Vaping has exploded in popularity with young people. But the case against e-cigarettes — for smokers and non-smokers — is mounting.

A man exhales while vaping, Dallas, Texas, 6 September 2019 (EPA-EFE/LARRY W. SMITH)

Or is it?

There’s a debate over whether e-cigarettes should be more strongly regulated. The U.S. federal government and public health officials lean strongly towards regulation and have been restricting the marketing of vaping products.

In Britain, e-cigarettes are more celebrated as an aide to help smokers stop their addiction to smoking tobacco, which kills more than 8 million people a year, according to the World Health Organisation.

E-cigarettes first hit the market about a decade ago, and the first versions were clunky, fist-sized devices that users filled with fluid that they usually bought separately.

Now the dominant products are prefilled, pod-based devices such as Juul, which resemble computer flash drives. Other versions look like fancy fountain pens or plastic cigarettes. Some produce a large cloud of vapour, while others allow users to exhale a stream that’s nearly invisible.

Where’s the danger?

Most people know that smoking is dangerous. Tobacco contains nicotine, one of the most addictive chemical substances known, and delivers other chemicals that cause lung disease, heart disease and more than a dozen different cancers.

But e-cigarette “juice” also contains nicotine, and sometimes a vape delivers much more nicotine than a cigarette. The flavours used in e-cigarette liquids are not well studied, but an outbreak of severe lung disease linked to vaping has put more than 2,600 people into hospitals in the United States and killed around 60.

The U.S. Centers for Disease Control and Prevention has found strong evidence that an oily compound called vitamin E acetate, used in the production of some vaping fluids, is causing the lung damage.

Vitamin E acetate is safe to eat, but there’s almost no research showing what it does when inhaled into the lungs. The same goes for most, if not all, the flavourings used in e-cigarettes. This includes THC, the active ingredient in cannabis that is an increasingly popular vape additive.

The damage can be short or long-term.

At first, doctors, public health experts and others embraced vaping as a safer alternative to smoking. It seemed that if smokers could switch to the seemingly cleaner e-cigarettes as a way to get their nicotine fix, it would save lives.

Public Health England, the government public health agency for England, issued a report in 2015 that said e-cigarettes are 95% safer than traditional cigarettes.

But it can take years for research to catch up to what’s happening in the real world.

Now researchers are finding that vaping can cause not only immediate health effects, such as the acute lung injuries seen in the United States, but also longer-term damage.

At the end of 2019, a team at the University of California San Francisco found that people who vape raise their risk of chronic lung diseases such as emphysema, asthma and chronic obstructive pulmonary disease by a third. People who both vaped and smoked more than tripled their risk.

What is more, vaping did not help most smokers quit. Fewer than 1% of smokers switched exclusively to vaping over three years, the researchers found.

Are there really any benefits to vaping?

“One of the biggest problems with e-cigarettes is that many people have switched to e-cigarettes believing it will help them quit tobacco products, which it doesn’t,” said Dr. Albert Rizzo, chief medical officer at the American Lung Association. WHO agrees the evidence is murky.

And there’s evidence that vaping is even more addictive than smoking. Juuls, for instance, use a formulation of nicotine called nicotine salts that make the product taste smoother and are absorbed more quickly into the body.

Luka Kinard started using e-cigarettes when he was in high school in North Carolina and now speaks frequently in public about his addiction. It took him 40 days in a rehabilitation programme to kick the habit.

“I thought Juuling was safer and even healthier than other tobacco products. But really, I had no idea what I was putting in my body,” he said.

Big Tobacco controls much of the vaping industry.

It’s becoming clear that vaping appeals most strongly to older teens and young adults. The U.S. National Academies commissioned a comprehensive report that found in 2018 that e-cigarette use was encouraging young people who never smoked before to try cigarettes.

While there still may be some debate over whether e-cigarettes can help smokers quit, there’s almost universal agreement that non-smokers, especially children, teens and young adults, should not use them at all.

Yet in the United States, where vaping is marketed the most aggressively, there’s an epidemic of teen vaping. More than a quarter of U.S. high school students now use vaping products. In response, regulators such as the U.S. Food and Drug Administration are moving to ban the fruit- and candy-flavored products that are most attractive to young people.

Who profits?

But the big tobacco companies that control much of the vaping industry want to keep and expand their customer base. They are fighting regulation in Washington and looking for markets elsewhere in the world.

Altria, the U.S. company that split from Marlboro maker Philip Morris in 2007, bought a 35% stake in Juul for nearly $13 billion in 2018. Altria CEO and chair Howard Willard has repeatedly said he wants to accelerate Juul’s global growth.

Maggie Fox has been reporting on health and science for more than 25 years and is currently a contributing writer to the Fuller Project and host of the One World, One Health podcast. She has covered conflict, politics and other international events from London, Hong Kong and Beirut. She has covered the cloning of Dolly the sheep, Ebola epidemics, stem cell technology, vaccine controversies and other stories for Reuters, CNN, National Journal, Medscape, STAT and NBC News. She lives outside Washington, DC.