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Expert Report on the Health Effects of E-Cigarettes vs. Combustible Cigarettes and Global Population Shifts

Executive Summary

The global public health landscape is undergoing a significant transformation due to the rise of e-cigarettes. While traditional combustible cigarettes remain the most harmful form of nicotine delivery, with well-documented lethal health consequences, the rapid proliferation of e-cigarettes has introduced new and complex public health challenges. This report provides a comprehensive, data-driven analysis of the health impacts of e-cigarettes versus traditional combustible cigarettes, the differences in risks posed by various e-cigarette types, and the statistical effect these products are having on the global smoking population. Our analysis reveals that while e-cigarettes are generally considered less harmful than traditional cigarettes due to the absence of combustion and its thousands of toxic chemicals, they are by no means safe. E-cigarette aerosols contain their own set of harmful substances, including heavy metals, volatile organic compounds, and known carcinogens.1 While the long-term health effects of e-cigarette use are largely unknown, emerging studies suggest links to severe lung injury (EVALI), cardiovascular disease, and chronic respiratory illnesses like asthma and Chronic Obstructive Pulmonary Disease (COPD).5 The type of e-cigarette device and e-liquid formulation are critical determinants of user risk and addiction potential. Notably, innovations like nicotine salts have made highly concentrated nicotine products smoother and more palatable, drawing in a new generation of users who might have been deterred by the harshness of traditional cigarettes.12 This has created a new public health crisis, with youth e-cigarette use rates exceeding adult use in many countries.14 Statistically, the global decline in the traditional cigarette-smoking population is being offset by a rise in e-cigarette users.15 While some adults may use e-cigarettes as a smoking cessation aid, a growing body of evidence suggests this method is often ineffective and can lead to "dual use" or a new form of sustained nicotine addiction.16 The data reveals a complex population shift where a decrease of millions of exclusive cigarette smokers is nearly perfectly balanced by an increase in exclusive e-cigarette users.15 This indicates that e-cigarettes are not simply a bridge to quitting but are creating a new cohort of nicotine users with uncertain long-term health outcomes.15 This report concludes that a nuanced, evidence-based approach is urgently needed to address this evolving epidemic, combining proven tobacco control measures with tailored regulations for e-cigarettes. This is essential to protect public health and prevent a new generation from becoming addicted to nicotine.

Section 1: Introduction to the Global Tobacco and Nicotine Landscape

1.1 Purpose and Scope: A Data-Driven Comparative Analysis

This report aims to provide a comprehensive, expert-level analysis of the health impacts of e-cigarettes (vaping) and traditional combustible cigarettes in response to the user's query. The analysis explores the nuanced differences in health effects, the influence of varying e-cigarette types, and the statistical impact on the global smoking population.

1.2 Public Health Context: From Epidemic to Evolution

The tobacco epidemic, historically driven by combustible cigarettes, has been one of the biggest public health threats the world has ever faced, claiming over 7 million lives annually.18 The World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) and its MPOWER measures have successfully reduced the global smoking population.18 However, this success has entered a new phase with the emergence of e-cigarettes, which were initially marketed as harm-reduction tools and smoking cessation aids.16 The central premise of e-cigarettes as a "healthier alternative" is a widespread public misconception that has created a new public health challenge.23 This misunderstanding goes beyond the simple fact that they are "less harmful".24 The public perception that vaping is either "safe" or even "worse than smoking" presents a false dichotomy that can lead to poor decision-making.23 Individuals attempting to quit may not fully escape their nicotine addiction by switching to e-cigarettes, or, worse, they may return to the more harmful combustible cigarettes based on the mistaken belief that e-cigarettes are more dangerous.24 This situation undermines decades of tobacco control efforts and creates a complex challenge for public health, obscuring the true message that e-cigarettes are "not safe, but less harmful than smoking." 23

Section 2: The Definitive Harms of Traditional Combustible Cigarettes

2.1 Toxic Chemistry: A Mixture of 7,000 Chemicals

Combustible cigarettes are a leading cause of preventable death, and their harms are scientifically and unequivocally well-documented.18 The act of burning tobacco creates a complex smoke mixture containing over 7,000 chemicals, with more than 60 of these being established carcinogens.1 Key carcinogens include polycyclic aromatic hydrocarbons (PAHs), N-nitrosamines (e.g., NNK and NNN), aromatic amines, and aldehydes (e.g., acetaldehyde), as well as heavy metals.29 These substances inflict genetic damage, causing mutations in critical genes like $KRAS$ and TP53, which can lead to uncontrolled cellular growth and, ultimately, cancer.29

2.2 Chronic Systemic Diseases: The Immense Health Burden

Smoking is the primary cause of Chronic Obstructive Pulmonary Disease (COPD), a progressive and debilitating lung disease that includes chronic bronchitis and emphysema.26 It is also a major cause of cardiovascular diseases, including heart disease, stroke, and blood clots.25 Smoking significantly increases the risk of at least 12 types of cancer, including lung cancer, which often has no symptoms until it is advanced.26 The harm from smoking is not merely a list of diseases; it represents a fundamental, systemic breakdown of the body's physiology.28 Each puff of a cigarette introduces a massive load of free radicals and oxidants, causing immediate and measurable oxidative damage to proteins, DNA, and lipids.28 This oxidative stress creates a continuous cycle of damage that accumulates over time, forming the causal pathway to major chronic diseases and death, providing a clear benchmark for comparing the risks of e-cigarettes.28

Section 3: The Emerging Health Risks of E-Cigarette Use

3.1 Composition and Formation of Harmful Aerosol

E-cigarettes heat a liquid ("e-liquid") composed of nicotine, flavorings, propylene glycol, and other additives to produce an aerosol, which is not harmless "water vapor".7 This aerosol contains its own set of harmful and potentially harmful substances, including heavy metals (lead, nickel, tin), ultrafine particles, and volatile organic compounds (VOCs).5 When the e-liquid is heated, new toxic compounds, such as aldehydes (formaldehyde, acetaldehyde, acrolein), are created through chemical reactions.5 Acrolein, in particular, is known to cause irreversible lung damage.31

3.2 Acute and Short-Term Health Consequences

E-cigarette use has been linked to a rise in cases of E-cigarette, or Vaping, Product Use-Associated Lung Injury (EVALI), a severe and potentially fatal lung illness.1 The outbreak, which peaked in 2019, was strongly associated with vitamin E acetate, a thickening agent found in illicit THC vaping products.1 Immediate side effects can include coughing, shortness of breath, eye irritation, headaches, and nausea.7 E-cigarettes have also been shown to cause an immediate increase in heart rate and blood pressure, putting the cardiovascular system into a "fight or flight" state.25

3.3 The Uncertainty of Long-Term Effects

One of the most significant concerns is the lack of data on long-term health effects, as e-cigarettes have not been on the market long enough for chronic diseases to develop and be studied.5 Researchers do not yet know all the effects vaping can have on the body.5 However, emerging data suggests links to chronic lung disease, asthma, and cardiovascular disease.5 Some damage, like lung scarring caused by diacetyl, may be permanent.7 The EVALI crisis, while primarily linked to specific additives 1, serves as a powerful indicator of the systemic risks in a largely unregulated market. E-liquid products are not standardized, and many products labeled "nicotine-free" contain nicotine, while flavorings have not been proven safe for inhalation.6 The EVALI crisis was a symptom of this underlying regulatory failure, highlighting the risk that unknown, unlisted, or unregulated chemicals or thermal degradation products could cause serious harm at any time. The lack of standardized testing and regulation means users are effectively participating in a large-scale, uncontrolled health experiment.6

Section 4: A Head-to-Head Comparison: Risk and Harm Reduction

4.1 The "Continuum of Risk" Model: Less Harmful, Not Safe

No tobacco or nicotine product is safe.8 However, the public health community generally acknowledges a "continuum of risk," with combustible cigarettes at the most harmful end.23 E-cigarettes are generally considered less harmful than smoking because the absence of combustion means they do not produce the vast majority of toxic chemicals and carcinogens found in cigarette smoke.5

4.2 Comparative Analysis of Health Outcomes

Health Concern Risk from Combustible Cigarettes Risk from E-Cigarettes Level of Evidence / Notes Cancer Primary cause of lung cancer and linked to at least 12 other cancer types.26 Creates over 60 known carcinogens through combustion.29 Contains known carcinogens like formaldehyde and acetaldehyde.7 Long-term risk is unknown, but some e-liquid ingredients are known to be carcinogenic.7 Decades of solid evidence vs. emerging data; long-term effects are unclear.7 Chronic Respiratory Disease Leading cause of COPD and chronic bronchitis.26 Worsens asthma and increases risk for new onset asthma.26 Can cause lung irritation and inflammation.5 Can worsen or cause asthma and COPD.5 Some flavorings like diacetyl can cause permanent lung scarring.7 Solid evidence vs. ongoing research on long-term impacts.7 Cardiovascular Disease Major cause of heart attack, stroke, and circulation problems.25 Causes immediate and long-term increases in heart rate and blood pressure.25 Causes immediate increases in heart rate and blood pressure.25 Research finds links to inflammation, oxidative stress, and precursors to cardiovascular risk.9 Solid evidence vs. early and emerging evidence.10 Addiction Nicotine addiction is a powerful, chronic, and relapsing disease.37 Nicotine is highly addictive, and high doses from e-cigarettes significantly increase addiction risk.7 Has harmful effects on the developing adolescent brain.7 Solid evidence vs. new mechanisms of addiction being studied.37 Acute Lung Injury Not applicable. EVALI is a serious lung injury associated with specific additives, which can be fatal.1 A unique risk of e-cigarettes.32

An often-overlooked and critical risk is "dual use", which is the concurrent use of both e-cigarettes and combustible cigarettes.16 Evidence suggests that dual users may have similar or even higher levels of toxins in their blood than exclusive cigarette smokers.24 Many users who attempt to quit smoking with e-cigarettes end up as dual users instead.16 While it may seem intuitive that cutting down on smoking would reduce harm, the evidence suggests otherwise.16 Dual use may increase the harm of toxins due to the ongoing irritation and inflammation of the throat and airways from e-cigarette use.16 Additionally, users may engage in compensatory behaviors to achieve their desired nicotine level, and the dual exposure to combustion and aerosol harms may amplify health problems.16

Section 5: The Nuances of E-Cigarette Technology and Health Impacts

5.1 Device Types and User Behavior

The e-cigarette market is highly fragmented, with hundreds of brands and models that vary widely in design and function.28 Key types include: Pod Systems: Often use high-concentration nicotine salts and are associated with a mouth-to-lung style of inhalation.39 Mods / Box Mods: Larger, more powerful devices that produce more vapor and typically use lower-concentration freebase nicotine e-liquids.28 Disposables: The fastest-growing market segment, popular for their low cost, ease of use, wide variety of flavors, and high nicotine content.41

5.2 Nicotine Formulation: Nicotine Salts vs. Freebase Nicotine

Freebase Nicotine: The purest form of nicotine, but it is alkaline and provides a harsh throat hit, especially at high concentrations.12 Nicotine Salts: Created by adding an acid, such as benzoic acid, to freebase nicotine.13 This lowers the pH, making the vapor feel smoother and less harsh, which allows users to inhale much higher concentrations of nicotine without discomfort.12 This innovation, pioneered by brands like JUUL, has fundamentally changed the nicotine delivery experience.12

5.3 The Risks of Flavorings and Additives

Flavorings are a primary reason youth initiate e-cigarette use.41 While many are "Generally Recognized as Safe (GRAS)" for consumption, their safety for inhalation is unproven.31 Inhaling flavorings can be toxic to the respiratory, cardiovascular, and circulatory systems.34 Specific flavorings like cinnamaldehyde, vanillin, menthol, and diacetyl have been shown to be cytotoxic.34 Diacetyl is known to cause "popcorn lung," or bronchiolitis obliterans, which leads to permanent lung scarring.7

Table: E-Cigarette Device and Formulation Analysis

Device Type Primary Nicotine Form Nicotine Concentration User Behavior Health Implications Pod Systems Nicotine Salts High (e.g., 20+ mg/ml) Mouth-to-lung inhalation High addiction potential due to smooth, high-concentration nicotine.39 Mod Systems Freebase Nicotine Low-to-medium (e.g., 3-6 mg/ml) Direct-to-lung inhalation Users may take more or larger puffs at higher wattages to compensate for lower nicotine, potentially increasing exposure to harmful substances.28 Disposables Nicotine Salts High Mouth-to-lung / high-frequency use High addiction potential targeted at new users due to convenience and wide availability.41

Section 6: Global Statistical Analysis of Smoking and Vaping Populations

6.1 Global Vaping and Smoking Trends

The global vaping population is estimated to have grown from 82 million in 2021 to 114 million in 2023.44 In the U.S., adult e-cigarette use increased from 3.7% in 2020 to 6.5% in 2023.33 Use among young adults aged 21-24 increased significantly from 10.1% in 2019 to 15.5% in 2023.33 Meanwhile, youth use declined from 7.7% in 2023 to 5.9% in 2024.42 However, over 1.6 million youth still use e-cigarettes, with more than a quarter using them daily.42 The global smoking population stands at 1.25 billion as of January 2024, a decrease of 19 million over the past two years.46

6.2 The "Gateway" vs. "Cessation" Debate

Cessation Efficacy: While some studies suggest e-cigarettes may help adults quit smoking, many who use them for this purpose end up as dual users.16 A major UC San Diego study found that e-cigarette use, even daily use, was associated with a lower rate of smoking cessation.17 The CDC notes that no e-cigarette has been approved by the FDA as a smoking cessation aid.6 Gateway Effect: There is "substantial evidence" that youth and young adults who use e-cigarettes are at an increased risk of using traditional cigarettes.8 A global review found that teens who vape are three times more likely to become smokers, and they may smoke more frequently and intensely.43

Table: Global Population Trends for Smoking and Vaping

Metric 2021 2023 2024 Source Global Vapers 82 million 114 million N/A 44 Global Smokers N/A 1.25 billion (as of 2022) 1.25 billion (as of Jan 2024) 46 U.S. Adult Vaper Rate 4.5% 6.5% N/A 33 U.S. Youth Vaper Rate N/A 7.7% 5.9% 42 Change in U.S. Exclusive Users (2017-2023) N/A 6.8 million fewer exclusive smokers vs. 7.2 million more exclusive e-cigarette users N/A 15

The most significant insight from the statistical data is that public health successes in reducing the combustible cigarette population are being offset by a new e-cigarette epidemic.15 In the U.S. from 2017 to 2023, the number of exclusive cigarette smokers decreased by 6.8 million, but this was nearly perfectly balanced by an increase of 7.2 million exclusive e-cigarette users.15 This data shows a nearly one-for-one substitution of one form of nicotine use for another.15 The rise in e-cigarette users is not a result of smokers successfully quitting but is primarily a new cohort of nicotine addicts, especially among younger adults aged 18-44.15 This challenges the entire harm-reduction model and reframes the issue from "smoking cessation" to "preventing a new generation from becoming addicted to nicotine." 15

Section 7: Conclusion and Future Recommendations

7.1 Synthesis of Findings

In conclusion, while traditional cigarettes are indisputably more harmful, e-cigarettes are not a benign alternative. Their long-term health effects are still unknown, but short-term evidence is concerning. The most serious risks are the potential for severe acute lung injury, chronic disease, and, most importantly, the creation of a new generation of nicotine addicts.15

7.2 Public Health Recommendations

Policymakers must implement strong, evidence-based e-cigarette regulations, including age restrictions, flavor bans, and advertising limits, as recommended by the WHO.19 Healthcare professionals should be better educated on the "continuum of risk" to correct public misconceptions and provide evidence-based cessation counseling.23 Public health campaigns, especially those targeting youth, should emphasize the risks of e-cigarettes and reinforce that avoiding all nicotine products is the only safe option.6

7.3 Need for Future Research

There is an urgent need for long-term longitudinal studies on the health effects of e-cigarettes on the brain, cardiovascular system, and lungs.5 Further research is also needed to better understand the efficacy of e-cigarettes as a cessation tool while controlling for confounding variables, as well as the mechanisms of addiction from nicotine salts and the toxicity of flavorings.16 참고 자료 The Health Risks Of E-Cigarettes Versus Traditional Cigarettes - Henry Ford Health, 8월 20, 2025에 액세스, https://www.henryford.com/blog/2024/06/the-health-risks-of-e-cigarettes-vs-traditional-cigarettes The facts about vaping - Respect your brain - NSW Health, 8월 20, 2025에 액세스, https://www.health.nsw.gov.au/tobacco/Pages/vaping-respect-your-brain.aspx Health effects of electronic cigarettes - Wikipedia, 8월 20, 2025에 액세스, https://en.wikipedia.org/wiki/Health_effects_of_electronic_cigarettes Study links teen vaping to increased risk of smoking and health ..., 8월 20, 2025에 액세스, https://www.york.ac.uk/news-and-events/news/2025/research/teen-vaping-smoking-health-issues/ Is vaping better than smoking for cardiorespiratory and muscle function? - PMC, 8월 20, 2025에 액세스, https://pmc.ncbi.nlm.nih.gov/articles/PMC7348661/ 5 Vaping Facts You Need to Know | Johns Hopkins Medicine, 8월 20, 2025에 액세스, https://www.hopkinsmedicine.org/health/wellness-and-prevention/5-truths-you-need-to-know-about-vaping Vaping (E-Cigarettes): What It Is, Side Effects & Dangers, 8월 20, 2025에 액세스, https://my.clevelandclinic.org/health/treatments/21162-vaping Health Effects of Vaping | Smoking and Tobacco Use - CDC, 8월 20, 2025에 액세스, https://www.cdc.gov/tobacco/e-cigarettes/health-effects.html www.michiganmedicine.org, 8월 20, 2025에 액세스, https://www.michiganmedicine.org/health-lab/why-vaping-bad-your-heart#:~:text=Vaping%20has%20been%20found%20to,term%20risks%20for%20your%20heart. 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