E-cigarettes: not a good alternative to tobacco smoking

E-cigarettes are electronic cigarettes. Instead of tobacco, a liquid in them is heated up. Consumers inhale the vapor that is produced by this. This process is referred to as vaping. E-cigarettes are also called vaporizers, or vapes for short.

An e-cigarette is composed of a vaporizer and battery-operated heating element. The liquid is added to a cartridge or a tank is filled with it. It may contain nicotine or be nicotine-free and is usually flavored. In Germany, liquids may contain a maximum of 20 milligrams of nicotine per milliliter. Other main constituents are glycerin, propylene glycol, aromatic substances and flavors.

Many smokers use e-cigarettes as a purportedly less harmful alternative to tobacco smoking. However, there are still no long-term studies on the health effects of e-cigarettes.

E-cigarettes are especially popular among adolescents, young adults and active smokers. Consumption has increased in recent years.

Nearly a third of people who normally smoke tobacco cigarettes have tried an e-cigarette before. Users of e-cigarettes also commonly smoke tobacco cigarettes. Nearly 9 out of 10 people who consume e-cigarettes also smoke tobacco cigarettes.

One in every five people aged 16 to 29 has smoked an e-cigarette. For adolescents aged between 14 and 17, the number is one in every six.

According to surveys, 2 to 3% of the population regularly uses e-cigarettes. Most of them do not smoke e-cigarettes as an alternative to tobacco cigarettes, but in addition to them.

The users of e-cigarettes inhale an aerosol that emerges from the liquid being heated up. It may contain nicotine or be nicotine-free. The liquid’s main constituents include:

• propylene glycol (solvent)
• glycerin (sugar alcohol)
• water
• ethanol (solvent)
• flavoring
• aromatic substances 

Except for nicotine, the components of the liquids are authorized for use in food. However, it is not yet known what the health effects are of inhaling them.

Depending on the performance, type and use of the e-cigarette and liquid, substances may be inhaled along with the vapor that can have an irritant effect or cause cancer. They include:

• formaldehyde
• acetaldehyde
• acrolein
• nickel
• chromium
• lead
• particulate matter

Many of these harmful substances also occur in tobacco smoke. Their concentration is usually lower in e-cigarettes. However, some substances like formaldehyde, lead and chromium may reach similarly high concentrations to tobacco smoke under certain conditions, while nickel concentrations can be even higher.

Nicotine and other components of the liquid in e-cigarettes cause both short-term and long-term reactions. The particles contained in the vapor are absorbed by the body into the lungs and released into the blood.

Currently known short-term effects of e-cigarettes in people include:

• irritation of the respiratory tract
• inflammations of the respiratory tract and bronchial tubes
• impaired lung function
• faster pulse and higher blood pressure
• stiffening of the vessels

It could moreover be shown in laboratory tests that e-cigarette aerosol

• is pro-inflammatory,
• is toxic for cells,
• and damages genetic material.

Liquids containing nicotine may trigger both wanted and unwanted reactions in users. A low dose of nicotine may act as a stimulant, increasing performance and concentration as well as reducing hunger for a short time. A high dose of nicotine may have a soothing and relaxing effect. The potential negative consequences of nicotine use include:

• nausea
• vomiting
• dizziness
• restlessness
• changes to the blood vessels
• circulatory disorders
• cardiac arrhythmia, irregular heartbeat
• impaired vision
• sleep disturbances and disorders
• shortness of breath (dyspnea)
• epileptic seizures

Nicotine can be physically and mentally addictive. When discontinued, it causes withdrawal symptoms and may cause a need for more and more nicotine.

According to previous studies, e-cigarettes are probably less harmful than conventional cigarettes. This is especially the case when they are used instead of tobacco cigarettes. On the other hand, if both conventional cigarettes and e-cigarettes are used, a higher health burden can be assumed.

E-cigarettes also have numerous health risks:

• They can damage the cardiovascular system.
• The vapor contains carcinogenic substances like formaldehyde.
• Aromas in the liquid may irritate the respiratory tract and cause allergies and inflammations.
• If the liquids contain nicotine, they may be addictive and increase the risk of thromboses, vascular diseases and strokes.

Furthermore, illegal or unauthorized ingredients have been detected in some liquids.

Can e-cigarettes harm non-smokers?

The vapor from e-cigarettes may be inhaled involuntarily along with the ambient air by people who do not smoke themselves. Passive smoking is a potential health risk. The Federal Institute for Risk Assessment (BfR) therefore recommends that e-cigarettes should only be used in designated smoking areas and not in the presence of pregnant women, children or sick people.

More and more people are trying e-cigarettes. In particular, children aged over 12 years, adolescents and young adults are interested in vaping. Many non-smokers also find e-cigarettes appealing.

Studies are coming to the conclusion that adolescents who experiment with e-cigarettes

• are more likely to try regular smoking
• and are later three times more likely to take up tobacco cigarettes.

Vaping liquids containing nicotine entails a risk of developing a dependency. The nicotine content specified in the packaging does not always correspond to the actual values. Some products from Australia, China and the USA have even contained nicotine in liquids that were labeled as nicotine-free.

Users cite the aromas and flavors of liquids in particular as a reason for their interest in e-cigarettes. Sweet aromas and fruity flavors are especially popular with children and adolescents. Some liquids have names like “Bubble Gum”, “Bonbons”, “Cotton Candy” and “Slushy”. The liquid tanks are often designed in a cartoon style which thus also appeals to young people.

Various regulations and laws are supposed to prevent children and adolescents from being enticed into using e-cigarettes. Purchasing and vaping e-cigarettes is only allowed from the age of 18. Liquids containing nicotine and e-cigarettes must be labeled and the sale handled in a way that protects young people. Furthermore, there is a ban on advertising on radio and television, in the print media and on the Internet. Sponsoring radio and television programs is also prohibited.

There are scientific studies suggesting that e-cigarettes may help with quitting smoking. As a result, they can reduce the desire to smoke and withdrawal symptoms.

A summary of different studies has revealed that e-cigarettes containing nicotine may contribute to reducing smoking by half. E-cigarettes with nicotine are more suitable for that than nicotine-free e-cigarettes, nicotine patches or nicotine chewing gums. However, a positive impact on health can only be achieved if smokers make a complete switch from tobacco cigarettes to e-cigarettes. But tobacco usually continues to be smoked at the same time. Furthermore, giving up nicotine completely after treatment is rarer if e-cigarettes are used instead of nicotine replacement therapy.

The positive effects of e-cigarettes for quitting smoking could only be shown in a few studies up to now, but not in “real life”. There are moreover no adequate long-term studies to draw a definite conclusion about possible long-term damage caused by e-cigarettes.

The World Health Organization (WHO) and medical guidelines therefore recommend against e-cigarettes being used for quitting smoking. 

Furthermore, switching to e-cigarettes does not change smoking habits. Vaping liquids containing nicotine makes no difference to users’ nicotine dependency. Studies conclude that some people reach for tobacco cigarettes again after a certain period of time.

What are other ways to successfully stop smoking?

Many people find it difficult to stop smoking and need support in doing so. They may get help in medical practices or with psychotherapists. A combination of psychotherapy and medications for treating nicotine addiction has the best impact.

To overcome withdrawal symptoms along with mental and physical dependency, there is a range of other measures. They include:

• motivational consultations and information
• nicotine replacement therapy (NRT) with nicotine patches, nicotine chewing gums and inhalers
• drugs such as bupropion or varenicline
• mindfulness methods
• hypnosis (hypnotherapy)

Acupuncture, acupressure or electrical stimulation are rated less suitable. The effectiveness of these methods has not been proven.

Free support for quitting smoking is offered by the Federal Center for Health Education (BZgA) on the website rauchfrei-info.de.

Furthermore, there is meanwhile a digital health application (DiGA) that offers support for quitting smoking. The health insurance providers cover the cost of the “Smokefree App”. More information about the app is available at nichtraucherhelden.de.

For questions about smoking and quitting smoking, the Federal Center for Health Education (BZgA) offers free phone support at:

Phone: (0800) 831 3131 (toll-free)

Staff are available at the following times:
Monday–Thursday: 10:00am–10:00pm
Friday–Sunday: 10:00am–6:00pm