How a fix for smoking sparked a new crisis

This story was originally published in The Highlight, Vox’s member-exclusive magazine. To get early access to member-exclusive stories every month, join the Vox Membership program today. Cigarettes are a public health nightmare: both highly addictive and highly dangerous. By the middle of the 20th century, nearly half of Americans were smokers, putting themselves at risk of lung cancer, emphysema, and other chronic and deadly health problems. And while smoking rates have fallen significantly over the decades, 29 million people in the US continue to light up because once you start, it can be hard to stop. Despite decades of aggressive anti-smoking measures, the toll from tobacco continues. Each year, approximately 225,000 people in the US are diagnosed with lung cancer (for which smoking remains the primary risk factor), while 125,000 Americans die from the disease. Add the deaths from heart disease and the other negative effects of regularly inhaling smoke, and the number of annual deaths related to smoking climbs to nearly 500,000, making it the leading cause of preventable death in the US. This public health crisis is precisely the problem that e-cigarettes were designed to address: delivering nicotine to people with a dependency on it, minus the dangerous chemicals produced by regular cigarettes. It’s been more than 20 years since their invention, and in that time e-cigarettes do appear to have had real public health benefits for smokers. At the population level, lung cancer rates have declined by about 20 percent over the past five years. While most of that progress is likely attributable to the continued drop in combustible smoking, most experts believe that e-cigarettes are helping pull that number downward. One 2016 projection estimated that by 2100, vaping could reduce deaths from tobacco use by as much as 25 percent compared to what might have happened in the absence of e-cigarettes. Public health experts have no doubt that e-cigarettes pose less of a health risk than smoking tobacco, so for the millions of smokers who want to quit but struggle against the pull of nicotine, e-cigarettes could be a literal lifesaver. But at the same time, it is increasingly clear that they present a new kind of health risk to the people who have never picked up a pack of Camels — and might never have had e-cigarettes not been introduced. That’s most obvious among young people who grew up in the years when smoking was sharply declining. By 2019, even as overall smoking rates had fallen to 14 percent, nearly one in three high schoolers said that they had vaped nicotine in the past 30 days. And notably, the percentage of US high school students who were vaping in 2019 was higher than the combined percentage of teens just five years earlier who had used any tobacco product. That means that the rapid rise of vaping almost certainly led to more young people consuming nicotine overall. Today, fewer than 2 percent of teens smoke traditional cigarettes or cigars, according to the Centers for Disease Control and Prevention, the lowest levels ever recorded. But four times as many vape. The CDC recently reported 15 percent of adults ages 21 to 24 in the US — the generation who came of age during the e-cigarette boom — still use e-cigarettes, as do 10 percent of those ages 18 to 20, while only 5 percent of adults ages 18 to 24 smoke regular cigarettes. Tobacco companies contributed to and profited from that surge. Juul, the brand most associated with the e-cig craze, was valued at nearly $40 billion in 2018 when the United States’ largest tobacco company, Altria, bought a stake in it. Juul would later pay a billion-dollar settlement for specifically targeting teens — even buying space on youth-based websites — with ads that featured young people vaping. Before vaping took off, traditional cigarette smoking was already declining; fewer than 20 percent of young people were smokers by 2010, down from 36 percent in 1997. But even as lots of previous smokers improved their health by pivoting to e-cigarettes, many nonsmokers found themselves hooked on these devices that deliver powerful doses of nicotine — a toxin that on its own can damage your heart and brain. Given all of this, the question remains: Is vaping a net improvement overall? Or have we, in trying to solve one public health crisis, inadvertently created a new one? If you already smoke, e-cigarettes are a better option When someone strikes a match and lights their cigarette, the butt’s temperature reaches more than 1,500 degrees Fahrenheit when they take a puff and it continues to burn at extremely hot temperatures until they stub it out. The dangerous toxins contained within a cigarette that damage people’s lungs and lead to the growth of cancerous tumors — tar and carbon monoxide and dozens more — are being released continuously throughout the process of smoking. When the Chinese pharmacist Hon Lik developed the first commercially viable e-cigarette in 2003, he sought to minimize those harmful chemicals. Lik’s father, a lifelong smoker, was dying from lung cancer. Lik himself had also struggled to quit and wanted an option that wouldn’t be as damaging to his own lungs. Today, there is a vast array of vaping products, but they largely work the same way: They use a battery to heat a small chamber filled with oil laced with nicotine and flavorings to somewhere between 200 and 500 degrees Fahrenheit to produce an aerosol vapor that the user then inhales. In laboratory studies, e-cigarettes emit only trace amounts of carbon monoxide, 99.8 percent lower than the traditional cigarettes, and they do not produce tar. That was the selling point. And in randomized experiments, which are tightly controlled by investigators, e-cigarettes have been shown to be much more effective at helping people quit traditional cigarette smoking than existing cessation aids like nicotine gums or patches. But the long-term impact on vapers now that these products have been on the market for more than a decade has been less clear. [Image: Disposable vapes for sale. https://platform.vox.com/wp-content/uploads/sites/2/2025/04/GettyImages-2211490939.jpg?quality=90&strip=all] US smoking rates had dropped from 23 percent in 2000 to 19 percent in 2010 (a 17 percent decrease); from 2010 to 2021, the period during which e-cigarettes were introduced and used widely, smoking rates fell by 40 percent. But the percentage of Americans who smoke has started to level off the past few years (it actually grew by 0.1 percent from 2021 to 2022) and precisely how much e-cigarettes are contributing to the overall decline, versus changes in the population or other smoking cessation tactics, can be difficult to discern. Notably the older generation of smokers, the people for whom vaping offers the most obvious health benefits, don’t appear to be switching to e-cigarettes at high enough rates to show up in large population surveys. And that’s creating a confusing picture for researchers: A 2018 report from the National Academy of Sciences that attempted to synthesize all of the studies available up to that time stated there was “moderate” evidence that e-cigarettes were effective as a smoking cessation tool — but noted there was a discrepancy between randomized trials where the effect was evident, and observational surveys where it was not. "“Clearly, what we know right now is e-cigarettes are not safe. They have an effect on the respiratory system, on the cardiovascular system.”" - Maciej Goniewicz, tobacco control researcher One recent study provided some of the strongest evidence yet for e-cigarettes’ health benefits. Researchers used the FDA’s decision to switch from regulating e-cigarettes as a pharmaceutical drug (as most smoking cessation products are) to a tobacco product to attempt to measure the effect of vaping’s proliferation in the 2010s. The regulatory change allowed more products to flood the market, rapidly making e-cigarettes much more accessible to consumers. They concluded that, compared to what would have happened if vape pens were not available, e-cigarettes were responsible for saving the equivalent of 677,000 years of life between 2011 and 2019. The basis of that finding — that e-cigarettes are more effective than nicotine patches or gum in convincing people to stop smoking — is sound, even if it had failed to show up in earlier observational studies. “E-cigarettes are a more attractive product for smokers,” said Maciej Goniewicz, a tobacco control researcher at the Roswell Park Comprehensive Cancer Center in Buffalo, New York. “They’re still inhaling nicotine, but it’s safer. They don’t see it as a medication.” The evidence for e-cigarettes’ benefit for smokers per se is growing. But there is also reason to believe they are not making as much of a difference as they could, for a surprising fact: Older smokers think e-cigarettes are dangerous, Goniewicz said, and it may be because of the news they consumed about vaping when these products came out. Take the “popcorn lung” scare: Journalists identified a chemical called diacetyl in some e-cigarettes that had been linked to severe lung injuries in a handful of workers at a microwave popcorn factory (thus, “popcorn” lung) in the early 2000s. But experts pointed out there had not actually been a single documented case of the condition among vape users, maybe because the levels of diacetyl are much lower in e-cigarettes than they are in the popcorn butter that was sickening the factory workers. That same year, counterfeit cannabis vapes that contained dangerous toxins and caused serious lung injuries attracted media scrutiny. The scandals, both real and sensationalized, delivered an unmistakable message to the public about vaping’s risks: Surveys show the number of people who believe e-cigarettes are more harmful than regular cigarettes started to rise in 2019, when popcorn lung was attracting headlines. People of all ages became more skeptical of e-cigarettes after those health scares, surveys show. And despite the likely benefits to smokers, even many doctors remain reluctant to recommend a product that does come with its own health risks, even if those risks are smaller than those associated with smoking. Goniewicz said clearer guidance to clinicians about how to talk about vaping, especially for patients for whom other methods have failed, might convince more smokers to swap their cigarettes for vapes in the real world. If you don’t already smoke, don’t vape The case for switching to e-cigarettes for smokers is strong. But for nonsmokers, no nuance is needed: If you don’t already smoke, don’t start vaping. It’s certainly not good for you. Vape pens produce some of the same harmful aerosols as regular cigarettes, such as formaldehyde and acrolein, and laboratory studies have found that vaping can injure a person’s respiratory system. “Clearly, what we know right now is e-cigarettes are not safe,” Goniewicz said. “They have an effect on the respiratory system, on the cardiovascular system. They affect the cells in the lungs. They affect veins and arteries.” E-cigarettes obviously deliver nicotine to the user’s body, often in greater and more efficient quantities than traditional cigarettes do: Vapers ingest as much nicotine from one 5 percent Juul pod as smokers do after smoking an entire pack of cigarettes. Nicotine can damage a smoker’s arteries and increase their blood pressure, and it has also been linked with depression and poor attention and memory — particularly in young people. And because nicotine is so addictive, just as it is for cigarettes, once people start vaping, it’s difficult for them to stop. Long-term use could increase the long-term health risks from nicotine use and from vaping itself, even if they never graduate to traditional smoking. But despite these clear drawbacks, nonsmoking teens at the time didn’t get the message. “Young people think they are absolutely safe,” Goniewicz said of the attitude in the early days of vaping. In the mid-2010s, surveys showed that young people perceived vaping as harmless, which could explain the dramatic and rapid increase in e-cig use among that generation. One 2017 survey of Florida high school students found that more than half of teens who had used e-cigarettes in the past 30 days thought they were not harmful to their health. More recent surveys show that these attitudes are shifting: A 2023 survey in the UK found that more than half of adults thought e-cigarettes were equally or more harmful than cigarettes, including 56 percent of people ages 18 to 34, with perceptions worsening over time. E-cigarette use also has dropped among middle and high schoolers today: The percentage of US youth who had vaped in the past 30 days fell from a staggering 30 percent in 2019 to 5.9 percent in 2024. For the young people who continue to vape, there may be health risks that we can’t anticipate yet. E-cigarettes produce much less of the toxins found in cigarette smoke, but we still don’t know the long-term impacts of persistent exposure to the trace amounts that they do produce. And e-cigarettes may be producing unique toxins that we’re not yet measuring for, said Alan Shihadeh, a professor of mechanical engineering at the American University of Beirut, who has studied air pollutants over his career and now focuses on e-cigarettes. “People keep asking me, ‘Is it safer?’ I could definitely say that I know hydrogen cyanide is found in combustible cigarettes, and I’m not seeing it much in electronic cigarettes, so that’s good,” he told me. But they can still expose vapers to harmful metals, including arsenic and lead, according to lab-based studies. But it will take time before we can actually measure out in the world whether fewer people are getting lung cancer and other smoking-related diseases. The reality is that these diseases take decades to develop, even for heavy tobacco smokers, and these products have been widely used for only a decade or so. And on top of those risks, the vaping industry has often operated with light regulations and lax enforcement of what regulations do exist. E-cigarettes can come in dozens of iterations — some are disposable and others are rechargeable; some can adjust their vaping temperatures and how much they deliver nicotine with each puff — and that adds to the uncertainty about the health effects. It’s almost impossible to be sure what’s being measured in a lab matches what is happening in the real world. “From one product to another, it’s producing a similar amount of nicotine, but you can get 10,000 times more formaldehyde than another product. There were these huge variations,” Shihadeh told me of his team’s laboratory experiments. “We also found there that you buy the same brand — the same everything as far as you are concerned — and they produce very different amounts of nicotine.” Vaping presents a genuine public health conundrum The public health dilemma presented by e-cigarettes is real — and experts disagree sharply in how policymakers should respond. Some experts and policymakers argue that the rise of e-cigarettes has caused us to lose ground on nicotine addiction after so much progress was made to eliminate tobacco use entirely. One of the dangers of e-cigarettes, these experts argue, is that they have destigmatized nicotine use again after the prior generation of public health campaigns had succeeded in turning people off it. It’s easier than ever to sneak a drag from your vape pen anywhere — the office, public transit, walking down the street — and far easier than finding a place to smoke after years of anti-smoking regulations. To those experts, the appropriate response would be to do to e-cigarettes what has been done to regular cigarettes: heavily restrict access and drive use as close to zero as possible. “Nicotine is a drug at the end of the day,” Shihadeh said. “In the best of my world, I would make these pharmaceutical-grade products available at the pharmacy with your doctor’s prescription or something like that. I would create a barrier to access.” But other experts argue that some people will inevitably choose to use nicotine, and public health strategy needs to grapple with that reality to reduce harm as much as is realistically possible. “How should public health look at those pros and cons? I don’t really know the answer,” Goniewicz told me. “The product is here. It’s not like we banned it and it will be eliminated.” The policy goal should be harm reduction, they argue: Rather than try to ban vaping out of existence, which seems doomed to fail, it’s better to focus on strategies like trying to better communicate what e-cigarettes are really for. Convince more existing smokers to use them to reduce if not eliminate the harms to their health, while minimizing the number of new people who pick up the habit. Vapes should be seen more like a nicotine patch or gum, a way for smokers to stop inhaling smoke. They are not a “safe” way to deliver nicotine, especially if you’ve never used that drug before. Too often, the conversation about vaping has swung too far to either extreme. Overreaction presents its own risks: A 2024 Yale study found that a well-intentioned ban on flavored vapes, intended to reduce use by young people, had led to some of those users switching to regular smoking. And meanwhile, ramping down the public health campaign against tobacco — as the Trump administration has proposed in laying off staff working on anti-smoking efforts and other tobacco regulation enforcement — risks swinging too far in the other direction and creating a public health crisis if vaping rates climb among the next generation. Whatever health problems might be created by e-cigarettes are certainly preferable to tobacco smoking. But we should start thinking now about how to help the current generation of vapers. “The peak, hopefully, is behind us,” Goniewicz told me. “Those young people who are vaping today, who started vaping today, and will be vaping for the coming years, we need to prepare to help them when the time comes when they want to quit.”

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How a fix for smoking sparked a new crisis