregnant women in a Maryland clinic found that the majority had heard of e-cigarettes, 13% had ever used them, and 0.6% were current daily users.[158] These findings are of concern because the dose of nicotine delivered by e-cigarettes can be as high or higher than that delivered by traditional cigarettes.[158] The rate of e-cigarette use among pregnant adolescents is unknown.[158]
Youth
The prevalence of vaping among adolescents is increasing worldwide.[155] There is substantial variability in vaping in youth worldwide across countries.[161] Over the years leading up to 2017 vaping among adolescents has grown every year since these devices were first introduced to the market.[75] There appears to be an increase of one-time e-cigarette use among young people worldwide.[162] The frequency of vaping in youth is low.[163] The result of youth e-cigarette use leading to smoking is unclear.[129] Most e-cigarette users among youth have never smoked.[129] Many youth who use e-cigarettes also smoke traditional cigarettes.[1] Some youths who have tried an e-cigarette have never used a traditional cigarette; indicating e-cigarettes may be a starting point for nicotine use.[1] Adolescents who would have not been using nicotine products to begin with are vaping.[164] Twice as many youth vaped in 2014 than also used traditional cigarettes.[165] Vaping seems to be a gateway to using traditional cigarettes in adolescents.[166] Youth who use e-cigarettes are more likely to go on to use traditional cigarettes.[94][95] The evidence suggests that young people who vape are also at greater risk for subsequent long-term tobacco use.[167] E-cigarettes are expanding the nicotine market by attracting low-risk youth who would be unlikely to initiate nicotine use with traditional cigarettes.[168] Data from a longitudinal cohort study of children with alcoholic parents found that adolescents (both middle and late adolescence) who used cigarettes, marijuana, or alcohol were significantly more likely to have ever used e-cigarettes.[158] Adolescents were more likely to initiate vaping through flavored e-cigarettes.[133] Among youth who have ever tried an e-cigarette, a majority used a flavored product the first time they tried an e-cigarette.[158] There is a greater likelihood of past or present and later cannabis use among youth and young adults who have vaped
Most youth are not vaping to help them quit tobacco.[124] Adolescent vaping is unlikely to be associated with trying to reduce or quit tobacco.[50] Adolescents who vape but do not smoke are more than twice as likely to intend to try smoking than their peers who do not vape.[129] Vaping is correlated with a higher occurrence of cigarette smoking among adolescents, even in those who otherwise may not have been interested in smoking.[171] Adolescence experimenting with e-cigarettes appears to encourage continued use of traditional cigarettes.[97] A 2015 study found minors had little resistance to buying e-cigarettes online.[47] An emerging concern is that nicotine, fruit flavors, and other e-liquid additives could incite teenagers and children to start using traditional cigarettes.[172] Teenagers may not admit using e-cigarettes, but use, for instance, a hookah pen.[173] As a result, self-reporting may be lower in surveys.[173] Experts suggest that candy-like flavors could lead youths to experiment with vaping.[93] E-cigarette advertisements seen by youth could increase the likelihood among youths to experiment with vaping.[174] A 2016 review found "The reasons for the increasing use of e-cigarettes by minors (persons between 12 and 17 years of age) may include robust marketing and advertising campaigns that showcase celebrities, popular activities, evocative images, and appealing flavors, such as cotton candy."[175] A 2014 survey stated that vapers may have less social and behavioral stigma than cigarette smokers, causing concern that vaping products are enticing youth who may not under other circumstances have used these products.[176] The frequency of vaping is higher in adolescent with asthma than in adolescent who do not have asthma.[177] Boys had experimented more often than girls.[134]
Motivation
There are varied reasons for e-cigarette use.[78] Most users' motivation is related to trying to quit smoking, but a large proportion of use is recreational.[78] Adults cite predominantly three reasons for trying and using e-cigarettes: as an aid to smoking cessation, a belief that they are a safer alternative to traditional cigarettes, and as a way to conveniently get around smoke-free laws.[168] Some users vape for the enjoyment of the activity.[79] Many e-cigarette users use them because they believe they are safer than traditional cigarettes.[130] People who think they pose less risk than cigarette smoking are more likely to vape.[180] A 2017 report found that smokers who previously vaped and quit though continued smoking, 51.5% believed that vaping is less risky than smoking [181] In contrast, 90% of former-smokers who vape believed vaping as less risky than cigarettes.[181] A 2017 report found that a minority of the respondents believed that replacing cigarettes with e-cigarettes would be helpful for their health.[182] Many users vape because they believe it is healthier than smoking for themselves or bystanders.[79] Usually, only a small proportion of users are concerned about the potential adverse health effects.[79] Some people say they want to quit smoking by vaping, but others vape to circumvent smoke-free laws and policies, or to cut back on cigarette smoking.[1] 56% of respondents in a US 2013 survey had tried vaping to quit or reduce their smoking.[89] In the same survey, 26% of respondents would use them in areas where smoking was banned.[89] Continuing dual use among smokers is correlated with trying to cut down on smoking and to get around smoking bans, increased desire to quit smoking, and a decreased smoking dependence.[183] Seniors seem to vape to quit smoking or to get around smoke‐free policies.[157] Concerns over avoiding stains on teeth or odor from smoke on clothes in some cases prompted interest in or use of e-cigarettes.[79] Some e-cigarettes appeal considerably to people curious in technology who want to customize their devices.[184] There appears to be a hereditary component to tobacco use, which probably plays a part in transitioning of e-cigarette use from experimentation to routine use.[6]
It is conceivable that former smokers may be tempted to use nicotine again as a result of e-cigarettes, and possibly start smoking again.[80] E-liquid flavors are enticing to a range of smokers and non-smokers.[148] Non-smoking adults tried e-cigarettes due to curiosity, because a relative was using them, or because they were given one.[7] College students often vape for experimentation.[3] Millions of dollars spent on marketing aimed at smokers suggests e-cigarettes are "newer, healthier, cheaper and easier to use in smoke-free situations, all reasons that e-cigarette users claim motivate their use".[185] Marketing messages echo well-established cigarette themes, including freedom, good taste, romance, sexuality, and sociability as well as messages stating that e-cigarettes are healthy, are useful for smoking cessation, and can be used in smoke free environments.[168] These messages are mirrored in the reasons that adults and youth cite for using e-cigarettes.[168] Exposure to e-cigarette advertising influences people to try them
The belief that e-cigarettes are safer than traditional cigarettes could widen their use among pregnant women.[50] If tobacco businesses persuade women that e-cigarettes are a small risk, non-smoking women of reproductive age might start using them and women smoking during pregnancy might switch to their use or use these devices to reduce smoking, instead of quitting smoking altogether.[85] Traditional cigarette users who have not used e-cigarettes had mixed ideas about their possible satisfaction and around a third thought that e-cigarettes might taste bad.[79] Among current e-cigarette users, e-liquid flavor availability is very appealing.[151] They feel or taste similar to traditional cigarettes, and vapers disagree about whether this is a benefit or a drawback.[79] Some users like that e-cigarettes resembled traditional cigarettes, but others did not.[79] E-cigarettes users' views about saving money from using e-cigarettes compared to traditional cigarettes are inconsistent.[79] The majority of committed e-cigarette users interviewed at an e-cigarette convention found them cheaper than traditional cigarettes.[79]
Some users stopped vaping due to issues with the devices.[79] Dissatisfaction and concerns over safety can discourage ongoing e-cigarette use.[187] Commonly reported issues with using e-cigarettes were that the devices were hard to refill, the cartridges might leak and that altering the dose was hard.[188] Smokers mainly quit vaping because it did not feel similar to traditional cigarettes, did not aid with cravings, and because they wanted to use them only to know what they were like.[183]
Progression
Many users may begin by using a disposable e-cigarette.[163] Users often start with e-cigarettes resembling traditional cigarettes, eventually moving to a later-generation device.[27] Most later-generation e-cigarette users shifted to their present device to get a "more satisfying hit",[27] and users may adjust their devices to provide more vapor for better "throat hits".[138] A 2014 study reported that experienced users preferred rechargeable e-cigarettes over disposable ones.[133] The most commonly used e-cigarettes in the UK are devices with refillable tanks.[189] Most users used either closed systems or open systems, and rarely used both.[133] Women were found to prefer disposable e-cigarettes, and young adults were found to pay more attention to modifiability.[133] Modifiability also was found to increase the probability of initiating e-cigarettes among adolescents.[133]
A 2013 study found that about three-fourths of smokers used a tank system, which allows users to choose flavors and strength to mix their own liquid.[133] Experienced e-cigarette users even ranked the ability to customize as the most important characteristic.[133] Users ranked nicotine strength as an important factor for choosing among various e-cigarettes, though such preference could vary by smoking status, e-cigarette use history, and gender.[133] Non-smokers and inexperienced e-cigarettes users tended to prefer no nicotine or low nicotine e-cigarettes while smokers and experienced e-cigarettes users preferred medium and high nicotine e-cigarettes.[133] There is an abundance of colors, designs, carrying cases, and accessories to accommodate the diversity in personal preferences
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