Health Effects and Demographics of Electronic Cigarette Users. A Comparison of Health Events
in Previous Smokers With Three or more years of Electronic Cigarette Experience.
Robert L. Cranfield MD
November 24, 2015
The purpose of this study was to assess not only the demographics of e-cig users,
but to assess health effects on users with 3 or more years of experience of use.
Anonymous online surveys as well as some local paper surveys were distributed
to electronic cigarette social media sites and local electronic cigarette stores in the
Southeastern United States. There were 573 respondents in a 6 month period from March to
August 2015. Subgroups analyzed were those with 3 or more years use, previous never users of
tobacco products ,and those who had no health issues while smoking .
E-cigarette users with 3 or more years of use were found to have a 96%
reduction in reported adverse health events after initiation use, and a resolution of 61.8% of
the measured existing health problems that developed while smoking. All groups of users
reported feeling an improvement in health after starting use, including those who were
previous never smokers. Never smokers who started use of electronic cigarettes developed no
health problems. Demographics showed that vapers were more likely male and Caucasian.
Those with 3 or more years of e-cig use were older, better educated and higher wage earners
than the group of vapers as a whole.
Conclusion: Electronic cigarettes have a dramatic and positive effect on the health of those
who are able to switch from cigarettes. This can have a tremendous social and economic impact
if their use becomes wide spread as a substitute for cigarettes. There does not appear to be a
significant health impact to never smokers who initiate use, although data is limited in this
Electronic cigarettes are devices composed of a battery and a tank which stores a reservoir of
liquid usually containing Propylene Glycol (PG), vegetable Glycerine (VG), flavors and, usually,
nicotine. The battery heats a coil which vaporizes the liquid which is then inhaled as an
alternate nicotine delivery system to combustible tobacco products. Articles appear regularly
speculating on the potential for harm of these relatively new devices, and about their potential
for harm reduction when used as a substitute or diversion from smoking.
Much of the literature to date focuses on the toxins found in e-cigarette vapor and their known
consequences in long term exposure. Some of these compare the levels of toxins found in e-
cigarettes to the same toxins found in cigarettes.
Some look at how e-cigarette vapor and
smoke from tobacco affect human or animal cell cultures.
There are studies that look at
short term changes in respiratory and cardiovascular function.
But little to no information
has been done to look at what the actual health effects of e-cigarettes have been in those who
have been using them for several years. Electronic cigarettes have been available in the modern
form since 2007, although the technology is evolving rapidly. Ideally this would give us an eight
year window to look for people who have been vaping or dual using and to see how their health
has changed. The ideal way to look at this would be to do a prospective study, however there is
mounting pressure to strictly regulate these products, which could unnecessarily restrict those
who might benefit from them. The duration of a prospective study could result in additional
preventable harm. Thus a retrospective analysis has immediate value.
There are over 480,000 deaths each year in the United States attributable to smoking of which
42,000 deaths were related to second hand smoke.
Additionally, there is a cost related to
direct care of health problems related to smoking and second hand smoke. According to one
study these costs in 2014 were approximately $170 billion.
According to the Department of
Health and Human Services, in 2014, there was more than $156 billion in lost productivity due
to premature death and exposure to second hand smoke.
This would put total cost for lost
productivity and direct health care costs at a combined $326 billion dollars. If we assume a
linear relationship between the relative safety of e-cigarettes and the lost lives and costs, and
use Nutt, et al
we can predict a savings of $309 billion and 456,000 lives in the US alone.
The reason for this study was to gather some basic information on vaping health and to
measure some demographics of vapers. There are 4 goals in this study
1. To identify those people who have 3 or more years of vaping experience, and see how
their health has been affected by changing to e-cigarettes. While it might take longer
than this to see some of the potential adverse health effects, it is extremely difficult to
get many people who have been using e-cigarettes longer simply because of the limited
time they have been available.
2. To look at those smokers who had no known health effects while smoking, and see
what, if any, adverse health effects developed subsequent to starting to use e-
3. To see if those who never smoked before vaping were more likely to develop adverse
health consequences as a result of vaping.
4. To measure demographics of e-cigarette users.
The source of information was an electronic survey distributed through social media to groups
of electronic cigarette users and paper surveys distributed to local e-cigarette shops in the
Southeastern United States. Participation was voluntary and anonymous. Several members of
the social medial groups shared the survey with friends or other groups. Because of the
distribution avenue, an unknown number were completed via a national group. The majority of
returned surveys were from the on line format. Over a period of 6 months, March to August
2015, there were 573 surveys returned. The vast majority (527) were from the online format
questionnaire. The questionnaire was made up of 2 parts. The first was demographics, the
second asked about the individual’s health while smoking and then again while using electronic
The sub-groups analyzed were
1. Smokers who had reported no adverse health events while smoking (n=136).
2. E-cigarette users who had 3 or more years of usage (n=108).
3. E-cigarette users who had not been smokers prior to use of e-cigarettes (n=10)
All respondents were asked these questions regarding diagnoses of adverse health events both
while smoking and while using e-cigarettes:
‘While smoking cigarettes were you diagnosed with any of the following health conditions?’
‘Since starting to use vapor products, have you been diagnosed with any of the following health
These adverse health events were the following for both questions:
High Blood Pressure (hypertension), Diabetes, Irregular heartbeat, Palpitations, Heart
disease, Heart attack, Stroke, Cancer of any sort, asthma, emphysema, Chronic
bronchitis, acute bronchitis, peripheral vascular disease, amputations related to
circulation problems, shortness of breath, recurring respiratory infections.
A different perspective would be to look not just at any newly diagnosed adverse health
conditions either while smoking or while using e-cigarettes, but to also measure whether any of
the conditions diagnosed while smoking had resolved after taking up e-cigarettes. So
additionally respondents were asked this question:
‘If you had any of these conditions’ (the same conditions outlined above), ‘since you started
using vapor products, have any of them resolved? If so, which ones?’
Respondents were asked about their subjective feelings of health while smoking and after
switching to vaping. They were asked to rate their perception of health on a 10 point scale with
1 being poorest and 10 being the best.
There were 108 participants who had been using electronic cigarettes for 3 or more years. The
results of their reported adverse health events were reviewed and are shown in Figure 1. On
average, they had 1.78 acute or chronic adverse events while smoking. While using electronic
cigarettes, they admit to an average adverse event rate of 0.07 per individual. This represents a
96% reduction in adverse health events.
For the health problems that respondents reported developing prior to use of e-cigarettes, on
average, respondents improved on or had resolution of 1.1 events. This is a 61.8% resolution
rate of conditions that developed while smoking. The breakdown is shown in Figure 2. The
largest change was in the subjective category of breathing (shortness of breath). There were
also significant resolutions or improvements in Hypertension, recurring respiratory infections,
palpitations and Acute or Chronic bronchitis. In the one person who reported a resolution of
diabetes, which is not associated with smoking, it is possible that they had begun a healthier life
style that allowed discontinuation of their meds. This individual also reported a resolution of
Only one of 136 previous smokers, who had reported no adverse health events while smoking,
developed any adverse health problems while using electronic cigarettes that could be
potentially related to their use. In the group of previous never smokers who started use of
electronic cigarettes, none reported developing any health problems as a result of use.
Ten out of the 573 people surveyed who admitted to be non-smokers prior to vaping. This
represented only 1.7% of the total survey group. Using the CDC’s statistic that 44% of those
who start using e-cigarettes were susceptible to smoking, these 10 people represent about 6
people (~1% of the total group) who started to use these products with no susceptibility to
smoke. There were none in this group who had reported any adverse health events prior to
initiating use of e-cigarettes, and none of this group developed adverse health events after
starting to use them. This survey agrees with others who have shown that there are very few
people who start to use electronic cigarettes who were not already using combustible tobacco
The results of the subjective assessment of health before and after starting to use e-cigarettes
were consistent from the main group of respondents to both subgroups. For the general group,
they rated their health while smoking at an average of 3.93, and after they switched to vaping
they had an improvement in their subjective health to an 8.27 average. (Figures 3 & 4) There
were small variations between the subgroups, but the trend was the same. The group that
started vaping with no prior cigarette use, also perceived their health as having improved by a
similar margin, although they did have a slightly higher initial assessment of health at 4.25.
These results are consistent with others who have assessed subjective health improvement.
The demographics of smokers have been well studied
, but as yet, there is little information
on the makeup of those who have made the switch to e-cigarettes. Questions were asked
regarding race, education level, income and gender. Those who identify as white or Caucasian
make up 90.5% of respondents. Asians made up 1.6%, Blacks or African Americans made up
1.2%, and Native Americans made up 1.4%. Both Caucasians and Native Americans made up
more than their relative percentage of the population, based on the US Census Bureau
statistics. (Fig. 5)
This issue of racial disparity in vaping can be of consequences if vaping is definitively shown to
reduce the harm of combustible tobacco products as African Americans and other minorities
have a higher prevalence of hypertension and cardiovascular disease than other racial or ethnic
groups. Smoking is a major contributor to both of those diseases.
The gender distribution is shown in Figure 6. There is no surprise that males make up the
majority (63.5%) of those using electronic cigarettes, as they are also in the majority in
combustible tobacco products (56.5%)
. However the disparity between genders is greater in
use of electronic cigarettes.
The age distribution varied between the main group and the 3 subgroups measured. As
measured among all respondents, the average age of all vapers was. 36.38 years. Those who
had 3 or more years experience were 3 years older with an average age of 39.36. Those who
started vaping with no prior smoking were the youngest group by almost 6 years, with an
average age of 30.63. Figure 7 is the distribution in age of all vapers who responded. There was
a double peak. This largest group of users was in the 31-35 age group.
Education level also varied from the main group to the 3 year or more group. There was not
enough data to draw conclusions from the previous never smokers group because of the
limited number of responses. The individuals who had 3 or more years of vaping tended to be
better educated than the group in general with a higher percentage of college graduates and
masters or doctoral degrees. See figures 8 and 9.
There was also an income difference between all vapers and those vaping 3 years or more.
Figure 10 and 11
Vapers with 3 or more years of vaping experience tended to be older, have a higher level of
education, and greater annual income than the general vaping population.
The survey also queried as to the strength of nicotine used. In older tanks, in order to achieve
the needed nicotine delivery, the concentration of nicotine had to be higher. In more modern
tanks, the amount of nicotine can be reduced in the liquid to achieve the same delivery. Also,
the nicotine concentration would need to be higher in those who were heavy smokers in order
to satisfy their needs. Figure 12 represents the distribution of nicotine concentrations in the
liquids of the respondents. Approximately half of the respondents use a 3 mg concentration or
less, and approximately 80% use 6 mg or less concentration.
It’s important to know the smoking history of respondents. The type of tobacco intake was
asked and for cigarette smokers, how many packs per day (PPD) were consumed. Not
surprisingly the survey showed a majority were regular cigarette users. They accounted for
93.9% of respondents. An additional 2.5 percent were social smokers, 2 percent used other
tobacco products such as pipe, cigar and chewing tobacco. Only 1.7% had not used tobacco
products previously. Figure 13.
Now that there has been extensive use of these products over several years, we can define the
length of use of these products (Figure 14). It is of interest that 40.8% have been using for more
than 2 years, and more than 10% of users have been more than 3 year users. Based on reviews
of the growth of people using e-cigarettes, there were about 480,000 people using these
products 3 years ago. If we assume the 10% of vapers now who were using e-cigarettes 3 years