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A systematic review of the effects of e-cigarette use on lung

function
Lucy Honeycutt1, Katherine Huerne1,2, Alanna Miller1, Erica Wennberg1, Kristian B. Filion1,3, Roland Grad1,4, Andrea S. Gershon5,
Carolyn Ells 1,2,4, Genevieve Gore6, Andrea Benedetti3,7, Brett Thombs1,3,8 and Mark J. Eisenberg 1,3,9 ✉

Given the increasing use of e-cigarettes and uncertainty surrounding their safety, we conducted a systematic review to determine
the effects of e-cigarettes on measures of lung function. We systematically searched EMBASE, MEDLINE, and PsycINFO databases via
Ovid, the Cochrane CENTRAL database, and the Web of Science Core from 2004 until July 2021, identifying 8856 potentially eligible
studies. A total of eight studies (seven studying immediate effects and one long-term effects, 273 total participants) were included.
The risk of bias was assessed using the Risk of Bias in Non-randomized Studies—of Interventions (ROBINS-I) and Cochrane risk of
bias tools. These studies suggest that vaping increases airway resistance but does not appear to impact forced expiratory volume in
one second (FEV1), forced vital capacity (FVC), or FEV1/FVC ratio. However, given the limited size and follow-up duration of these
studies, larger, long-term studies are required to further determine the effects of e-cigarettes on lung function.
npj Primary Care Respiratory Medicine (2022)32:45 ; https://doi.org/10.1038/s41533-022-00311-w
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INTRODUCTION the PROSPERO register of systematic reviews (CRD42021227121)10.

The first electronic cigarette (e-cigarette) was patented and This systematic review is reported following the Preferred Reporting
marketed in 20041. Since then, e-cigarette use (or “vaping”) has Items for Systematic Reviews and Meta-Analyses (PRISMA)
grown exponentially across the globe2. As the use of vaping guidelines11.
devices evolves with policy, the consequences of vaping on health
are becoming an increasingly important public health issue.
Search strategy and study selection
E-cigarettes are being studied for harm reduction in individuals
who use cigarettes and as a smoking cessation aid, as they are Using a search strategy (Supplementary Tables 1–5) developed by
believed to be less harmful to health than smoking3. However, an experienced health sciences librarian (G.G.), we systematically
there is increasing evidence demonstrating adverse respiratory searched EMBASE, MEDLINE, and PsycINFO databases via Ovid, the
effects of vaping compared to vaping abstinence. In particular, an Cochrane CENTRAL database, and the Web of Science Core from
outbreak of E-Cigarette and Vaping-Associated Lung Illness (EVALI) 2004 (the year of the first e-cigarette patent) until July 12, 2021. We
brought the short-term respiratory consequences of vaping into additionally conducted a gray literature search by searching the
question, especially if cannabis or THC-containing products are websites of key governmental and public health organizations (the
used4. Other short-term respiratory changes that have been linked World Health Organization, Health Canada, the US Centers for
to vaping include increased airway resistance5, breathing diffi- Disease Control and Prevention, the US Food and Drug Adminis-
culty6, and transient lung inflammation7. Vaping has also been tration, the Canadian Center on Substance Use and Addiction, the
associated with chronic respiratory conditions such as asthma8 European Centre for Disease Prevention and Control, and the
and chronic bronchitis9. Despite these reports, the short- and European Public Health Association). Additional articles were
long-term respiratory safety of vaping is still largely unknown. identified by manually searching the reference lists of included
Several small studies have examined the effects of e-cigarettes on publications as well as SCOPUS and Google Scholar (first ten pages).
lung function, including measures such as forced expiratory Articles were included if they reported quantitative primary data on
volume in one second (FEV1), forced vital capacity (FVC), and changes in lung function associated with vaping, defined as the use
airway resistance. However, no evidence syntheses have been of any device that functions by transforming an e-liquid to an
completed on this topic. Therefore, we conducted a systematic aerosol using metal coils, among human participants of any age.
review to determine the effects of vaping on measures of lung Studies of cells and those conducted in animals were excluded.
function. Studies using heat-not-burn devices were also excluded, as these do
not meet the above definition of vaping. Eligible studies included
randomized controlled trials (RCTs), non-randomized studies of
METHODS interventions (NRSIs), and cohort studies; cross-sectional studies and
Our systematic review was conducted following a protocol case reports were excluded. We included studies that used non-
developed prior to initiating the review, which was registered on users of both vaping devices and conventional cigarettes as a

1
Lady Davis Institute for Medical Research, Jewish General Hospital/McGill University, Montreal, QC, Canada. 2Biomedical Ethics Unit, Departments of Medicine and Social Studies
of Medicine, and Division of Experimental Medicine, McGill University, Montreal, QC, Canada. 3Departments of Medicine and of Epidemiology, Biostatistics and Occupational
Health, McGill University, Montreal, QC, Canada. 4Department of Family Medicine, McGill University, Montreal, QC, Canada. 5Division of Respirology, Department of Medicine,
Sunnybrook Health Sciences Centre and the University of Toronto, Toronto, ON, Canada. 6Schulich Library of Physical Sciences, Life Sciences, and Engineering, McGill
University, Montreal, QC, Canada. 7Respiratory Epidemiology and Clinical Research Unit, Centre for Outcomes Research and Evaluation, Research Institute of the McGill University
Health Centre, Montreal, QC, Canada. 8Departments of Psychiatry, Psychology, and Biomedical Ethics Unit, McGill University, Montreal, QC, Canada. 9Division of Cardiology, Jewish
General Hospital/McGill University, Montreal, QC, Canada. ✉email: mark.eisenberg@mcgill.ca

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comparison group and those that used a pre- and post-design in early signs of respiratory disease. Secondary outcomes included:
which individuals acted as their own controls. Inclusion was not findings on lung function; Computed tomography (CT) findings of
restricted by language or country of publication. Abstracts and emphysema, airway remodeling, and small airway loss; respiratory-
conference proceedings were included if sufficient data could be related quality of life and exercise limitations; incidence and/or
extracted from these publications. prevalence of respiratory disease as well as exacerbations of
Search results were downloaded from databases into reference previous respiratory disease; and health care resource use including
management software (EndNote X9) or manually added (e.g., for gray respiratory disease-related ambulatory care, emergency depart-
literature results). Duplicates were removed in EndNote and entries ment visits, and hospitalization. Given the limited number of studies
were uploaded to Covidence (Veritas Health Innovation, Melbourne, available and the heterogeneity of the data extracted from these
Australia), a systematic review software. Two reviewers (L.H. and K.H.) studies, no meta-analysis was conducted.
independently screened the titles and abstracts of all identified
publications for eligibility. Citations considered potentially eligible by
either reviewer, based on the pre-specified review inclusion/exclusion Risk of bias
criteria (Supplementary Table 6), were retrieved for full-text screening The risk of bias in included publications was assessed indepen-
and assessed for inclusion. The reasons for exclusion after full-text dently by two reviewers (L.H. and K.H.), and discrepancies were
review were annotated in Covidence and any disagreements were resolved by consensus or, if necessary, by a third reviewer (A.H-L.).
resolved by consensus or a third reviewer (A.H-L.). The risk of bias of included non-randomized studies (pre-post
studies, NRSI with non-vaping reference group, cohort study) was
Data extraction assessed using the Risk of Bias in Non-randomized Studies—of
Two independent reviewers (L.H and K.H.) extracted methodological, Interventions (ROBINS-I) tool12. The ROBINS-I tool evaluates
demographic, and outcome data from included studies in duplicate; intervention-specific outcomes for a study through seven domains
disagreements were detected in Covidence and were resolved by which assess the risk of bias pre-intervention, at-intervention, and
consensus or, if necessary, by a third reviewer (A.H-L.). Extracted data post-intervention. For each outcome of interest extracted from an
included study characteristics (first author, journal, year of publica- included study, the risk of bias within each domain was reported as
“low”, “moderate”, “serious”, or “critical”. Included RCTs were
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tion, years(s) of data collection, funding, data source, study design,

recruitment strategy, duration of follow-up, country of origin, sample assessed using the Cochrane Collaboration’s Tool for Assessing
size); population characteristics (sex, gender, age, race, ethnicity, Risk of Bias (ROB V1)13. Similar to ROBINS-I, this tool evaluates the
socioeconomic status, dose/frequency of e-cigarette use, conven- risk of bias through the assessment of five domains; for each
tional cigarette smoking status, smoked cannabis use); and vaping outcome of interest extracted from an included study, the risk of
behavior, including the type of vaping device used (e.g., disposable bias for each domain was reported as “low risk of bias”, “high risk of
e-cigarette vs. pod device such as JUUL), vaping products used (e.g., bias”, or “unclear risk of bias.” All eligible publications were included
nicotine cartridges exclusively vs. THC cartridges exclusively vs. dual in the qualitative synthesis regardless of their assessed risk of bias.
use of nicotine and THC products), and source of the vaping product
(informal [i.e., friends, family members, or dealers] vs. commercial
[i.e., vape shops, stores, dispensaries]). Reporting summary
Initially, extracted outcomes of primary interest were respiratory Further information on research design is available in the Nature
signs and symptoms, as these are important to patients and are the Research Reporting Summary linked to this article.

Fig. 1 PRISMA flow diagram of included studies assessing the effect of e-cigarettes on lung function.

npj Primary Care Respiratory Medicine (2022) 45 Published in partnership with Primary Care Respiratory Society UK
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Table 1. Characteristics of studies examining the effects of e-cigarettes on lung function.

Study Location Design Intervention/Exposure Comparator Sample size Participant population Outcomes of interest
and timing

Short-term studies
Palamidas 2017 Greece NRSI (pre-post) 10 min vaping with EC Smokers: none 76 55 smokers: 16 COPD: 12/16 male, 61 ± 9 FEV1, FVC, FEV1/FVC,
Non-smokers: years; 11 asthma: 4/11 male, 37 ± 10 years; airway resistance, specific
11 mg or 0 mg 28 no respiratory history: 16/28 male, airway conductance,
nicotine 41 ± 10 years oxygen saturation
21 healthy nonsmokers: 9 in 11 mg group:
5/9 male,35 ± 13 years; 12 in 0 mg group:
7/12 male, 34 ± 10 years
Palamidas 2013 Greece NRSI (pre-post) 10 min vaping with EC Smokers: none 70 Group A (nicotine e-cig): nine never- airway resistance, specific
Non-smokers: smokers and 51 smokers (24 with no overt airway conductance
11 mg or 0 mg airway disease, 11 asthma, 16 COPD)
nicotine Group B (nicotine-free e-cig): 10 never-
smokers
Coppeta 2018 Italy NRSI (pre-post) EC and CC, 15-min sessions on EC or CC 30 30 nonsmokers: 17/30 male, FEF25-75, FEV1, FEV1/FVC
different days (15 puffs EC) 32.6 ± 2.75 years
Kizhakke USA (CA) NRSI (non- EC, unspecified duration (only in non-vapers 16 9 vapers: 6/9 male, 21 ± 2 years FEV1, FEV1/FVC, FVC,
Puliyakote 2021 vaping baseline vapers) or vapers Seven nonsmokers: 4/7 male, 23 ± 5 years oxygen saturation
reference group)
Ferrari 2015 Italy RCT CC and nicotine-free EC ad EC or CC 20 Ten smokers: 4/10 male, 42.3 ± 12.6 years FEF25, FEF50, FEF75, FEV1,
libitum for 5 minutes in two Ten nonsmokers: 7/10 male, FEV1/FVC, FVC
different sessions 36.2 ± 12.3 years
Boulay 2017 Canada RCT Three inhalations of EC per none 30 30 subjects, all nonsmokers: 20 healthy FEV1, FEV1/FVC, FVC,
minute for 1 h; 2 × 1-h sessions (age 20–37 years); ten asthmatic (age oxygen saturation
1 week apart 21–40 years)
Staudt 2018 USA (NY) RCT Two sessions 30 min apart, ten nicotine or 10 Nicotine group, seven nonsmokers: 4/7 FEV1, FEV1/FVC, FVC,
puffs EC non-nicotine male, 40.4 ± 11.2 years oxygen saturation
Non-nicotine group, three nonsmokers: 1/
3 male, 39.7 ± 6.7 years
Long-term studies
Polosa 2017 Italy NRSI 3.5 year follow-up of none 21 9 vapers: 6/9 male, 26.6 ± 6.0 years FEF25, FEF25-75, FEV1, FEV1/
(cohort study) nonsmokers and vapers at 12 12 nonsmokers: 8/12 male, 27.8 ± 5.2 years FVC, FVC
(±1), 24 (±2), and 42 (±2) months
after baseline visits

CC conventional cigarette, COPD chronic obstructive pulmonary disease, EC electronic cigarette, FEF25 forced expiratory flow 25%, FEF50 forced expiratory flow
50%, FEF75 forced expiratory flow 75%, FEF25-75 maximum mid-expiratory flow, FEV1 forced expiratory volume in one second, NRSI non-randomized study of
intervention, RCT randomized controlled trial.

Table 2. Quality assessment of randomized controlled trials examining the effects of e-cigarettes on lung function, as defined by the Cochrane
Collaboration Risk of Bias tool (version 1).

Random Allocation Blinding of Blinding of Incomplete Selective Other bias

sequence concealment participants and outcome outcome data reporting
generation personnel assessment

Ferrari 2015 Unclear Unclear Low Low Unclear Low High

Boulay 2017 Unclear Unclear Low Unclear Low Unclear Unclear
Staudt 2018 Unclear Unclear Low Unclear Low Low Low

Table 3. Quality assessment of non-randomized studies of interventions examining the effects of e-cigarettes on lung function, as defined by the
ROBINS-I tool.

Bias due to Bias in the Bias in the Bias due to Bias due to Bias in the Bias in the Overall
confounding selection of classification of deviations from the missing data measurement selection of the
participants for interventions intended of outcomes reported result
the study intervention

Palamidas 2013 Moderate Moderate Low Low No No Moderate Moderate

Information Information
Palamidas 2017 Moderate Low Low Low Low No Low Moderate
Information
Polosa 2017 Serious Low Low Low Moderate Low Moderate Serious
Coppeta 2018 Low Low Low Low No Moderate Low Moderate
Information
Kizhakke Moderate Low Moderate Low Low Moderate Low Moderate
Puliyakote 2021

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Table 4. Results on measures of lung function before and after the use of an e-cigarette (or conventional cigarette, where specified). Results are shown as mean ± standard deviation.

SpO2 (T0)% SpO2 (T1)% FEV1 T0 %pred or L or FEV1 T1 % FEV1 T2 FEV1/FVC (T0) %obs or L or FEV1/FVC FEV1/ Airway Airway Airway Airway
effect size [95% CI] pred or L or %pred effect size [95% CI] (T1) %obs FVC (T2) Resistance Resistance Conductance Conductance
effect size or L or or L or %obs or (T0) kPa L−1 (T1) kPa L−1 (T0) sec−1 (T1) sec−1
[95% CI] effect effect size L or sec−1 sec−1 kPa−1 kPa−1
size [95% CI] effect
[95% CI] size
[95% CI]

Palamidas 2013
Smokers n = 51 - - - - - - - - 0.284 ± 0.13a 0.308 ± 0.14a 1.197 ± 0.50a 1.060 ± 0.42a
Nonsmokers - - - - - - - - 0.246 ± 0.07a 0.292 ± 0.05a 1.313 ± 0.22a 1.109 ± 0.18a
(11 mg§) n = 9
Nonsmokers (0 - - - - - - - - 0.247 ± 0.03a 0.333 ± 0.08a 1.213 ± 0.29a 0.944 ± 0.18a
mg§) n = 10
Ferrari 2015

npj Primary Care Respiratory Medicine (2022) 45

Smokers n = 10 - - −1 [−6.1 to 4.1] - - 2 [−2.0 to 6.1] - - - - - -
vs Nonsmokers
CC n = 10
Smokers n = 10 - - −2.1 [−5.7 to 1.6] - - −0.1 [−9.8 to 3.0] - - - - - -
vs Nonsmokers
EC n = 10
Palamidas 2017 %pred %pred
COPD Smokers 96.4 ± 1.9a 95.8 ± 1.8a 69 ± 18 - - 59 ± 10 - - 0.43 ± 0.18 0.47 ± 0.17 0.54 ± 0.19 0.52 ± 0.19
n = 16
L Honeycutt et al.

Asthma 97.2 ± 1.5 96.6 ± 1.4 93 ± 14 - - 79 ± 11 - - 0.38 ± 0.13a 0.40 ± 0.11a 0.84 ± 0.31 0.80 ± 0.33
Smokers n = 11
Healthy 98.2 ± 1.0a 97.1 ± 1.5a 102 ± 15 - - 81 ± 6 - - 0.29 ± 0.12a 0.31 ± 0.13a 1.16 ± 0.47a 1.03 ± 0.40a
Smokers n = 28
Nonsmokers 97.4 ± 2.1 97 ± 0.7 114 ± 16 - - 82 ± 2 - - 0.25 ± 0.07a 0.29 ± 0.06a 1.31 ± 0.22a 1.11 ± 0.18a
(11 mg§) n = 9
Nonsmokers (0 98.4 ± 0.9 98.4 ± 0.5 104 ± 10 - - 86 ± 4 - - 0.24 ± 0.04a 0.32 ± 0.08a 1.20 ± 0.27a 0.95 ± 0.18a
mg§) n = 12
Boulay 2017 L L L L
Healthy 97 ± 3 98 ± 1 3.9 ± 0.7 3.9 ± 0.7 - 0.80 ± 0.05 0.81 ± 0.05 - - - - -
Nonsmokers
n = 20
Asthma 98 ± 1 98 ± 1 3.4 ± 0.4 3.4 ± 0.4 - 0.78 ± 0.08 0.79 ± 0.08 - - - - -
Nonsmokers
n = 10
Coppeta 2018 L L L L L L
Nonsmokers - - 3.53a,b 3.48a 3.51b 82.2a,b 81.7a 81b - - - -
(CC) n = 30*
Nonsmokers - - 3.55a 3.51a 3.53 82.1a 81.6a 81.5 - - - -
(EC) n = 30*
Staudt 2018 %pred %pred %obs %obs
Nonsmokers 99 ± 1 99 ± 1 112 ± 15 113 ± 11 - 81 ± 3 83 ± 3 - - - - -
Nicotine n = 7
Nonsmokers 99 ± 2 98 ± 1 103 ± 9 91 ± 8 - 81 ± 4 76 ± 4 - - - - -
Non-Nicotine
n=3
Nonsmokers 99 ± 1 99 ± 1 110 ± 14 107 ± 15 - 81 ± 33 81 ± 4 - - - - -
Total Cohort

Published in partnership with Primary Care Respiratory Society UK

n = 10
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RESULTS

% obs % observed, % pred % predicted, CC conventional cigarette, CI confidence interval, COPD chronic obstructive pulmonary disease, EC e-cigarette, FEV1 forced expiratory volume in one second, FEV1/FVC ratio
Conductance
(T1) sec−1 As our search did not identify studies which focused on the broad
outcomes detailed above, we chose to limit our focus to studies
Airway

of FEV1 to forced vital capacity, L liters, SpO2 oxygen saturation, T0 baseline (all studies), T1 1 min (Coppeta), 10 min (Palamidas, both studies), 60 min (Boulay), 120 min (Staudt), T2 15 min (Coppeta).
-

-
kPa−1
on lung function. Our database searches identified 14,307
potentially eligible studies (Fig. 1). After duplicates were removed,
8856 titles and abstracts were assessed. After this initial screening,
Conductance

44 full texts were retrieved and reviewed in further detail, yielding

(T0) sec−1

eight studies eligible for inclusion.

Airway

-
kPa−1

Study and participant characteristics

(T1) kPa L−1

Of the eight included studies (273 total participants), seven14–20

Resistance

involved short-term exposure to e-cigarettes with immediate

Airway

-
sec−1

outcome assessment, and the remaining study followed vapers

and non-vapers over 3.5 years21 (Table 1). This prospective cohort
study examined 21 participants (12 nonsmokers and nine vapers)
(T0) kPa L−1

at means of 12 (standard deviation: 1), 24 (2), and 42 (2) months

Resistance

after baseline21. Of the seven short-term studies, four were NRSIs

Airway

-
sec−1

(three pre-post studies14–16 and one NRSI with a non-vaping

reference group20) and three were RCTs17–19. Among these seven
studies, two included 70–80 participants14,15 and five included
FVC (T2)

[95% CI]
%obs or

10–30 participants16–20. Exposures varied in terms of e-cigarettes,

effect
FEV1/

L or

size

e-liquids, and vaping session timings. Most studies did not expand
-

on their definition of “non-smoker/non-vaper”15,16,18–21, but two

(T1) %obs

effect size

studies clarified that these participants were never-smokers14,17.

FEV1 T2 FEV1/FVC (T0) %obs or L or FEV1/FVC

[95% CI]
or L or

One of these two studies further elaborated that participants had

-

no exposure to tobacco products or e-cigarettes17. Few studies

gave detailed information on the type of e-cigarette used. Three
L0.80 ± 0.03c%pred95 ± 3c

L0.86 ± 0.04c%pred102±5c

studies reported a specific brand or product (Blu17, eGo16, Joytech

elips-C series18, Puff bar20). Polosa et al. listed some of the various
e-cigarettes used by participants throughout the longitudinal
effect size [95% CI]

study, including standard refillable (eGo style products) and more

advanced refillable (Provari, Innokin, Joytech, eVIC, Avatar Puff)21.
The remaining studies did not report a specific brand, though one
study described the e-cigarette used as a “1st generation
e-cigarette popular in Greece”15. All studies clarified whether the
e-cigarettes used during the study contained nicotine.
[95% CI]
or L or
%pred

effect

Risk of bias
size

The included RCTs (n = 3)17–19 had an unclear risk of bias, with

-

-
pred or L or

each study demonstrating an unclear risk of bias in 3+ domains

FEV1 T1 %

effect size
[95% CI]

(Table 2). This was primarily due to missing information in the

-

manuscripts required to make an adequate judgment, such as a

lack of detail surrounding randomization. The risk associated with
the blinding of participants and personnel was judged to be low
L3.5 ± 0.4c%pred97±8

L4.3 ± 0.9c%pred99±8
SpO2 (T0)% SpO2 (T1)% FEV1 T0 %pred or L or

for all 3 included RCTs. These studies were not blinded, and one
effect size [95% CI]

was placebo-controlled. However, it was judged that this lack of

blinding would not influence measures of lung function. Of the
included non-randomized studies (n = 5)14–16,20,21, four14–16,20
were judged to be at moderate risk of bias and one21 was found
Significant difference between groups at baseline.

to have a serious risk of bias (Table 3). The most consistent source
of bias in these studies was bias due to confounding, with only
one16 study judged to have a low risk of bias due to confounding.
Significant difference between T0 and T2.
Significant difference between T0 and T1.

Of the remaining four studies, three14,15,20 were found to have a

99 ± 1

moderate risk of bias due to confounding and one21 was found to

-

be at serious risk of bias due to confounding, with important

confounding variables not accounted for in the design or analysis.
98 ± 2

98 ± 1
Kizhakke Puliyakote 2021

Nicotine concentration.

Effects of E-cigarette use on lung function

Table 4 continued

Seven studies14–20 reported immediate measures of lung function

after short-term exposure to e-cigarettes (Table 4), including FEV1,
FVC, and FEV1/FVC. Two studies, Boulay et al. and Staudt. et al.
Vapers n = 9
Nonsmokers

suggested no changes in FEV1 or FEV1/FVC after vaping among

nonsmokers17,19. Kizhakke Puliyakote et al. observed lower base-
n=7

line FEV1 and FEV1/FVC values among nonsmokers compared to

vapers20. Coppeta et al. found a decrease in FEV1 and FEV1/FVC
b

§
a

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Table 5. Prospective cohort study (Polosa 2017) on the effect of e-cigarette use on lung function over time. Results are presented as mean ±
standard deviation.

Baseline 12 ± 1 months 24 ± 2 months 48 ± 2 months

FEV1 (L)
NonSmokers (n = 12) 4.08 ± 0.30 4.06 ± 0.2 4.03 ± 0.26 3.78 ± 0.71
Vapers (n = 9) 3.82 ± 0.78 3.81 ± 0.78 4.11 ± 0.30 3.87 ± 0.76
FVC (L)
NonSmokers (n = 12) 5.03 ± 0.48 4.97 ± 0.42 5.01 ± 0.45 5.02 ± 0.42
Vapers (n = 9) 4.93 ± 0.95 4.80 ± 0.82 4.82 ± 0.91 4.87 ± 0.83
FEV1/FVC (%)
NonSmokers (n = 12) 81.45 ± 5.03 82.02 ± 4.67 80.86 ± 6.18 82.06 ± 4.25
Vapers (n = 9) 78.49 ± 3.46 79.01 ± 3.63 78.46 ± 2.34 79.08 ± 2.83
FEF25-75 (L)
NonSmokers (n = 12) 3.43 ± 0.64 3.49 ± 0.61 3.53 ± 0.57 3.56 ± 0.58
Vapers (n = 9) 3.29 ± 0.70 3.29 ± 0.60 3.30 ± 0.75 3.33 ± 0.64
FEF25-7 maximum mid-expiratory flow, FEV1 forced expiratory volume in 1 s, FVC forced vital capacity, L liters.

among nonsmokers after 1 min of vaping; however, these values separately based on conventional smoking status. Other studies
returned to baseline after 15 min16. used a “sham” vaping session for controls where either an
Airway resistance and specific airway conductance after 10 min e-cigarette with an empty cartridge (i.e., without e-liquid) or
of vaping were measured in two14,15 of the seven short-term second-hand smoke were used. More commonly, studies were
studies (Table 4). Both Palamidas et al. 2013 and 2017 suggested conducted on smokers only, without nonsmokers as a compar-
that vaping increased airway resistance and decreased specific ison group. Future studies could analyze subgroups based on
airway conductance among nonsmokers and smokers with and both smoking and vaping status to allow for a more detailed
without respiratory disease. Oxygen saturation was assessed in quantitative analysis.
four studies15,17,19,20. Three studies suggested no changes after E-cigarettes are becoming more popular for recreational use
vaping, with only Palamidas et. al. 2017 suggesting decreased
and are being studied for harm reduction among smokers as a
oxygen saturation following vaping among smokers with and
smoking cessation aid, as they are believed to be less harmful to
without asthma15.
Long-term changes (3.5 years) in lung function measurements health than smoking. However, there are limited data available
were assessed in only one small (n = 21) study (Polosa 2017)21. and virtually no long-term studies assessing how prolonged
This study suggested that FEV1, FVC, FEV1/FVC, and forced mid- e-cigarette use could impact lung function. As the use of vaping
expiratory flow (FEF25-75) did not change over time among vapers devices evolves and becomes more widespread, the health
and non-vapers (Table 5). consequences of vaping are becoming an increasingly important
public health issue. This is a knowledge gap that must be
addressed. Knowledge of the safety of e-cigarettes, particularly
DISCUSSION their long-term safety, will inform public health policy and
This systematic review was designed to determine the effect of e-cigarette regulations, as well as the guidance clinicians, offer to
vaping on measures of lung function. We found that there were their patients on smoking harm reduction. For these policies,
only eight studies in the literature assessing this issue, all of which regulations, and guidelines to be developed, we must under-
were small, and only one examined longer-term outcomes (3.5 stand how e-cigarettes can influence one’s health. This includes
years follow-up). In general, these studies suggest that there are establishing the effects of e-cigarettes on clinical outcomes such
no acute changes associated with vaping. However, airway as respiratory symptoms (cough, dyspnea), measures of lung
resistance and conductance may be influenced by e-cigarettes, function, and risk of developing respiratory disease. Further
with two studies reporting changes in these values in multiple research is required to elucidate the short- and long-term
population subgroups. It is important to note that there were few
consequences of vaping to determine whether e-cigarettes are
studies available for this systematic review and that most of these
studies focused on the acute effects of vaping; therefore, these truly a “safer” alternative to traditional cigarettes for smoking
results are suggestive but not definitive, and future research must cessation or for recreational use. Future studies should be long-
be conducted in this area. Furthermore, three of the included term, have large sample sizes, and may include different types of
studies had an unclear risk of bias, four had a moderate risk of e-cigarettes as well as conventional cigarettes for comparison. In
bias, and one had a serious risk of bias, which further limits the addition, it is important for future research to include clinical
interpretation of this review’s findings. outcomes as described above. This will allow for better
In addition to the limitations above, this review lacks translation of the research findings to help inform clinical
subgroup analyses or a meta-analysis. This is due to the decision-making.
heterogeneity of the included studies, both in terms of study
design and outcomes. Few studies were eligible for this review
due to the variation in study designs and definitions of DATA AVAILABILITY
e-cigarettes and smoking status. For example, some studies No additional data were available, as this study is a knowledge synthesis that relied
included both conventional cigarette smokers and nonsmokers on aggregate, published results available in the public domain. Any inquiries should
in their definition of “non-vapers” and did not analyze data be directed to the corresponding author.

npj Primary Care Respiratory Medicine (2022) 45 Published in partnership with Primary Care Respiratory Society UK
 L Honeycutt et al.
7
Received: 9 May 2022; Accepted: 6 October 2022; ACKNOWLEDGEMENTS
The authors would like to thank Jenna Glidden and Andrea Hebert-Losier for their
assistance with study screening, data abstraction, and risk of bias assessment. The
authors would also like to thank Francesca Frati, who peer-reviewed the search
strategy. This work was funded by the Canadian Institutes for Health Research (#HEV-
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