By now, it seems pretty clear that using e-cigarettes, or vaping, is bad for your lungs. But research about exactly how vaping affects the lungs is in the initial stages, says Johns Hopkins lung cancer surgeon Stephen Broderick.

“In the last 24 to 36 months, I’ve seen an explosive uptick of patients who vape,” reports Broderick. “With tobacco, we have six decades of rigorous studies to show which of the 7,000 chemicals inhaled during smoking impact the lungs. But with vaping, we simply don’t know the short- or long-term effects yet and which e-cigarette components are to blame.”

Although there’s no definitive answer at this point, experts do have a theory about how vaping harms lungs.

What Happens When You Vape

Both smoking and vaping involve heating a substance and inhaling the resulting fumes. With traditional cigarettes, you inhale smoke from burning tobacco. With vaping, a device (typically a vape pen or a mod — an enhanced vape pen — that may look like a flash drive) heats up a liquid (called vape juice or e-liquid) until it turns into a vapor that you inhale.

“Vaping is a delivery system similar to a nebulizer, which people with asthma or other lung conditions may be familiar with,” says Broderick. “A nebulizer turns liquid medicine into a mist that patients breathe in. It’s a highly effective way of delivering medicine to the lungs.”

The Chemicals You Inhale When Vaping

Instead of bathing lung tissue with a therapeutic mist, just as a nebulizer does, vaping coats lungs with potentially harmful chemicals. E-liquid concoctions usually include some mix of flavorings, aromatic additives and nicotine or THC (the chemical in marijuana that causes psychological effects), dissolved in an oily liquid base. “We think that some of the vaporized elements of the oil are getting deep down into the lungs and causing an inflammatory response,” explains Broderick.

The substance at the center of investigation is vitamin E. It’s often used as a thickening and delivery agent in e-liquid. And, while it’s safe when taken orally as a supplement or used on the skin, it’s likely an irritant when inhaled. It’s been found in the lungs of people with severe, vaping-related damage.

Other common substances found in e-liquid or produced when it’s heated up may also pose a risk to the lungs. These include:

• Diacetyl: This food additive, used to deepen e-cigarette flavors, is known to damage small passageways in the lungs.
• Formaldehyde: This toxic chemical can cause lung disease and contribute to heart disease.
• Acrolein: Most often used as a weed killer, this chemical can also damage lungs.

How Vaping Can Affect Your Lungs

Over time, as e-cigarette use continues, experts will gain a better understanding of how vaping affects the lungs. What we do know right now is that several lung diseases are associated with vaping:

Vaping and Popcorn Lung

“Popcorn lung” is another name for bronchiolitis obliterans (BO), a rare condition that results from damage of the lungs’ small airways. BO was originally discovered when popcorn factory workers started getting sick. The culprit was diacetyl, a food additive used to simulate butter flavor in microwave popcorn.

Diacetyl is frequently added to flavored e-liquid to enhance the taste. Inhaling diacetyl causes inflammation and may lead to permanent scarring in the smallest branches of the airways — popcorn lung — which makes breathing difficult. Popcorn lung has no lasting treatment. There are, however, treatments that manage BO symptoms, such as:

• Coughing
• Wheezing
• Chest pain
• Shortness of breath

Vaping-Related Lipoid Pneumonia

Unlike the classic pneumonia caused by infection, lipoid pneumonia develops when fatty acids (the building blocks of fat) enter the lungs. Vaping-related lipoid pneumonia is the result of inhaling oily substances found in e-liquid, which sparks an inflammatory response in the lungs. Symptoms of lipoid pneumonia include:

• Chronic cough
• Shortness of breath
• Coughing up blood or blood-tinged mucus

“There’s isn’t a good treatment for lipoid pneumonia, other than supportive care, while the lungs heal on their own,” says Broderick. “The single-most important thing you can do is identify what is causing it — in this case vaping — and eliminate it.”

Primary Spontaneous Pneumothorax (Collapsed Lung) After Vaping

Primary spontaneous pneumothorax, or collapsed lung, occurs when there’s a hole in the lung through which oxygen escapes. This can be the result of an injury — such as a gunshot or knife wound — or when air blisters on the top of the lungs rupture and create tiny tears.

Those who develop these blisters are usually tall, thin people who had a period of rapid growth during adolescence, says Broderick. Because of the accelerated growth, a weak point may blister and develop at the top of the lungs. On their own, these blisters don’t typically produce symptoms. You don’t know you have them, unless they rupture. Smoking — and now vaping — are associated with an increased risk of bursting these blisters, leading to lung collapse.

“At Johns Hopkins, we’re seeing a rash of collapsed lungs in younger people,” reports Broderick. “We always ask if they’ve been smoking, and they’ll often say, ‘No, I don’t smoke. But I do vape.’ Now we tell patients not to smoke or vape if they want to avoid another lung collapse and surgery in the future.”

Signs of a collapsed lung include:

• Sharp chest or shoulder pain
• Shortness of breath
• Difficulty breathing

Oxygen treatment and rest may be all that’s need for a collapsed lung to heal. But more advanced cases require a chest tube to drain leaked oxygen from the body cavity or surgery to repair the hole in the lung.

Can Vaping Cause Lung Cancer?

Cancer is definitely a concern, given that vaping introduces a host of chemicals into the lungs. But vaping products haven’t been around long enough for us to learn whether or not they cause cancer.

“We do know that smoking tobacco forces tiny particles to be deposited deep in the bronchial tree and can lead to the development of cancer. The same may be true for vaping,” says Broderick.

Secondhand Vapor Isn’t Safe Either

It’s a myth that secondhand emissions from e-cigarettes are harmless. Many people think the secondhand vapor is just water, but this couldn’t be farther from the truth. The vapor emitted when someone exhales contains a variety of dangerous substances, which may include:

• Nicotine
• Ultrafine particles
• Diacetyl
• Benzene (a chemical found in car exhaust)

Although secondhand vapor may not affect the lungs the same way as vaping, it is better to avoid it, if possible.

What to Do If Your Lungs Hurt

If you smoke or vape, don’t brush off chest or lung pain as something that’s normal. If you have pain or other symptoms associated with breathing difficulties, such as shortness of breath and chronic cough, it’s important to see a doctor.

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