Vaping and Other Tobacco Products

Medical Disclaimer: This content is for educational purposes only and does not constitute medical advice, diagnosis, or treatment. Information is based on current medical literature and clinical guidelines but may not apply to your specific situation. Individual responses vary based on personal medical history and concurrent conditions. Always consult qualified healthcare providers for medical decisions. Never delay seeking medical care based on content you’ve read. If experiencing a medical emergency, seek immediate medical attention.

These articles provide education to enhance your healthcare partnership. All treatment decisions should involve your healthcare team. Use this knowledge to have informed discussions, not replace medical care.

In Brief

The products people use instead of cigarettes — e-cigarettes, smokeless tobacco, cigars, and hookah — differ enormously in how they affect the heart, and the honest picture is neither reassuring across the board nor uniformly alarming. The organizing principle from Article 1 applies here: most of smoking’s cardiovascular harm comes from combustion products, not from nicotine, so the key question for each product is how much combustion and toxicant exposure it involves. E-cigarettes are the most studied and most debated. They expose users to far fewer toxicants and little or no carbon monoxide compared with cigarettes, and high-certainty evidence shows they help more people quit smoking than nicotine-replacement therapy — but they are not risk-free, they have real acute cardiovascular effects from nicotine, and their long-term cardiovascular consequences are not yet known.¹,²,³ Crucially, the benefit depends on switching completely: people who continue to smoke while vaping (dual users) carry the same cardiovascular risk as people who only smoke.⁴ Smokeless tobacco, cigars, and hookah each carry cardiovascular risk that is real, product-specific, and — for hookah especially — often underestimated.⁵,⁶,⁷ The through-line is simple: “not a cigarette” does not mean “safe for the heart.” This article explains how each product compares and what the evidence does and does not establish.

“Not a Cigarette” Is Not the Same as “Safe”

The practical question behind this entire article is direct: can switching from cigarettes to another tobacco or nicotine product reduce the risk of heart disease? The honest answer is yes — but it depends entirely on which product is used, and on whether cigarettes are stopped completely rather than merely supplemented.

The previous articles covered the harm of smoking, the dependence behind it, the recovery after quitting, the medications that help, and the practical work of stopping. This article turns to the products many people use as alternatives to cigarettes — the most contested topic in the series, which deserves a calibrated, evidence-loyal treatment rather than a tribal one. Strong advocates present vaping as near-harmless and strong opponents present it as equivalent to smoking; neither position matches the evidence. The task here is to report what the data actually show for each product, including where the evidence is strong, where it is mixed, and where it is simply not yet available.

One principle organizes the whole discussion: combustion is the organizing biological principle behind cardiovascular harm from tobacco. As Article 1 established, most of smoking’s cardiovascular damage comes from the products of combustion — carbon monoxide, oxidizing chemicals, and fine particulates — while nicotine, though it drives dependence and has real cardiovascular effects of its own, is not the main cause of the vascular injury, heart attacks, and strokes that smoking produces. That distinction is the key to this entire article. The relevant question for any alternative product is: how much combustion does it involve, and how much toxicant exposure does it deliver? The answers differ dramatically across e-cigarettes, smokeless tobacco, cigars, and hookah — which is exactly why “not a cigarette” cannot be equated with “safe.”

This is where a public health concept called harm reduction applies. When complete nicotine abstinence is not immediately achievable, replacing a highly dangerous product with a substantially less dangerous one can lower health risk — not because the alternative is safe, but because different products expose users to very different levels of toxic substances. For the heart, the largest reduction comes from eliminating combustible cigarettes. Harm reduction should therefore never be confused with risk elimination.

Risk exists on a spectrum, not in two fixed categories of “safe” and “dangerous.”

This is the seventh article in the series. It follows the articles on quitting and precedes the article on cannabis and the heart. A reader trying to decide about any of these products should hold two facts together: continued cigarette smoking is among the most dangerous things a person can do to their cardiovascular system, and “less harmful than cigarettes” is a real but limited claim that is not the same as “harmless.”

E-Cigarettes (Vaping)

E-cigarettes are the most used, most studied, and most argued-about of these products, so they warrant the most detailed treatment.

What they are and how they compare. An e-cigarette heats a liquid — usually containing nicotine, flavorings, and a propylene glycol or glycerol base — to produce an inhalable aerosol. Because nothing is burned, the user is not exposed to the combustion of tobacco. This is the central difference from a cigarette, and it matters. E-cigarette aerosol delivers far fewer toxicants than cigarette smoke, and little or no carbon monoxide, while still delivering nicotine and some other potentially harmful compounds.²,³ Carbon monoxide matters because it reduces the blood’s oxygen-carrying capacity and contributes to the vascular injury described in Article 1, so its near absence from e-cigarette aerosol is one of the major biological differences from cigarette smoke. On the measure that drives most of smoking’s cardiovascular harm — exposure to combustion products — e-cigarettes are substantially lower than cigarettes. This is the legitimate basis for the statement that they are less harmful than smoking.

Cardiovascular effects: what is known. Less harmful is not the same as harmless, and e-cigarettes do have measurable cardiovascular effects. The nicotine they deliver activates the sympathetic nervous system, acutely raising heart rate and blood pressure, and short-term studies have found effects on vascular function along with markers of oxidative stress and inflammation after vaping.²,³ These acute effects are real and are largely attributable to nicotine. What is not yet clear is how they translate over years of use.

What is uncertain. The honest limitation is that e-cigarettes are relatively new, so long-term cardiovascular outcome data — heart attacks, strokes, and deaths over decades — do not yet exist in the way they do for cigarettes.² This reflects how cardiovascular evidence is built rather than any specific alarming finding: heart attacks and strokes develop over long periods, so outcome studies require many years of follow-up, and e-cigarettes have not been in wide use long enough to have produced that record. The available evidence is generally reassuring but remains incomplete. In a large prospective analysis of a US national study (the PATH study), people who used only e-cigarettes had a cardiovascular disease risk that did not differ significantly from non-users, and that was roughly 30 to 40% lower than that of people who smoked — though this lower-than-smoking difference reached statistical significance only for the broadest cardiovascular composite, and the number of events among exclusive e-cigarette users was small, which limits precision.⁴ Some cross-sectional studies have suggested associations between e-cigarette use and heart attack or stroke, but these are heavily confounded by participants’ prior smoking and by dual use, and cannot establish that vaping caused the events.⁴ Even the PATH analysis, though prospective and carefully adjusted, is observational: it can describe associations and narrow confounding, but it cannot prove causation. The accurate summary is that exclusive e-cigarette use appears substantially less harmful to the heart than smoking, that it is very unlikely to be risk-free, and that the long-term picture remains genuinely uncertain.

Using e-cigarettes to quit. On cessation, the evidence is now strong. High-certainty evidence from a large living systematic review shows that nicotine e-cigarettes help more people stop smoking than nicotine-replacement therapy (relative risk 1.55) — in absolute terms, roughly 4 more quitters per 100 — with a similar rate of common unwanted effects.¹ This is a genuine finding and should not be dismissed. At the same time, e-cigarettes are consumer products, not regulator-approved cessation medications, and the approved medications covered in Article 5 remain the preferred first-line treatments, because their efficacy and safety have been established through extensive randomized clinical trials. E-cigarettes are best understood as one evidence-based route out of smoking among several, most useful for people who have not succeeded with approved treatments.

The dual-use problem. This is the point that most changes the cardiovascular calculation. The benefit of e-cigarettes depends on completely replacing cigarettes, not adding vaping on top of smoking. In the same prospective study, people who both smoked and vaped — dual users — had cardiovascular risk that did not differ from that of people who only smoked.⁴ In other words, dual use preserves the substantial cardiovascular risk of smoking; the reduction in harm requires stopping cigarettes entirely. This matters because dual use is common: many people intend to switch but continue smoking some cigarettes, and in doing so keep most of the cardiovascular danger. By contrast, a small randomized trial found that smokers who switched completely to e-cigarettes showed short-term improvement in vascular function compared with those who kept smoking, with the greatest benefit among those who avoided dual use — though this was a one-month study of a surrogate measure, not long-term outcomes.⁹ For the heart, the message is unambiguous: partial substitution is not the goal, and complete substitution is.

A note on EVALI and on never-smokers. Two points prevent common misunderstandings. First, the outbreak of severe lung injury reported in 2019, known as EVALI, was linked primarily to vitamin E acetate used as a thickener in illicit THC-containing vaping products, not to commercial nicotine e-cigarettes — and it was a lung-injury condition rather than a cardiovascular one.⁸ It should not be confused with the cardiovascular questions discussed here, though it is a real reminder that unregulated inhaled products carry unpredictable risks. Second, everything favorable said here about e-cigarettes applies to their use by people who already smoke and are trying to quit. For people who have never smoked, and for young people especially, there is no cardiovascular case for starting; the sensible course is not to begin using an addictive product with real, if lower, risks and unknown long-term effects.

Smokeless Tobacco

Smokeless tobacco — chewing tobacco, moist snuff, and the Swedish product snus — delivers nicotine through the lining of the mouth without any combustion. Applying the combustion principle, this should place it well below cigarettes for cardiovascular harm, and it does. But well below cigarettes is not the same as harmless.

The evidence indicates a real, if modest, cardiovascular risk. A systematic review and meta-analysis of studies from Sweden and the United States found that smokeless tobacco use was associated with an increased risk of fatal heart attack (on the order of 13% higher) and of fatal stroke, with a modest absolute increase.⁵ A large 2025 pooled analysis of US cohorts likewise found that non-cigarette tobacco products, including smokeless tobacco, were associated with cardiovascular events, while cigarettes carried by far the largest risk.⁶ Two patterns are consistent across the literature: the cardiovascular risk from smokeless tobacco is considerably smaller than that from cigarettes, and it is nonetheless greater than the risk in people who use no tobacco at all.⁵,⁶ Smokeless products are also not uniform: Swedish snus is pasteurized rather than fermented and contains lower levels of certain carcinogens (tobacco-specific nitrosamines) than products such as American moist snuff — a difference that matters more for cancer risk than for the nicotine-driven cardiovascular effects, which are common to all of them. The nicotine it delivers has cardiovascular effects, and some products carry additional concerns, including a recognized risk of oral cancer. Smokeless tobacco is a clear example of the article’s theme: a product much less harmful than cigarettes that still carries measurable cardiovascular risk and sustains nicotine dependence.

Cigars

Cigars are a combustion product, and that fact largely determines their cardiovascular profile. Cigar smoke contains the same categories of harmful combustion products as cigarette smoke. The common belief that cigars are safe because the smoke is often not inhaled is only partly protective: even without deep inhalation, exposure occurs through the mouth and the surrounding air, and people who do inhale — or who smoke cigars frequently or as a substitute for cigarettes — take on risk that approaches that of cigarette smoking.

The outcome data bear this out. In a large 2025 pooled analysis of US cohorts, current cigar use was associated with an increased risk of stroke, atrial fibrillation, and heart failure compared with never using cigars (hazard ratios of roughly 1.25 to 1.32).⁶ As with the other products, cigarettes produced the largest and most consistent increases in cardiovascular risk across outcomes, but cigars were clearly not neutral.⁶ One caveat applies to interpreting these figures: many cigar smokers currently or previously smoked cigarettes, which makes cigar-specific risk difficult to isolate — the pooled analysis adjusted for cigarette use, but residual confounding is hard to eliminate entirely.⁶ An occasional cigar is a lower-exposure event than a pack-a-day cigarette habit, but regular cigar use is a combustion exposure with real cardiovascular consequences. Avoiding inhalation reduces exposure but does not eliminate cardiovascular risk.

Hookah (Waterpipe)

Hookah, also called waterpipe or shisha, is the product whose cardiovascular risk is most widely underestimated. It is frequently perceived as a mild, social, and relatively harmless activity, in part because the smoke is cooled and passed through water. That perception is mistaken, and the reason is combustion.

A hookah uses burning charcoal to heat tobacco, and the resulting smoke is inhaled over long sessions that often last 30 to 60 minutes.⁷ The exposure is not small. According to an American Heart Association scientific statement, compared with a single cigarette, a single hookah session generates on average roughly 70 times the tar and about 11 times the carbon monoxide, and delivers around 2.5 mg of nicotine — comparable to two or three cigarettes.⁷ The burning charcoal is a major source of carbon monoxide — the same toxicant central to cigarette harm described in Article 1. A single session acutely raises blood pressure, heart rate, and arterial stiffness, and long-term waterpipe use is associated with an increased risk of coronary artery disease.⁷ Of all the products in this article, hookah is the one where the gap between public perception and cardiovascular reality is widest: cooling the smoke through water changes neither the toxicant load nor the risk.

How the Products Compare

The table below summarizes the comparison. The organizing variable is combustion, because that is what most determines cardiovascular harm; every characterization is drawn from the cited evidence.

The pattern is consistent with the combustion principle: the two combustion products, cigars and hookah, sit closest to cigarettes, while the two non-combustion products, e-cigarettes and smokeless tobacco, are substantially lower — though neither is free of cardiovascular risk.

Common Beliefs vs What the Evidence Shows

Several widespread beliefs about these products are inaccurate in ways that matter for the heart.

What This Means

The evidence across these products fits one pattern: cardiovascular harm tracks combustion and toxicant exposure. The two non-combustion products — e-cigarettes and smokeless tobacco — are substantially less harmful to the heart than cigarettes, while the two combustion products — cigars and hookah — carry more, and none is free of cardiovascular risk.

For e-cigarettes specifically, the benefit is real but conditional: it comes from replacing cigarettes completely, because dual use preserves the risk of smoking. And nothing here is a reason for a person who does not smoke — particularly a young person — to start.

A simple way to hold the whole comparison: e-cigarettes and smokeless tobacco are meaningfully better than cigarettes but not safe; cigars offer far less cardiovascular advantage than many people assume, and hookah essentially none; and not one of these products is safe for the heart. The safest option for cardiovascular health remains using no tobacco or nicotine product at all.

What This Means for You

• If you smoke and are trying to quit: the approved medications and support in Articles 5 and 6 are the first-line, best-evidenced route; if those have not worked, completely switching to nicotine e-cigarettes is supported by high-certainty evidence and is substantially less harmful than continuing to smoke.¹,⁴
• If you vape and still smoke: eliminating the cigarettes is the step that matters most — dual use carries the same cardiovascular risk as smoking, and only complete substitution reduces it.⁴
• If you have never smoked: there is no cardiovascular reason to start any of these products, and this applies with particular force to young people.
• If you use cigars, hookah, or smokeless tobacco believing they are safe: the evidence does not support that belief — each carries genuine cardiovascular risk, hookah more than its mild reputation suggests.⁵,⁶,⁷
• If you have established heart disease or significant risk factors: make these decisions with a clinician who knows your history, not on the basis of a product’s marketing.

How Strong Is the Evidence?

Not all of the conclusions in this article rest on equally certain evidence, and knowing the difference is part of using it well. The table below summarizes how confident the current evidence is in each main conclusion.

Clinical Bottom Line

Among the products people use instead of cigarettes, cardiovascular harm tracks combustion. E-cigarettes and smokeless tobacco, which involve no combustion, are substantially less harmful to the heart than cigarettes but are not risk-free; cigars and hookah, which do involve combustion, carry cardiovascular risk that is closer to cigarettes, with hookah far more dangerous than its mild reputation suggests.²,⁵,⁶,⁷ E-cigarettes are the most important case: they help more people quit than nicotine-replacement therapy, with high-certainty evidence, and expose users to far fewer toxicants — but their long-term cardiovascular effects are unknown, and their benefit depends entirely on switching completely, since dual users retain the full cardiovascular risk of smoking.¹,³,⁴,⁹ For a person who smokes, complete substitution with a less harmful product is a real improvement; for a person who does not, none of these products has a cardiovascular rationale. “Not a cigarette” is not the same as “safe for the heart.”

What Comes Next

This article covered nicotine and tobacco products used in place of cigarettes; the next turns to a different inhaled substance. Article 8 examines cannabis and the heart — its acute cardiovascular effects, what observational evidence suggests about heart attack and stroke, why the evidence is still evolving, and why legality and social acceptance do not settle the question of cardiovascular safety.

Key Terms

Combustion products: The carbon monoxide, oxidizing chemicals, and fine particulates produced by burning tobacco, responsible for most of smoking’s cardiovascular harm; their presence or absence largely determines a product’s cardiovascular risk.

Dual use: Using e-cigarettes and smoking cigarettes at the same time; associated with the same cardiovascular risk as smoking alone, because the cigarettes are still being smoked.

E-cigarette (vaping): A device that heats a nicotine-containing liquid to produce an inhalable aerosol without combustion, delivering nicotine with far fewer toxicants than cigarette smoke.

EVALI: E-cigarette or vaping product use-associated lung injury; a 2019 outbreak linked primarily to vitamin E acetate in illicit THC-containing products, distinct from the cardiovascular questions around nicotine e-cigarettes.

Hookah (waterpipe): A device that uses burning charcoal to heat flavored tobacco, delivering high levels of smoke and carbon monoxide per session and carrying real cardiovascular risk.

Smokeless tobacco: Chewing tobacco, moist snuff, or snus, used orally without combustion; carries a modest but real increase in cardiovascular risk and sustains nicotine dependence.

Complete substitution: Fully replacing cigarettes with a less harmful product; the condition required for a smoker to gain cardiovascular benefit from switching.

References

1. Lindson N, Butler AR, McRobbie H, et al. Electronic cigarettes for smoking cessation. Cochrane Database Syst Rev. 2025;11(11):CD010216. https://doi.org/10.1002/14651858.CD010216.pub10
2. National Academies of Sciences, Engineering, and Medicine. Public Health Consequences of E-Cigarettes.Washington, DC: The National Academies Press; 2018. https://doi.org/10.17226/24952
3. Benowitz NL, St Helen G, Nardone N, et al. Twenty-four-hour cardiovascular effects of electronic cigarettes compared with cigarette smoking in dual users. J Am Heart Assoc. 2020;9(23):e017317. https://doi.org/10.1161/JAHA.120.017317
4. Berlowitz JB, Xie W, Harlow AF, et al. E-cigarette use and risk of cardiovascular disease: a longitudinal analysis of the PATH Study (2013–2019). Circulation. 2022;145(20):1557–1559. https://doi.org/10.1161/CIRCULATIONAHA.121.057369
5. Boffetta P, Straif K. Use of smokeless tobacco and risk of myocardial infarction and stroke: systematic review with meta-analysis. BMJ. 2009;339:b3060. https://doi.org/10.1136/bmj.b3060
6. Tasdighi E, Yao Z, Jha KK, et al. Cigar, pipe, and smokeless tobacco use and cardiovascular outcomes from Cross Cohort Collaboration. JAMA Netw Open. 2025;8(1):e2453987. https://doi.org/10.1001/jamanetworkopen.2024.53987
7. Bhatnagar A, Maziak W, Eissenberg T, et al. Water pipe (hookah) smoking and cardiovascular disease risk: a scientific statement from the American Heart Association. Circulation. 2019;139(19):e917–e936. https://doi.org/10.1161/CIR.0000000000000671
8. Blount BC, Karwowski MP, Shields PG, et al. Vitamin E acetate in bronchoalveolar-lavage fluid associated with EVALI. N Engl J Med. 2020;382(8):697–705. https://doi.org/10.1056/NEJMoa1916433
9. George J, Hussain M, Vadiveloo T, et al. Cardiovascular effects of switching from tobacco cigarettes to electronic cigarettes. J Am Coll Cardiol. 2019;74(25):3112–3120. https://doi.org/10.1016/j.jacc.2019.09.067

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