The truth about vaping and your health: We are finally getting answers - and this is why leading experts are getting increasingly worried...

When consultant breast surgeon Professor Kefah Mokbel is planning to operate on a patient who vapes, he always asks them to quit a few weeks before the surgery. It’s something that more surgeons are now doing. ‘When it comes to medical matters, my colleagues and I treat vapers just like we do smokers – we know that vaping has a negative physiological effect on the body,’ Professor Mokbel told Mail+.

‘The nicotine in a vape increases heart rate, pushes up blood pressure and causes the blood vessels to narrow and constrict, which all increase the risk of poor post-operative wound healing.

‘People who vape also have higher complication rates with problems such as pneumonia and thrombosis, leading to dangerous blood clots – so if someone vapes regularly we tell them to quit to improve their outcome.’

While acknowledging that vaping is safer than smoking tobacco, Professor Mokbel and other experts are becoming increasingly concerned about the potential health risks.

‘There is no doubt in my mind that e-cigarettes are more harmful than has been acknowledged up to now – the question is, how harmful?’ asks Professor Mokbel, who is based at St George’s NHS Hospital in London.

15 per cent of 16- to 24-year-olds in the UK vape, up from 11.1 per cent in 2021. The Government plans to prohibit sales of vapes to under-18s

And it’s a question that could matter to a lot of people: Vapes are now used daily or occasionally by 4.5million Britons, according to the latest Opinions and Lifestyle Survey.

The habit is becoming especially popular with the young – 15 per cent of 16- to 24-year-olds in the UK vape, up from 11.1 per cent in 2021.

‘Knowing what I know about the health risks of vaping, I find it disheartening that so many young people are taking up vaping not because they are smokers trying to quit but because they see it on social media and they think it is cool,’ adds Professor Mokbel.

And while a 2015 report by Public Health England stated that vaping is 95 per cent less harmful than smoking, the Government is now sufficiently worried that it’s planning to prohibit the sale of vapes to under-18s.

Vapes are electronic devices that heat liquid (also known as ‘e-liquid’), which usually contains nicotine, flavourings and thickening agents, turning it into an aerosol you inhale.

Because they deliver a nicotine hit without exposure to many of the harmful chemicals found in tobacco, most experts agree that they are useful ways to help smokers cut down on their tobacco use or quit altogether.

‘Vaping has a place when it comes to helping people quit smoking and it is positive to see smokers switch to it,’ Hazel Cheeseman, deputy chief executive at the charity Action on Smoking and Health, told Mail+.

‘However, it is a source of concern that we appear to have a growing level of use of vapes by teenagers and young adults who might not have smoked,’ she says.

‘Quantifying the health risks to these people is really difficult, though unlikely to be anything like the health risks from smoking.’

Yet other experts are concerned about the evidence now stacking up against vapes.

‘Vapes may not contain tar, which forms a sticky layer on the inside of the lungs and contains most of the cancer-causing and other harmful chemicals in tobacco smoke, but they contain carcinogens including heavy metals,’ says Professor Mokbel.

Professor Kefah Mokbel, a consultant breast surgeon, says he has 'no doubt' that e-cigarettes are more harmful than has been acknowledged up to now

Another concern is the flavourings added to the vape liquid (and that make them so appealing).

Some including the buttery compounds diacetyl and acetylpropionyl which – while safe for use in food – have been associated with the development of respiratory problems such as reduced lung function when inhaled.

Other common flavours – menthol, coffee, strawberry, chocolate, cinnamon, sweet tobacco, caramel and vanilla – contain compounds that in lab studies have been shown to produce inflammatory responses.

Meanwhile sweeteners including sucrose and glucose are converted by heat into compounds called reactive aldehydes, thought to be a leading cause of heart and lung disease in smokers.

While there is little research looking into their effect on the lungs of vapers specifically, laboratory studies using stem cells and mice suggest they do have a toxic effect.

Worries extend to vapes’ design, with injuries caused by the devices exploding as a result of battery failure.

In the US, from 2015 to 2017, there were an estimated 2,035 e-cigarette explosion and burn injuries seen in hospital emergency departments.

So should you be worried about the health risks of vaping? We talked to leading experts to find out what it really does to your body.

Could it slow your brain?

Most people use vapes containing nicotine (although you can get nicotine-free versions) which activates receptors throughout the nervous system, including those in the brain that affect the release of the feel-good chemical messenger dopamine. This can occur within just seconds of the first inhalation, and over time this reaction can lead to addiction.

The amount of nicotine in every draw depends on the brand but as a general rule of thumb, manufacturers advise that ten puffs on your vape are about the same as ten puffs on a cigarette.

While nicotine was once thought to be relatively harmless healthwise, if addictive, there are now questions about this, too.

The US Surgeon General has spoken about how exposure to nicotine during adolescence appears to alter the structure and function of the developing brain.

Separately, vapers report the same cognitive problems – such as memory loss and loss of concentration – as seen in smokers, according to a 2020 study published in the journal PLOS One, which looked at data from over 886,000 adults.

But some experts are not convinced: For instance, Clive Bates, a former director of ASH, has said that the evidence that nicotine affects the human brain ‘comes only from a few rodent studies’, and that ‘the rodent brain does not offer a reliable proxy for the human brain’.

Heart doctor's warning

The nicotine in vapes can increase your heart rate in minutes – but it may also have longer-term effects.

Adults who regularly used e-cigarettes did significantly worse on exercise stress testing – where they make you walk/run on a machine while checking your heart rate and breathing etc – than people who did not use any nicotine products, according to research presented at the American Heart Association conference in 2022.

Vapers also showed signs of heart and blood vessel malfunction.

Then last year the American Heart Association published a statement on the impact of vaping, saying that long term, it had a direct effect on the cardiovascular system, resulting in ‘cardiac remodelling’ – changes to its structure and/or function in response to injury – which could in turn, lead to heart failure and heart rhythm problems.

‘Research has shown nicotine does not cause acute cardiac events [such as heart attacks] or coronary heart disease and is not carcinogenic,’ says Julie Ward, a senior cardiac nurse at the British Heart Foundation.

Vapes should not be used by those who have never smoked, and especially not by children, says Julie Ward, a senior cardiac nurse at the British Heart Foundation  (stock image)

‘But nicotine is a problem for people with heart disease. It raises the heart rate – so you should tell your GP if you have heart disease and are using nicotine replacements, such as vapes.

‘There is growing evidence to show that e-cigarettes can be a useful tool to help smokers to quit, and that, in the short term at least, they are less harmful to cardiovascular health than tobacco cigarettes.

‘But this does not mean they are risk-free. They should not be used by those who have never smoked, and especially not by children. More research is needed on the long-term impact of vaping on your heart and blood vessels.’

A study by the University of Dundee in 2019 found that vaping may be less harmful to blood vessels than smoking cigarettes, with long-term smokers who swapped to e-cigarettes experiencing significant vascular improvements within four weeks.

But Jacob George, a professor of cardiovascular medicine and therapeutics, who led the trial, said: ‘It is crucial to emphasise that e-cigarettes are not safe, just less harmful than tobacco cigarettes when it comes to vascular health. Smoking of any kind is a preventable risk factor for heart disease.’

Link to leaky gut

Perhaps more surprising is vaping’s potential effect on gut health.

New research suggests that the chemicals found in vape aerosol loosen the gut barrier and trigger inflammation.

A lab study, published in the journal iScience in 2021, found that long-term use of nicotine-free e-cigarettes led to a ‘leaky gut’, where the intestinal wall becomes more permeable, allowing microbes and other molecules to escape into the blood, resulting in chronic inflammation.

‘Such inflammation can contribute to a variety of diseases and conditions, including inflammatory bowel disease, certain cancers, furred-up arteries, type 2 diabetes and arthritis,’ says Dr Aditi Sharma, an immunologist and researcher at the University of California, San Francisco, who was involved in the study.

The researchers found that vaping attacks ‘the tight junction proteins, the guards that keep the cells of the gut tight and in place, which eventually causes a leaky gut, which allows easy passage of its constituents into the bloodstream – it is more severe form of IBS,’ she told Mail+.

Raises risk of catching Covid?

Vaping may impact the immune system. A new study, published in January this year in the American Journal of Physiology, found that vapers are susceptible to infection by SARS-CoV-2, the virus that causes Covid-19.

The researchers at the University of California, Riverside, found that vapes with propylene glycol and vegetable glycerin, which make up the base of all e-liquids, alone or along with nicotine, boosted your changes of Covid-19 infection.

However, people who used vapes containing benzoic acid had the same risk of Covid as people who didn’t vape – this is linked to the acidity of the ingredients, suggested Rattapol Phandthong, a postdoctoral researcher who led the study.

In other words, some products may increase your susceptibility to a SARS-CoV-2 infection.

Many young people are taking up vaping not because they want to quit smoking but because they see it on social media and think it is cool, some specialists say

Worryingly, inhaling e-cigarette vapour could damage neutrophils, the first-line of defence of the immune system (previous research has shown that damage caused to neutrophils by cigarette smoking can lead to long-term lung damage).

Researchers at the University of Birmingham took neutrophils from the blood of healthy people who didn’t smoke or vape and exposed them to 40 puffs of unflavoured vape, regarded as a low daily exposure.

Results showed that while the neutrophils remained alive, they couldn’t move (this was true for both nicotine and nicotine-free vapes), so they couldn’t tackle threats to the body.

The cancer fear

Vaping cartridges contain more than 500 chemicals, most of them carcinogens, according to a 2020 study published in the journal Toxics.

These chemicals included formaldehyde, acetaldehyde, benzene, toluene, ethylbenzene, and xylene.

‘Formaldehyde is known as a Class 1 carcinogen,’ says Professor Mokbel.

‘Vaping has been linked to various types of cancer, including head and neck cancers, lung cancer and female breast cancer, as well as blood, prostate, and bladder cancers,’ he adds.

Some animal and lab studies on cells suggest that vaping may produce the kinds of DNA damage, inflammation and other biological alarm bells that are known to precede a tumour.

In one study, published in the journal Proceedings of the National Academy of Sciences, mice were exposed to vaping aerosol for 54 weeks, and were found to be more likely to develop lung and bladder cancer than their non-vaping counterparts.

The evidence on cancer and vaping, while based on lab studies, ‘is robust’, says Professor Mokbel – but he admits more research needs to be done to accurately assess the impact.

And compared with smoking, vaping is substantially less harmful, according to a 2022 review of studies, by King’s College London, which compared biomarkers in blood tests from smokers and vapers – this found that the use of vaping products led to a substantial reduction in exposure to toxins that promote cancer, lung disease and cardiovascular disease.

Hazel Cheeseman adds: ‘According to the King’s College London review, there is little evidence to suggest that vaping leads to cancer but that doesn’t mean that there would not be other health risks over time.’

Questions over link to gum disease

Vaping can dry out your mouth because propylene glycol and nicotine, both found in e-liquids, reduce saliva production.

Additionally, propylene glycol is a humectant, meaning it draws moisture from inside the mouth and into the vapour.

Vaping also appears to affect the make up of the microbes in the mouth, which are important for dental and general health – in a six-month study published in 2022, researchers at New York University found vapers had more of the Fusobacterium and Bacteroidales species: Both are linked to gum disease.

Several markers of inflammation and immune response were also higher in smokers and e-cigarette users than in non-smokers.

However, more work is needed to better understand how e-cigarette use alters the mouth microbes and its impact on gum health and disease.

Could it give you spots and wrinkles?

Cigarette smoking has been linked to various skin conditions, including acne, rosacea, hyperpigmentation and wrinkles.

While there is less data about vaping, the nicotine in vapes is the main concern, according to Dr Justine Hextall, a consultant dermatologist with Western Sussex Hospitals NHS Trust and medical director of the Tarrant Street Clinic in Arundel.

‘Nicotine constricts blood vessels and reduces blood flow to the skin which means that less oxygen reaches the cells and essential nutrients are in shorter supply,’ she explains.

‘This all contributes to premature ageing. Nicotine also affects collagen production – which provides the structure for skin – leading to reduced skin elasticity and more visible wrinkles.’

Dr Hextall adds: ‘Some people may be allergic to additives in vape e-liquid including propylene gly-col, which can cause contact dermatitis if the it touches their skin.’

This can happen accidentally when refilling non-disposable vapes.

There is some evidence linking smoking to acne, which is essentially a chronic inflammatory condition that occurs where there are abundant sebaceous glands, including the face and back.

However, the jury is still out on whether vaping nicotine can make acne more likely.

PS: And don't forget your lungs...

There is a worrying lack of evidence for the long-term effect of inhaled nicotine – vaping simply hasn’t been around long enough for people to do the studies.

Nonetheless, Hazel Cheeseman says: ‘We know that exposure to all sorts of pollutants can damage your lungs over time so it is reasonable to think that vaping could impact the lungs if you use vapes for a long time.’

Asthma + Lung UK says: ‘People with asthma tell us it can irritate their airways.’

Rarely, vaping has been linked to lipoid pneumonia, where the alveoli (the tiny air sacs in the lungs) fill up with dead white blood cells laden with fatty material, causing inflammation and infection.

This is believed to be due to the vegetable glycerin in vapes which is often extracted from palm or coconut oil.

There may be a risk from ‘passive’ vaping, too.

A study in the journal Tobacco Regulatory Science in 2021 found that the vapour from e-cigarettes contains tiny particles of air pollution, known as PM2.5, which can get into the lungs and cause inflammation.

According to Professor Mokbel, who has just published a major review of the evidence linking air pollution such as PM2.5 to cancer, ‘it has now become clear that vaping is a very important source of small particulates, like the ones found in diesel fumes, which can penetrate deep into the lungs and enter the bloodstream.

‘When we look at air pollution and its health effect, it usually takes 20 years of observation before we can assess the risk so we just don’t know how serious this could be.’

However, some studies have shown short-term exposure to second hand vapour is not harmful.