Vaping, often presented as a harmless, modern alternative to traditional cigarettes, is increasingly under the spotlight as emerging research reveals a darker side. This guide aims to demystify the reality of vaping, focusing particularly on the potential link between vaping and lung disease. Drawing from the insightful letters written by Dr Ricardo Jose to The Lancet and BMJ, this article delves into the potential risks associated with vaping, the possible complications that could arise in the lungs, and the role of vaping in smoking cessation.

What is Vaping?

Vaping is a practice that involves inhaling and exhaling an aerosol, often mistaken for harmless water vapour, generated by an electronic device known as an e-cigarette. Resembling a USB stick, pen, or even a traditional cigarette, these gadgets heat up a liquid – typically composed of nicotine, flavourings, and various chemicals – transforming it into an inhalable mist. Originally, they were introduced as a ‘safer’ alternative to traditional smoking. However, increasingly, evidence points towards what could be an alarming correlation between vaping and various lung diseases.

What is Found in Vaping Products?

Vaping products, on the surface, contain a straightforward mixture of nicotine, flavourings, and substances like propylene glycol or vegetable glycerine. However, this doesn’t capture the full picture.

E-cigarettes and vaping products in the UK are regulated primarily by the Tobacco and Related Products Regulations 2016 (TRPR), which is enforced by the Medicines and Healthcare products Regulatory Agency (MHRA). This regulation was introduced to ensure minimum standards for the safety and quality of all e-cigarettes and refill containers (otherwise known as e-liquids).

Key elements of the regulations include:

  1. Size Limits: E-liquids cannot be sold in quantities greater than 10ml. Also, e-cigarettes and disposable cartridges cannot have a capacity greater than 2ml.
  2. Nicotine Strength: The nicotine strength of e-liquids cannot exceed 20mg/ml.
  3. Product Approval: All e-cigarette and e-liquids must be notified to the MHRA before they can be sold. Retailers must check that their products have been notified where necessary.
  4. Ingredient Restrictions: Certain ingredients are banned, including colourings, caffeine, and taurine.
  5. Labelling and Packaging: Products must be child-resistant and tamper-evident. They must include a new health warning on the packaging: “This product contains nicotine which is a highly addictive substance.” The warning must cover 30% of the surface area of the box and must be included on at least two sides.
  6. Promotion and Advertising: There are restrictions on promoting and advertising e-cigarettes, especially where the marketing is targeted at under-18s or non-smokers.
  7. Leaflet: E-cigarettes must come with an information leaflet about safe use.

Furthermore, the flavourings used in e-cigarettes are a cause for concern. While they may be approved for oral consumption, the safety of inhaling them into the lungs is less clear. When heated and inhaled, these flavourings may contribute to lung damage, thereby enhancing the risk of vaping lung disease. Diacetyl, which is harmful to the lungs, although banned in the UK has been found in low concetrations in e-cigarette liquid. Furthermore, high levels of nickel and lead have been found in these liquids.

Is Vaping Harmful?

Despite the widespread belief that vaping is a entirely harmless activity, the reality could not be more different. Dr Ricardo Jose, has outlined in his letters to The Lancet and BMJ, that e-cigarettes can introduce several potentially toxic substances into the lungs. These toxins can potentially pave the way for an array of lung diseases and complications, debunking the myth of vaping as a ‘clean’ substitute for smoking.

What are the Lung Complications Seen with Vaping?

The number of vaping-related lung complications appears to be on the rise, particularly among younger demographics. Conditions that were once mostly seen in older, traditional smokers, such as Acute Respiratory Distress Syndrome (ARDS) and acute lung injury, are now increasingly reported among young vapers.

Chronic conditions such as chronic obstructive pulmonary disease (COPD) and emphysema, both of which involve long-term breathing problems and poor airflow, also appear to be linked with vaping. There’s also an alarming association with a condition known as ‘popcorn lung’ or bronchiolitis obliterans. This irreversible disease damages the tiny airways in the lungs, causing persistent coughing, wheezing, and difficulty breathing.

Is Vaping Helpful for Smoking Cessation?

The role of vaping in smoking cessation is a complex issue. The World Health Organisation (WHO) maintains a cautious stance on the matter, recognising that while some smokers have successfully used e-cigarettes to quit, there is not enough evidence to endorse vaping as a universally effective smoking cessation aid.

Likewise, the British Thoracic Society (BTS) states that while e-cigarettes are undoubtedly less harmful than smoking, they should not be considered completely safe. They propose that e-cigarettes should only be used for smoking cessation if other options have failed and if there’s a clear intent to stop smoking altogether. In other words, they are not to be seen as a first-line option for quitting smoking. It is important to note that traditional smoking cessation methods with nictoine replacement therapy, varenicline, bupropion, and cognitive behavioural therapy, have good success rates.

The Problem of Dual Smoking and Vaping

Dual use, a pattern where smokers use both traditional cigarettes and e-cigarettes, is a growing issue. This practice leads to heightened nicotine intake and a double exposure to a variety of harmful chemicals. This can exacerbate lung complications and potentially increase the risk of severe lung conditions.

Vaping and Inflammation: A Pathway to Future Lung Disease?

The discussion becomes increasingly complex when we consider the possibility that vaping could cause inflammation in the lung tissues. Sustained inflammation is known to damage the delicate structures within our lungs, potentially leading to severe complications. Recent evidence suggests that the inhalation of aerosol from e-cigarettes can indeed trigger this inflammatory response, as shown in laboratory studies.

Over time, it is plausible that this inflammation may cause progressive lung damage, eventually resulting in chronic conditions such as COPD, emphysema, and ARDS. These conditions often carry debilitating symptoms and significantly impact quality of life. The concern is that such an inflammatory pathway may set the stage for these conditions in individuals who vape, even those who are young and otherwise healthy.


The narrative that presents vaping as a benign alternative to traditional smoking is coming under increasing scrutiny. As further research unfolds, it’s becoming alarmingly clear that vaping is far from risk-free. It is vital to communicate these risks and the potential for serious lung disease and complications associated with vaping, particularly to the younger generation. As Dr Ricardo Jose highlights in his letters, an unregulated industry combined with a lack of awareness could have severe implications for public health in the years to come.


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