Users who exhale through the nose may expose themselves to health risks different from those faced by people who smoke cigarettes.

People who smoke e-cigarettes and hookahs may be at a higher risk of inflammation and cancers of the nose, sinuses, and throat because of the way they exhale when using these devices, according to a new study.

Researchers found that vapers and hookah users are more than twice as likely to exhale particles through their nose than people who smoke cigarettes, who typically exhale the emissions from their mouth.

“This matters because the way vapers and hookah smokers use their devices may expose the nose and sinuses to far more emissions than cigarettes, which may in turn increase their risk of upper respiratory diseases,” says the study's lead author, Emma Karey, PhD, a postdoctoral research fellow in the department of environmental medicine at NYU Langone Health in New York City. The findings were published on February 28 in Tobacco Use Insights journal.

Electronic cigarettes (e-cigarettes), electronic hookahs (e-hookahs), and vape pens allow the user to inhale a vapor that may contain nicotine as well as flavorings, solvents, and other chemicals. E-cigarettes and e-hookahs come in many shapes, including cigarettes, pipes, pens, USB sticks, cartridges, and refillable tanks, pods, and mods.

Cigarette smoking remains more popular than vaping; 16 percent of U.S. adults smoke, compared with 6 percent who report they have vaped (including the use of e-cigarettes) within the past week, according to a July 2021 Gallup poll.

Vaping is more popular among some groups:

To investigate how people used e-cigarettes, vaping devices, and hookahs, researchers discreetly observed 122 cigarette smokers and 123 vapers on the streets of New York City between March 2018 and February 2019. They also monitored 96 people smoking inside two Manhattan hookah bars.

They found 63 percent of vapers and 50 percent of hookah users exhaled through their nose, while only 22 percent of e-cigarette users did.

Investigators found that more than 70 percent of those who used pod-like devices exhaled through their nose at some point during the observation period, while 50 percent of modular tank–style users did the same.

Dr. Karey points out that users may exhale through the nose because vaping products come in a variety of flavors, such as pineapple, bubblegum, and blue raspberry. “Vapers may be more likely to exhale through their nose because scent enhances taste,” she says.

In an earlier, related study, the researchers found increased damage in the nasal passages of vapers and hookah users. The device users had as much as 10 times higher inflammation than those who smoked traditional cigarettes.

“This type of sustained inflammation is where we start to become concerned with pathologies and diseases; it suggests there may be sustained injury to that tissue,” says Karey.

The link between how people smoke and their potential health risks has been seen before, says the study's senior author, Terry Gordon, PhD, a professor in the department of environmental medicine at NYC Langone Health. “For example, when people smoke cigars, they don’t inhale as deeply, and they get more oral cancers compared with cigarette smokers, who inhale more deeply,” he says.

These findings are in line with what is already known about the risks these products bring, says Adam Goldstein, MD, MPH, a professor in the UNC department of family medicine and the director of tobacco intervention programs at the UNC School of Medicine in Chapel Hill, North Carolina. Dr. Goldstein was not involved in the new research.

“We have already known for a long time that combustible tobacco products, like cigarettes, water pipes, and cigars, cause multiple cancers in multiple different organs of the body, including elevated risks for cancers related to nasal sinuses. These cancer-causing agents enter the bloodstream and tissues of most every organ,” says Goldstein.

Although vaping is likely safer than combustible tobacco, at least in laboratory studies, that doesn’t mean it’s safe, he says. “Vaping exposes users to many toxic chemicals. Regardless of how they're smoked, smoking products like hookah are deadly to the user as well as those exposed to secondhand hookah smoke,” says Goldstein.

E-cigarettes, vaping pens, and hookahs all may carry a different type of risk depending on how they are used, says Karey. “The most important health endpoints may no longer be a ‘one-size-fits-all’ for these new and emerging alternative products — how people are using them may change where the risk ends up,” she says.

Diseases of both the nose and lungs should be considered when evaluating different smoking methods before judging whether one is riskier than another, adds Dr. Gordon.

Goldstein questions whether further research on different tobacco products or potential differences in risks based on subtle changes in smoking behavior is what’s needed. “For instance, we spent two decades believing that filters on cigarettes made them safer. This belief was entirely false, and it distracted from our need to understand much better how people can attempt to and stay quit,” he says.

E-cigarettes and vape pens have not been approved by the U.S. Food and Drug Administration (FDA) as a smoking cessation method, but some people use them that way. E-cigarettes have not been shown to be a safe or effective way to quit smoking, according to MedlinePlus.

There’s a divide in the health community about e-cigarettes and vaping, says Karey. “These could be a harm-reducing tool if a person is going to either do this or smoke cigarettes. However, if adolescents are starting to smoke e-cigarettes and they never would have smoked cigarettes, you’re introducing potential harm where there would have otherwise been no risk,” she says.

The use of e-cigarettes may actually increase the likelihood of later cigarette smoking. A study published in February 2021 in Pediatrics found that young people ages 12 to 24 who used e-cigarettes were three times more likely to eventually become daily cigarette smokers.

A few things to keep in mind when considering e-cigarettes, according to MedlinePlus:

Both the authors and Goldstein agree that the take-home message of the study should not be that vapers or hookah users should change the way they exhale. Instead, people should focus on the free resources that are available in every state to help people quit smoking for good, says Goldstein.

If you want to quit smoking, the CDC offers information and materials on how to get started.

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