Vaping in teenagers linked to cough, anxiety, and transition to cigarettes: what a review of 81 studies showed
Vaping in children and adolescents is linked not only to cough and respiratory irritation. A large systematic review found associations with worsening respiratory health, anxiety and depression, nicotine dependence, and subsequent initiation of regular cigarette smoking.
The researchers screened more than 14,000 scientific publications, assessed 325 papers in detail, and included 81 studies in the final analysis. The results covered eight domains—from the respiratory system and mental health to sleep, oral health, and effects of exposure during pregnancy.
The authors emphasize an important limitation: a significant portion of the data comes from observational studies. Therefore, an observed association does not necessarily mean that vaping was the direct cause of the problem.
Cough, wheezing, and bronchitis symptoms were more common
Some of the most consistent findings concerned the respiratory system.
In young people who use e-cigarettes, studies more often recorded cough, wheezing, bronchitis symptoms, and chest discomfort. Exacerbations of asthma were also reported.
This is consistent with what is known about the composition of e-cigarette aerosols. In addition to nicotine and flavorings, heavy metals, toxic carbonyl compounds, and fine particles have been found in various products.
However, the composition varies greatly between devices and e-liquids, so the presence of a specific substance in one product cannot automatically be generalized to all e-cigarettes.
Studies also found a link with mental health
The review authors found consistent associations between vaping and poorer mental health outcomes.
Among young e-cigarette users, anxiety, depressive symptoms, panic disorder, and anhedonia—a reduced ability to experience pleasure—were more frequently reported.
The authors of the publication in Nature also draw attention to data suggesting that young vapers were almost twice as likely to report suicidal thoughts, plans, or attempts.
But this result requires especially cautious interpretation.
These studies do not allow us to automatically conclude that vaping causes depression or suicidal behavior. Reverse causality is possible: adolescents with pre-existing psychological problems may be more likely to start using nicotine. In addition, social and behavioral factors can influence both phenomena.
The most alarming result: progression to regular cigarettes
The researchers paid particular attention to children and adolescents who had never smoked regular cigarettes before starting vaping.
Longitudinal studies allowed them to track what happened to these individuals later.
Estimates varied widely across studies, but e-cigarette users were approximately 2–12 times more likely to subsequently start smoking regular cigarettes compared to those who did not vape.
This range should not be interpreted as an exact risk for an individual adolescent: studies differed in participant age, vaping frequency, follow-up duration, and definition of regular smoking.
Nevertheless, the direction of the results was fairly consistent. For some young people, e-cigarettes may not replace regular smoking but precede it.
This is fundamentally different from the situation in adult smokers. For a person already dependent on cigarettes, nicotine e-cigarettes may be used as one of the tools for quitting tobacco. For an adolescent who has never used nicotine, there is no such potential benefit.
Why dependence can develop quickly
Modern e-cigarettes can deliver nicotine to the body efficiently, and some products provide nicotine levels comparable to or even higher than regular cigarettes.
The spread of nicotine salts plays a particular role. They allow the use of relatively high nicotine concentrations while producing a less harsh sensation during inhalation.
This may be especially significant for people who have never smoked and are not used to the irritating effects of tobacco smoke.
Additional appeal comes from sweet and fruity flavors, compact devices, and attractive designs.
Adolescence is considered a particularly sensitive period for the development of nicotine dependence. Symptoms—such as craving for nicotine and discomfort when it is absent—can appear even in those who do not use e-cigarettes daily.
Review also identified less obvious signals
The studies pointed not only to respiratory and mental health problems.
E-cigarette users were more likely to report gum inflammation, dry mouth, and ulcers. Some studies also found itching, redness and dryness of the eyes, blurred vision, allergic rhinitis, and atopic dermatitis.
There are also preliminary data on a possible link with sleep disturbances.
A separate part of the review addressed exposure to e-cigarettes during pregnancy. Studies reported higher frequencies of certain adverse outcomes in infants, but the evidence base in this area is currently much smaller than for respiratory symptoms and subsequent smoking.
Therefore, the authors consider these results more as signals requiring further investigation rather than as definitively proven causal effects.
What can really be said about the risk
The systematic review did not show that every adolescent who uses e-cigarettes will necessarily experience the listed problems.
Nor does it prove direct causality for all identified conditions.
But the scope of the data changes the perception of vaping as a problem confined only to the lungs.
The most consistent associations today are observed with cough, wheezing and bronchitic symptoms, worsening mental health outcomes, and subsequent initiation of regular smoking.
Long-term consequences remain less studied: e-cigarettes have become widespread relatively recently, so scientists have yet to determine what happens after many years of regular use.
This is exactly what makes the situation of adolescents fundamentally different from the use of e-cigarettes by adult smokers for quitting tobacco. It is not about replacing an existing harmful habit, but about starting nicotine use at an age when dependence can develop especially quickly.
Based on materials from: Nature, Archives of Disease in Childhood, Royal College of Paediatrics and Child Health.
