E-cigarettes or electronic nicotine delivery systems (ENDS) go by many names – the most common name is “e-cigarette,” but other terms include e-cigs, vapes, vape pens, mods and tanks. For the purposes of this resource we refer to the entire category as “e-cigarettes.”
E-cigarette use among young people has skyrocketed in recent years and remains at epidemic levels: about one in five high school students used e-cigarettes in 2020, many of whom were not smokers in the first place.
A 2018 Truth Initiative study published in Tobacco Control found that among current youth and young adult JUUL users, the majority — 63% — did not know that the product always contains nicotine. Anecdotally, youth are reporting signs of severe dependence, such as inability to concentrate in class, using an e-cigarette upon waking, and using e-cigarettes at night after waking with a craving.
The U.S. Surgeon General has said there is an “e-cigarette epidemic among youth.” Most e-cig lawsuits have been filed by young adults or parents of underage children who were unaware of the side effects of vaping.
Many people who filed lawsuits say they became addicted to using e-cigaretes which led to or worsened their conditions. They claim they were unaware that vape fluids contained high levels of nicotine, a highly addictive substance.
There is evidence that indicates that vaping exacerbates COVID-19 infection rates.
- A paper published in June 2020 states that although there is no direct evidence suggesting the increased susceptibility of smokers/ vapers towards COVID-19 infection, various indirect studies prove that this population is at higher risk of severe symptoms and need for mechanical ventilation, compared to non-smokers.30 While analyzing factors associated with severe disease outcomes in patients admitted to hospitals in Wuhan, China, researchers showed that patients with a history of smoking were significantly higher in the progression group with severe symptoms than in the improvement group of patients showing recovery (27.3% vs 3%).
- A 2020 study with 1607 observations in their data found positive associations between the proportion of vapers and the number of COVID-19 cases and deaths in each U.S. state. With every 1% increase in weighted proportion of vapers in each state, the number of COVID-19 cases and deaths were significantly greater, suggesting that vapers may potentially be more susceptible to COVID-19.
- A 2020 study surveying adolescents and young adults 13-24 years old found that in comparison to non-users, testing positive for COVID-19 was five times more likely for people who had ever used e-cigarettes only, seven times more likely for people who had ever used both e-cigarettes and combustible cigarettes, and 6.8 times more likely for people who had used e-cigarettes and combustibles in the past 30 days. Potential reasons cited for why e-cigarette and cigarette use were associated with testing positive for COVID-19 include:
- Heightened exposure to nicotine and other chemicals in e-cigarettes adversely affecting lung function
- Repeated touching of one’s hands to the mouth and face during e-cigarette use
- Sharing e-cigarette devices
Research on the link between vaping and COVID-19 outcomes is rapidly evolving and more research is needed to clarify the relationship. However, there is evidence that indicates that vaping exacerbates COVID-19 infection rates.
RE E-CIGARETTES LESS HARMFUL THAN CIGARETTES?
It is generally accepted that e-cigarettes produce fewer of the toxins found in cigarette smoke. However, it is becoming increasingly apparent that this frame is not adequate to tell the entire story regarding individual health impacts. The most recent evidence suggests that e-cigarettes may pose their own unique health harms and that comparison to cigarettes may not be the only relevant question for determining their impact on individual health. Indeed, the growing evidence of potential health risks related to e-cigarette use has led some researchers to question whether e-cigarettes are safer than combustible cigarettes. For more information see “Health Effects”.
The recent outbreak of vaping related lung injuries also supports caution with respect to e-cigarettes. While a substantial number of cases in the recent outbreak of vaping related lung illness (see “Health Effects”) appear to be related to THC vaping and the CDC recently identified vitamin E acetate as a chemical of significant concern, the agency has been cautious to say it has not found a single cause and continues to recommend caution with respect to all vaping as the investigation continues. At minimum, this outbreak dramatically demonstrates the dangers of an unregulated market in inhaled substances with no premarket review for consumer safety.
We also note the frequently cited claim from Public Health England that e-cigarettes are definitively — 95% — safer than traditional cigarettes. First, this analysis was originally conducted in 2013, prior to recent research on health effects of vaping. Moreover, further analysis into the original research finds that the evidence for such a statistic remains unclear and not fully comprehensive, among other concerns about author and funding conflicts of interest. The Public Health England claim also fails to acknowledge the reality of the potential for negative net public health impact among a population of users that have otherwise never used tobacco products or the lack of clinical and long-term evidence of these products’ safety in humans, regardless of current smoking status.
While a 2018 National Academies of Sciences, Engineering, and Medicine report found substantial evidence that exposure to toxic substances from e-cigarettes is significantly lower compared to combustible cigarettes, recent studies are showing that is not the end of the story on health impact. It now appears that e-cigarettes may present their own unique health risks, including to the respiratory and cardiovascular systems. Given the products’ relatively recent introduction to the marketplace, further research is needed to evaluate the short and long term health impacts of e-cigarettes.
The evidence for e-cigarettes’ effectiveness as a cessation tool also remains inconclusive and, until an FDA review, the safest, most evidence-based cessation strategy should include a combination of counseling, nicotine replacement therapy, and/ or cessation drugs like varenicline, approved by the FDA. Moreover, while the basic technology behind e-cigarettes is consistent, there is enormous variability within the product category and there is no typical e-cigarette. The products include different ingredients, different hardware and deliver highly variable amounts of nicotine and potentially toxic chemicals, including heavy metals such as cadmium, lead, nickel, tin and copper. This variation makes it difficult to issue overall public health recommendations about the category and demonstrates the huge and long-standing need for pre-market review of these products.
E-CIGARETTE ON SOCIAL MEDIA
- A 2018 study found that exposure to e-cigarette advertisements on social media among young adults was strongly associated with positive expectations of e-cigarette use — like the idea that using e-cigarettes would provide a pleasurable taste and smell and that it was safe and socially acceptable. These outcomes were also found to be directly correlated with current use.
- Even among non-smokers, exposure and marketing through social media linked e-cigarettes with increased perceptions of stylishness and popularity. Of the study participants, 19% regularly saw e-cigarette ads on Facebook and 16% on Instagram, and even more participants reported having seen e-cigarette related posts on Facebook (24%) and Instagram (20%).
- The largest e-cigarette forum (/r/ electronic_ cigarette) on reddit had over 203,000 subscribers as of April 2021.27 Another subreddit, titled /r/UnderageJUUL, at one point contained 844 members before it was shut down by reddit. Posts included discussions of flavors as well as methods of obtaining JUULs or pods. Most posts in this thread did not reference age, but those that did, mentioned ages from 13 to over 21.
- A 2018 study found that e-cigarette users who are male and younger were the most likely to participate in online discussion forums related to e-cigarettes.
- Additional research has shown that celebrity endorsements of e-cigarettes on social media can have an impact on young adults. A study of college undergraduates found that the appearance of celebrities on an e-cigarette social media brand page significantly increased intentions to use e-cigarettes and positive attitudes towards the devices. This effect was not seen in those who saw non-celebrity endorsers or pages displaying only the product.
- A September 2020 study found that the top 10 videos featuring Puff Bars on the social media app Tik Tok received between 2.8 and 42.4 million views. The three most popular videos featured individuals pushing large amounts of used Puff Bars over the edge of a desk with the audio “nicotine addiction check,” suggesting using the product was addictive. While none of these videos were confirmed to be ads or sponsored by Puff Bar, the study suggests further research is needed to assess how the presence of these products on social media impacts exposure youth initiation of vaping products and harm perception.
The last five years have seen enormous spikes in youth e-cigarette use rates.
- In 2017, 11.7% of high school students had used an e-cigarette in the past 30 days. By 2018, that number had risen to 21% and, by 2019, 27.5% of high school students had used e-cigarettes in the past month. That number dropped to 19.6% in 2020.
- The current use rate among middle schoolers rose from 0.6% in 2011 to 10.5% in 2019. The rate dropped to 4.7% in 2020.
- The National Institute on Drug Abuse’s Monitoring the Future Study (MTF), instead of measuring high school and middle school prevalence, measures prevalence in 8th, 10th, and 12th graders.
- In 2020 MTF found that 18% of 8th, 10th, and 12th graders reported vaping nicotine in the past 30 days, flat from 18.1% in 2019.
- The percent of 8th, 10th, and 12th graders using JUUL dropped from 15.8% in 2019 to 10.4% in 2020. Since roughly doubling from 2017 to 2019, (from 7.5% to 16.5% for 8th graders, 15.8% to 30.7% for 10th graders, and 18.8% to 35.3% for 12th graders), the percentage of teenagers who said they vaped in the past 12 months remained constant in 2020 at 16.6% of 8th graders, 30.7% of 10th graders, and 34.5% of 12th graders.
- In 2019, reported e-cigarette use among adults over the age of 18 was highest among adults aged 18-24 years old (9.3%). Over half (56%) of these e-cigarette users reported they had never smoked cigarettes.
- E-cigarettes were the second most commonly used tobacco product, with 4.5% (10.9 million) of U.S. adults reporting use of the product in 2019.
What to know about vaping-related illnesses
As of Dec. 27, 2019, nearly 2,561 cases of lung injury (EVALI) caused by inhalation of vitamin E acetate, or “popcorn lung,” have been reported in all 50 states, the District of Columbia, and two U.S. territories (Puerto Rico and U.S. Virgin Islands) and have led to 55 deaths during that time, according to the Centers for Disease Control and Prevention (CDC)Trusted Source.
Some of the people affected by vaping illnesses include children.
The CDCTrusted Source recommends people avoid using e-cigarettes and vaping products, particularly those containing THC oil, because they’re likely to contain vitamin E acetate.
Some states with legal marijuana are proactively warning marijuana users that vaping liquids has been known to cause severe lung injuries and death.
To stay up to date on the latest vaping-related illness news, check the CDC websiteTrusted Source for regular updates.
Vaping uses concentrated extracts or ground dry herb
When people vape, they consume concentrated marijuana. It seems to be a much more potent delivery system than smoking. In other words, you’ll get more high from vaping than from smoking.
Vaping can be more intense
Researchers have determined that the effects of vaping marijuana are much stronger than smoking.
In one studyTrusted Source, researchers found that first-time and infrequent marijuana users were more likely to experience adverse reactions from the enhanced delivery of THC caused by vaping when compared to smoking.
Both take effect fast
Both smoking and vaping have an almost immediate effect on the body. Their effects peak within 10 to 15 minutes.
- CBD can cause liver injury.
- CBD can affect how other drugs you are taking work, potentially causing serious side effects.
- Use of CBD with alcohol or other drugs that slow brain activity, such as those used to treat anxiety, panic, stress, or sleep disorders, increases the risk of sedation and drowsiness, which can lead to injuries.
- Male reproductive toxicity, or damage to fertility in males or male offspring of women who have been exposed, has been reported in studies of animals exposed to CBD.
- Changes in alertness, most commonly experienced as somnolence (drowsiness or sleepiness).
- Gastrointestinal distress, most commonly experienced as diarrhea and/or decreased appetite.
- Changes in mood, most commonly experienced as irritability and agitation.
- What happens if you take CBD daily for sustained periods of time?
- What level of intake triggers the known risks associated with CBD?
- How do different methods of consumption affect intake (e.g., oral consumption, topical , smoking or vaping)?
- What is the effect of CBD on the developing brain (such as on children who take CBD)?
- What are the effects of CBD on the developing fetus or breastfed newborn?
- How does CBD interact with herbs and other plant materials?
- Does CBD cause male reproductive toxicity in humans, as has been reported in studies of animals?
A note about marijuana strains
There are many strains of marijuana, each having slightly different effects on the body. Sativa strains are thought to be more stimulating. Others, called indica, are more relaxing. It’s worth noting marijuana strains can affect people quite differently. Just because a certain strain has purported properties doesn’t mean you’ll get those exact effects.
Because the harmful effects of smoking are well known and the health effects of vaping are unknown (and possibly very serious), it’s understandable that you might want to seek an alternative way to use marijuana.
If you’re looking to consume marijuana in the least risky way, ingesting it might be the way to go.
Edible marijuana products, or edibles can be any food or beverage. They include, but aren’t limited to:
- coffee creamer
Effects take more time
Keep in mind that ingesting marijuana doesn’t have an immediate effect. Having too much can lead to adverse physical and mental reactions, such as:
- panic attack
- elevated heart rate
But when eaten in moderation, edibles seem to have no apparent harmful health effects that are known yet.
Marijuana needs to be heated
Eating “raw” marijuana won’t have the same effects on the body as consuming marijuana-based products prepared correctly. Marijuana has to be heated in order for its chemical compounds to be activated. Cooking it can do that.
Start small and keep waiting
It can take up to 2 hours for the effects of ingested marijuana to hit and around 3 hours for them to peak. Effects are often long lasting — anywhere from 6 to 8 hours.
For this reason, it’s important to start slowly. Consume a very small amount if you’re ingesting marijuana for the first time. For example, a common dose for edibles is 10 milligrams of THC. If you’re just starting out, opt for 2 to 5 milligrams of THC.
Focus on CBD instead
If you seek the purported beneficial health effects of marijuana without the high, you may want to seek out CBD oil and products that contain it. Note: the CDCTrusted Source does not recommend vaping any liquid, including CBD oil.
Note, however, that CBD products aren’t regulated by the Food and Drug AdministrationTrusted Source. If you do buy them, it’s important to do so from a reputable distributor.
Do’s and don’ts for edibles
- When consuming edibles, eat some other food along with them.
- Don’t drive or operate machinery while under the influence of edibles. They may affect your judgement time and behavior.
- Keep edibles away from children, pets, and anyone else who shouldn’t eat them.
- Don’t drink alcohol or use other drugs when taking edibles. It can intensify the effects.
- Don’t have more if you’re “not feeling it.” Just wait.
While more research on the effects of consuming marijuana is needed, it appears we can conclude that smoking any substance — including marijuana — is generally not good for you.
New research suggests vaping liquids may also be detrimental to health and can cause serious problems, including death. So, it seems the least harmful way of consuming marijuana may be to eat it.
However, researchers note that long-term marijuana use and THC exposure may increase the risk of psychosis and mental health disorders.
If you want to get the health benefits of marijuana with the least amount of risks, it seems CBD products might be the way to go — though you won’t get high from using them.
Is CBD Legal? Hemp-derived CBD products (with less than 0.3 percent THC) are legal on the federal level, but are still illegal under some state laws. Marijuana-derived CBD products are illegal on the federal level, but are legal under some state laws. Check your state’s laws and those of anywhere you travel. Keep in mind that nonprescription CBD products are not FDA-approved, and may be inaccurately labeled.
- Borodovsky JT, et al. (2016). Smoking, vaping, eating: Is legalization impacting the way people use cannabis? DOI:
- Caporale A, et al. (2019). Acute effects of electronic cigarette aerosol inhalation on vascular function detected at quantitative MRI. DOI:
- Giroud C, et al. (2015). E-cigarettes: A review of new trends in cannabis use.
- Grinspoon P. (2018). Cannabidiol (CBD) — what we know and what we don’t.
- Hazekamp A, et al. (2006). Evaluation of a vaporizing device (Volcano) for the pulmonary administration of tetrahydrocannabinol.
- Is there a link between marijuana use and psychiatric disorders? (2019).
- Johns Hopkins Medicine. (2018). Vaping cannabis produces stronger effects than smoking cannabis for infrequent users [Press release].
- Legal medical marijuana states and DC. (2019).
- MacCallum CA, et al. (2018). Practical considerations in medical cannabis administration and dosing. DOI:
- Marijuana. (n.d.).
- Marijuana and lung health. (2019).
- Outbreak of lung injury associated with e-cigarette use, or vaping, products. (2019).
- Spindle TR, et al. (2018). Acute effects of smoked and vaporized cannabis in healthy adults who infrequently use cannabis: A crossover trial. DOI:
- Wang M, et al. (2016). Decarboxylation study of acidic cannabinoids: A novel approach using ultra-high-performance supercritical fluid chromatography/photodiode array-mass spectrometry. DOI:
- What you need to know (and what we’re working to find out) about products containing cannabis or cannabis-derived compounds, including CBD. (2019).