We were unable to perform meta-analyses of exposures between vapers and non-users. However, some interventional studies (such as RCTs, longitudinal and cross-over studies) have suggested that CO exposure may be reduced to levels similar to those of non-users in smokers who switch completely to the use of vaping products. For cardiovascular disease, we did not identify any studies in people with existing cardiovascular disease, so we could not achieve the second review objective. We assessed the relative and absolute risks of vaping associated with biomarkers of cardiovascular disease, where data were available (between vapers and smokers, and between vapers and non-users). And where possible, we included comparisons between different population groups. The pharmacokinetic studies are consistent with studies discussed in Chapter 7 on biomarkers of nicotine exposure and potential toxins, which generally showed lower nicotine exposure from the use of vaping products for short periods of time (up to 7 days) than from smoking. However, in medium and long-term studies (up to 2 years), there was moderate evidence of similar exposure to nicotine due to vaping compared to smoking. For experienced adult vapers, there was considerable evidence of comparable exposure to nicotine from vaping and smoking. There has been evidence to support that people who vape compensate for lower nicotine concentrations over time with compensatory puffs (e.g., flushing more frequently, buffering larger amounts of aerosol, or taking longer puffs). The UK Steam Act aims to stop the sale of vaping equipment or starter kits, rather than regulating ownership. While this is possible under the age of 18, try to avoid buying, renting or owning such nicotine products, as you never know what can cause you problems. The age at which you are legally considered an adult varies from country to country, usually most countries use it as a guide to being able to vape responsibly. In France, Sweden, Germany and most European countries, the legal age to vape is 18, in Japan it is also 18, and in the United States and Canada, the legal age for vaping is 18, with the exception of a number of states and provinces.

The prevalence of vaping among adults in England was lower than the prevalence of smoking in all groups and appeared to have increased by about 1 percentage point from 2020 to 2021 to 6.9% to 7.1%. This corresponded to about 3.1 to 3.2 million vapers. In 2022, based on ASH-A data, the prevalence of vaping among adults in England was 8.3%. Current results show that more experienced users of vaping products adjust their buffering behavior to achieve higher nicotine levels. However, this does not compensate for the lower nicotine exposure after a single session of vapor compared to smoking a cigarette. We found that during long-term vaping sessions or when a person can vape as much or as often as they want (ad libitum), experienced vapers achieve nicotine levels comparable to smoking (as shown by data on nicotine biomarkers). The ability of vapers to adjust their puff behavior to the mirror of smoking suggests that vaping allows users to carefully control their nicotine levels. This could be a problem if people who use vaping products with lower nicotine concentrations compensate by increasing their puffs, thereby increasing exposure to other ingredients, including potentially harmful ones. We will explore this topic in more detail in the following chapters. A recent systematic review found that limiting nicotine levels in vaping products could reduce smoking cessation. Fruit flavors were most popular among young people currently vaping (51.5% in 2021 ASH-Y).

This was followed by menthol/mint (13%), followed by chocolate/dessert/candy/sweets (9.3%), which is similar to the data in our 2021 report. Similarly, definitions should not include simultaneous smoking and should only include people who vape exclusively. This is particularly important for cross-sectional studies, but longitudinal studies should also use objective measures to assess concurrent smoking. Yes of course. It applies to all vaping products/e-cigarettes, whether online or offline. In fact, the review of vaping products online is stricter. If you decide to make a purchase from online businesses, they will go through an age verification process. You will be asked for age information and a valid ID. If you do not submit these details, you will not be able to purchase the vaping product. If you do not meet their criteria or the legal age to buy, you will not be able to verify the final transaction. More research is needed on biomarkers of exposure in vapers, particularly in the UK where we found a lack of studies.

We would encourage research with longitudinal and transversal designs. Although longitudinal research is more robust, particularly in terms of changes over time, cross-sectional research also provides information on exposure through realistic and naturalistic patterns of use.

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