A new comprehensive review led by the Indian Council of Medical Research–National Institute of Cancer Prevention and Research (ICMR-NICPR) raises serious concerns about vaping—a trend that is gripping India.
Analysing data from 12 global studies with over 1.2 million participants, researchers found that e-cigarette users face a significantly higher risk of heart attacks, up to 53 per cent higher than non-users. Alarmingly, even those who switched from conventional cigarettes to vaping experienced more than double the risk of heart attack compared with people who quit all tobacco and nicotine products.
This evidence challenges the popular belief that vaping is a safe way to quit smoking. While e-cigarettes produce vapour instead of smoke, they still deliver nicotine, a substance known to affect heart rate, blood pressure, vascular health, and platelet function.
While e-cigarettes are widely marketed and perceived as a safer alternative to conventional smoking, health experts caution that this belief is misleading. The absence of smoke or tar does not make vaping harmless, as e-cigarettes still deliver nicotine and other toxic substances that adversely affect the heart and blood vessels. In this context, the ICMR-led review adds to growing evidence that e-cigarettes are not a risk-free option and may pose serious, and often underestimated, threats to cardiovascular health, particularly for those who switch rather than quit nicotine altogether.
What the ICMR study found
The ICMR-led review systematically analysed 12 observational studies encompassing over 1.2 million individuals. The researchers extracted 26 estimates, including 11 for myocardial infarction (heart attack) and 15 for stroke. The results revealed that e-cigarette users had 1.53 times higher odds of experiencing a heart attack compared with non-users. Even after adjusting for conventional cigarette use, the risk remained elevated, with e-cigarette users showing a 1.24 times higher likelihood of heart attack. The findings were particularly concerning for former smokers who switched to e-cigarettes, as this group faced a 2.52 times higher risk of myocardial infarction compared with individuals who had completely quit tobacco and nicotine products. Stroke risk followed a similar pattern, with former smokers using e-cigarettes showing substantially higher risks than non-users.
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These results challenge the perception that e-cigarettes are harmless alternatives to smoking. Although they do not produce tar or carbon monoxide, e-cigarettes still deliver nicotine and other toxic compounds that can adversely affect cardiovascular health.
The study concluded that, "The use of e-cigarettes may be linked with a higher risk of myocardial infarction as well as stroke, even after adjusting for cigarette smoking as a confounder or in those who were former conventional cigarette smokers. Further well-designed longitudinal studies are needed to confirm these findings and inform policymakers on the health effects of e-cigarette use."
Limitations of the study
The review acknowledges several important limitations. “The majority of the studies were conducted in the USA and only one study was retrieved from Japan. In view of the variation in the contents of e-cigarette products, usage behaviours, and regulatory environments among countries, the results may not be directly generalizable to other populations.” Most of the studies included in the review were cross-sectional, which limits the inference of causality between e-cigarette use and cardiovascular events.
The authors also noted that “the majority of the studies scored low on the quality assessment. Hence, there is a need to conduct robust, well-designed studies on this topic.” While most studies either included non-smokers or adjusted for conventional cigarette use as a confounder, the potential effect of undisclosed current or former smoking cannot be excluded. Additionally, there was a lack of detailed information regarding the frequency and duration of e-cigarette use, making it difficult to assess any duration-dependent effects on cardiovascular health. Another limitation highlighted was “the high heterogeneity in majority of the results,” reflecting variability across studies.
Implications for India
Although e-cigarettes have been banned in India since 2019 under the Prohibition of Electronic Cigarettes (Production, Manufacture, Import, Export, Transport, Sale, Distribution, Storage and Advertisement) Act, their use continues, particularly among adolescents, a concern highlighted by a Lancet commentary. “In India, before the 2019 ban, the health authorities did not permit the use of e-cigarettes for pleasure, nor for smoking cessation. However, e-cigarette products have gradually entered the Indian market through various forms of marketing strategies to consumers,” the commentary noted, pointing to the growing accessibility of these products despite legal restrictions.
The commentary further warned that, “Despite the ban, Indian authorities are struggling to regulate the use of e-cigarettes, in particular due to the black market. This is threatening the country's efforts to control tobacco. The 2019 ban was a right, timely, and important public health decision, but preventing use of e-cigarettes, especially in adolescents, still remains a challenge and more needs to be done."
Another 2023 study on educated young adults revealed that, despite the nationwide ban, e-cigarettes continue to be accessible in India. The survey, conducted among 840 tertiary-educated young adults, found that 23 per cent reported ever using e-cigarettes, while 8 per cent were dual users of both tobacco and e-cigarettes. Only 8 per cent of e-cigarette users reported daily use, with access primarily through retail outlets and social networks. Interestingly, just under two-thirds of participants who were aware of e-cigarettes recognised their harmful chemical content, yet 31 per cent of non-users expressed curiosity, and 23 per cent intended to try them within the following year.
The study concluded, “Despite a complete ban, young people are still able to access e-cigarettes in India. Greater education about harms associated with vaping and more intensive monitoring and enforcement could assist in reducing uptake in relatively high-prevalence groups such as educated young adults.”
Further highlighting the risks, a 2023 review titled ‘Impact of Vaping on Lungs: An Indian Prospect’ noted the popularity of vaping among youth and the potential for widespread harm. “Nowadays, electronic cigarettes, or vape pens, are very popular among young people. It has now turned into a pattern to utilize a vape without a doubt, even though it has numerous side effects that the youths don't realise. This is more harmful than smoking as numerous substances are present that can cause a ton of harm to the human body.”
The psychiatric impact of vaping has also been highlighted in recent research. A 2025 editorial titled ‘Vaping: The emerging epidemic and its psychiatric implications in India’ warned of the broader mental health consequences of nicotine addiction. “Vaping presents a multifaceted public health challenge in India, with significant psychiatric implications. The addictive potential of nicotine, coupled with the psychosocial factors driving its use, necessitates a comprehensive approach to address this emerging epidemic. By strengthening regulations, raising public awareness, integrating vaping into substance use programs, and fostering research, India can mitigate the mental health risks associated with vaping and protect its population, particularly the youth, from the harmful consequences of this trend.”
A more recent umbrella review synthesising 69 systematic reviews reinforced these concerns, providing a comprehensive evaluation of the health impacts of electronic nicotine delivery systems (ENDS).
The review reported consistent evidence of increased cardiovascular and respiratory risks, mental health issues, and substance abuse among ENDS users, especially adolescents. Cardiovascular effects included elevated heart rate and blood pressure, endothelial dysfunction, and increased platelet activity. Respiratory consequences included reduced lung function, higher asthma incidence, and chronic obstructive pulmonary disease. Mental health concerns, such as depression and suicidality, were also reported, along with evidence of carcinogen exposure in some ENDS users. The umbrella review concluded, “Exposure to ENDS is harmful to various organ systems, especially the cardiovascular and respiratory systems. Comprehensive regulatory measures and public health strategies are necessary to curb the use of ENDS, particularly among young people.”
Dr (Prof) Tarun Kumar, Associate Director and Head of the Medanta Moolchand Heart Centre, said the ICMR-led review reinforces long-standing concerns among cardiologists that vaping is not a safe alternative to smoking, particularly when it comes to heart health.
“E-cigarettes pose serious health risks, including addiction to nicotine, lung damage such as EVALI, asthma, COPD and even lung scarring. They are also linked to cardiovascular problems like high blood pressure and vascular dysfunction,” he said, adding that users are exposed to “cancer-causing chemicals, heavy metals and volatile organic compounds, with long-term effects still being studied, especially on brain development in young people.”
Dr Kumar explained that nicotine remains the central threat, regardless of how it is delivered. Even without tar or carbon monoxide, vaping can raise heart rate, increase blood pressure and narrow blood vessels. “All forms of smoking, whether conventional cigarettes or vaping, worsen vascular disease. This includes heart attacks, heart failure, stroke, hypertension, peripheral artery disease and cancer,” he said.
Referring to the ICMR review, he noted that cardiovascular risk persists even among people who switch from cigarettes to e-cigarettes. Stroke risk, in particular, was higher among former smokers who took up vaping. “Symptoms like breathlessness are often attributed only to lung problems, but they can also indicate cardiac involvement. Vaping affects both systems,” he said.
On the widespread perception that vaping is safer than smoking, Dr Kumar was unequivocal. “No, it is not recommended. Vaping is not a harm-reduction tool for heart health. It is equally harmful, and in some cases worse than conventional cigarette smoking,” he said.
Government’s regulatory framework
From a public health perspective, Dr Kumar said India’s 2019 ban on e-cigarettes remains essential but cannot work in isolation. Despite the ban, access among young people continues. “Regulation and advisories cannot be one-time measures. Public memory is short, so enforcement and awareness have to be continuous,” he said.
He added that sustained efforts through schools, colleges, media and public campaigns are critical. “The harms of vaping need to be repeatedly reinforced. Only consistent awareness and enforcement can reduce its growing appeal among the youth,” he said.
In a written reply in the Rajya Sabha, Minister of State for Home Affairs Nityanand Rai reaffirmed that e-cigarettes are prohibited under the Prohibition of Electronic Cigarettes Act (PECA), 2019, which bans the “production, manufacture, import, export, transport, sale, distribution, storage and advertisement of electronic cigarettes.”
Clarifying enforcement and investigation, the minister stated that the Narcotics Control Bureau (NCB) has not investigated any cases involving the seizure of e-cigarettes or vape devices containing narcotic substances. He noted that the responsibility for enforcing the Act lies with state and Union Territory law enforcement agencies.
Addressing concerns around illegal imports and misuse, the government outlined several measures to strengthen surveillance and interdiction, particularly at airports and ports. These include intelligence-based operations by the Directorate of Revenue Intelligence and Customs, passenger profiling using the Advance Passenger Information System (APIS), risk-based targeting, non-intrusive inspection methods such as baggage and container scanning, and coordination with multiple enforcement agencies. Field officials are also regularly sensitised to emerging smuggling methods, while trained canine (K9) squads have been deployed at airports to detect narcotics. Legal action, including arrest and prosecution, is taken whenever illicit substances are detected.
The minister further clarified that there is currently no proposal to amend the Narcotic Drugs and Psychotropic Substances (NDPS) Act, 1985, in relation to e-cigarettes. However, the government continues to implement broader measures aimed at preventing substance abuse and supporting de-addiction.
Among these initiatives is the National Narcotics Helpline, “MANAS (Madak-Padarth Nished Asoochna Kendra),” a 24×7 toll-free service (1933) designed as an integrated platform for citizens to report and seek help on drug-related issues via calls, SMS, chatbots, email and web portals. In addition, a separate toll-free de-addiction helpline (14446) provides primary counselling and immediate assistance; according to official data, it has received more than 4.3 lakh calls so far.
The government has also rolled out the Nasha Mukt Bharat Abhiyaan (NMBA) across all districts, reaching over 24.9 crore people, including 8.7 crore youth and 6 crore women. Awareness and sensitisation programmes are conducted through the National Institute of Social Defence (NISD) in collaboration with bodies such as SCERT and Kendriya Vidyalaya Sangathan, targeting students, teachers and parents. Educational tools like Navchetna modules and teacher training materials have been developed to address drug dependence, coping strategies and life skills, while outreach activities, ranging from rallies and street plays to radio programmes and campus campaigns, are organised throughout the year in schools, colleges and universities.
This story is done in collaboration with First Check, which is the health journalism vertical of DataLEADS.
