e-Cigarette Use and Risk of Chronic Respiratory Conditions in Adults

Ishandeep Gandhi; Nicole Tenegra; Rami Elmasry

Blue-Gray Nails and Skin

May 2026

Art and Science of Providing Reassurance

FPIN's Clinical Inquiries

From the Family Practice Inquiries Network

e-Cigarette Use and Risk of Chronic Respiratory Conditions in Adults

Ishandeep Gandhi, MD

Nicole Tenegra, MD

Rami Elmasry, MD, DC

American Family Physician. 2026;113(5):497.

Author disclosure: No relevant financial relationships.

This clinical content conforms to AAFP criteria for CME.

CLINICAL QUESTION

Does e-cigarette use increase the risk of chronic respiratory conditions in adults?

EVIDENCE-BASED ANSWER

Physicians should counsel adults to avoid use of e-cigarettes because they may increase the risk of asthma and chronic obstructive pulmonary disease (COPD). (Strength of Recommendation[SOR]: B; meta-analysis of three cross-sectional studies and one longitudinal study and SOR: B; meta-analysis of seven observational studies, respectively.) Use of e-cigarettes has been associated with a higher rate of self-reported asthma-COPD overlap syndrome. (SOR: C; cross-sectional study.)

EVIDENCE SUMMARY

A 2025 meta-analysis of seven observational studies (N = 3,552,424) that included patients older than 18 years examined the association between e-cigarette use and COPD. Two studies enrolled participants older than 40 years. One study included only women between ages 18 and 44 years.¹

The studies encompassed patients with a wide range of e-cigarette use, such as daily users and former users, and those with and without a history of combustible cigarette smoking. The findings from the random-effects meta-analysis showed that exposure to e-cigarettes among noncigarette smokers was associated with a higher likelihood of COPD (pooled relative risk = 1.50; 95% CI, 1.27–1.73).¹

A 2021 meta-analysis reviewed epidemiologic studies on the association of e-cigarette use with asthma and COPD. Of the 15 studies on asthma, four included adults only (n = 474,416). Three studies were cross-sectional and one was longitudinal. Of the nine studies on COPD, seven were cross-sectional and two were longitudinal (n = 873,777).²

Participants in the four adult asthma studies were 18 years and older, were former or current e-cigarette users, and had been diagnosed with asthma by a health professional. Participants in the nine COPD studies were 18 years and older, were former or current users of e-cigarettes, and had been diagnosed with COPD by a physician, nurse, or other clinician. The meta-analysis found that e-cigarette users had increased odds of asthma (adjusted odds ratio [OR] = 1.40; 95% CI, 1.23–1.58) and increased odds of developing COPD (adjusted OR = 1.49; 95% CI, 1.36–1.65) compared with non–e-cigarette users.²

A 2021 cross-sectional study used self-reported data from individuals 18 years and older from the Behavioral Risk Factor Surveillance System from 2016 (n = 486,303), 2017 (n = 450,016), and 2018 (n = 437,436) to assess the association between e-cigarette use and a self-reported diagnosis of asthma, COPD, or asthma-COPD overlap syndrome. Participants who smoked more than 100 combustible cigarettes in their lifetime and those who reported using e-cigarettes in the past were excluded from the study.³

Of the 469,077 participants who never smoked combustible cigarettes, 4,368 never-smokers were 1: 1 propensity score-matched with 4,368 e-cigarette users based on age, sex, race or ethnicity, and education level. After adjusting for these confounding variables, the study found that e-cigarette users had a higher likelihood of self-reported asthma (OR = 1.26; 95% CI, 1.25–1.27), COPD (OR = 1.44; 95% CI, 1.42–1.46), and asthma-COPD overlap syndrome (OR = 2.27; 95% CI, 2.23–2.31) than those who never smoked.³

ISHANDEEP GANDHI, MD; NICOLE TENEGRA, MD; and RAMI ELMASRY, MD, DC, Decatur Family Medicine Residency Program, Southern Illinois University, Decatur

Address correspondence to Ishandeep Gandhi, MD, at igandhi53@siumed.edu.

Author disclosure: No relevant financial relationships.

1.Song C, Hao X, Critselis E, et al. The impact of electronic cigarette use on chronic obstructive pulmonary disease: a systematic review and meta-analysis. Respir Med. 2025;239:107985.
2.Wills TA, Soneji SS, Choi K, et al. E-cigarette use and respiratory disorders: an integrative review of converging evidence from epidemiological and laboratory studies. Eur Respir J. 2021;57(1):1901815.
3.Bircan E, Bezirhan U, Porter A, et al. Electronic cigarette use and its association with asthma, chronic obstructive pulmonary disease (COPD) and asthma-COPD overlap syndrome among never cigarette smokers. Tob Induc Dis. 2021;19:23.

Clinical Inquiries provides answers to questions submitted by practicing family physicians to the Family Physicians Inquiries Network (FPIN). Members of the network select questions based on their relevance to family medicine. Answers are drawn from an approved set of evidence-based resources and undergo peer review. The strength of recommendations and the level of evidence for individual studies are rated using criteria developed by the Evidence-Based Medicine Working Group (https://www.cebm.net).

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This series is coordinated by John E. Delzell Jr., MD, MSPH, associate medical editor.

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