Electronic Cigarettes and Peripheral Artery Disease: Are Vapes Safer?

Citable definition: Peripheral artery disease (PAD) is a chronic atherosclerotic condition (buildup of fatty plaques inside artery walls) in which narrowed arteries reduce blood flow to the limbs — most commonly the legs — causing symptoms ranging from exercise-induced leg pain to critical limb ischemia and amputation risk. Electronic cigarettes (e-cigarettes, or “vapes”) deliver nicotine and other aerosolized compounds that acutely impair vascular function; growing evidence indicates they are not a cardiovascular-safe substitute for tobacco smoking.

What Is Peripheral Artery Disease — and Why Does Smoking Matter?

PAD affects an estimated 200 million people worldwide, according to available data (Fowkes FGR et al., Lancet, 2013; PMID 23915883). In Europe, prevalence rises steeply with age, reaching 15–20% in adults over 70, according to available data. In the United States, according to available data, more than 6.5 million Americans aged 40 and older live with the condition.

Tobacco smoking is one of the strongest modifiable risk factors for PAD. Nicotine and combustion byproducts promote endothelial dysfunction (damage to the inner lining of blood vessels), accelerate atherosclerosis (hardening and narrowing of arteries), and increase blood clot formation. Smokers are two to four times more likely to develop PAD than non-smokers, according to available data (Fowkes FGR et al., Lancet, 2013; PMID 23915883).

Against this backdrop, millions of patients and healthcare providers have looked to e-cigarettes as a supposedly “cleaner” bridge away from tobacco. The question our vascular specialists at Petit Veinard keep encountering is blunt: are vapes actually safer for your arteries? The answer emerging from the science is deeply uncomfortable for the vaping industry.

For a broader overview of how lifestyle choices affect leg artery health, visit our vascular health resource centre.

How E-Cigarettes Affect Your Arteries: The Mechanisms

Nicotine Is Still the Problem

Whether delivered by a combustible cigarette or a sleek USB-shaped device, nicotine triggers the same cascade of vascular stress. It stimulates the sympathetic nervous system (the body’s “fight or flight” system), causing:

• Vasoconstriction — arteries narrow, reducing blood flow
• Elevated heart rate and blood pressure — the heart works harder
• Platelet activation — blood becomes more prone to clotting
• Oxidative stress — free radicals damage artery walls

A 2020 study by Tsai, Byun, Shin, and colleagues, published in the Journal of Physiology, examined the effects of e-cigarettes and vaping devices on cardiac and pulmonary physiology. According to the authors, nicotine-containing vaping products may contribute to acute cardiovascular stress responses (Tsai MC et al., J Physiol, 2020; PMID 32030788).

Arterial Stiffness: A Direct PAD Precursor

Arterial stiffness (reduced elasticity of artery walls, measured by pulse wave velocity) is an independent predictor of cardiovascular events and is directly implicated in the progression of PAD.

A randomized, double-blinded pilot study by Franzen, Willig, Cayo Talavera, and colleagues (2018) compared the acute vascular effects of e-cigarettes and conventional cigarettes against a sham (placebo) condition. Both e-cigarette and conventional cigarette use significantly worsened peripheral and central hemodynamics and increased arterial stiffness compared to the sham group. The authors reported that e-cigarette use produced vascular changes comparable to those observed with tobacco cigarettes (Franzen KF et al., Vascular Medicine, 2018; PMID 30025506).

This pilot study provides early evidence challenging the assumption that vaping is safer for peripheral arteries than conventional smoking, though larger confirmatory studies are needed.

Beyond Nicotine: The Aerosol Itself

The 2023 American Heart Association (AHA) Scientific Statement on the cardiopulmonary impact of electronic cigarettes — one of the most authoritative documents on the subject to date — synthesized evidence showing that e-cigarette aerosols contain not only nicotine but also:

• Acrolein and formaldehyde — reactive aldehydes that damage endothelial cells
• Heavy metals (nickel, lead, chromium) — leached from heating coils
• Ultrafine particles — which penetrate deep into the lungs and enter systemic circulation, promoting systemic inflammation

According to the authors, the statement concluded that e-cigarettes are not without cardiovascular risk and that their potential effects on vascular function warrant careful clinical attention (Rezk-Hanna M, Williamson E et al., Circulation, 2023; DOI: 10.1161/CIR.0000000000001128).

Symptoms of PAD: What Vaping Patients Should Watch For

PAD is frequently underdiagnosed because many patients attribute their symptoms to aging or general unfitness. The classic symptom is intermittent claudication (from the Latin claudicare, to limp) — a reproducible cramping or aching pain in the calf, thigh, or buttock that appears after a predictable distance of walking and resolves within minutes of rest.

Symptoms organized by frequency:

Source: 2017 ESC/ESVS Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases (Aboyans et al., Eur J Vasc Endovasc Surg, 2018; PMID 28851596)

If you have been vaping and experience leg pain when walking that disappears at rest, do not assume it is muscle fatigue. Consult a physician or vascular specialist.

Diagnosis: What to Expect at the Vascular Clinic

A vascular specialist will typically begin with a simple, painless bedside test:

• Ankle-Brachial Index (ABI): The ratio of blood pressure measured at the ankle to that measured at the arm. An ABI below 0.90 is diagnostic of PAD. Values below 0.40 indicate severe disease.
• Duplex ultrasound: Uses sound waves to visualize blood flow and identify blockages.
• CT angiography (CTA) or MR angiography (MRA): Cross-sectional imaging that maps the entire arterial tree of the legs, used when intervention is being planned.
• Digital subtraction angiography (DSA): The gold-standard invasive imaging technique, typically reserved for pre-procedural planning.

The 2017 ESC/ESVS guidelines recommend ABI measurement as the first-line diagnostic tool in all patients with suspected PAD (Aboyans et al., 2018; PMID 28851596). The AHA/ACC 2016 Guideline on the Management of Patients with Lower Extremity PAD similarly endorses ABI as a Class I recommendation (Gerhard-Herman et al., Circulation, 2017; PMID 27840333).

Treatment: From Lifestyle Change to Endovascular Intervention

Conservative and Medical Management

Smoking and vaping cessation is the single most impactful intervention a PAD patient can make. Studies show that quitting smoking slows PAD progression, reduces amputation risk, and improves long-term survival.

Endovascular and Surgical Options

For patients with disabling claudication or critical limb ischemia (CLI — severe PAD threatening limb survival), revascularization (restoring blood flow) may be necessary:

• Balloon angioplasty and stenting — a catheter-based procedure to open narrowed arteries; aortic stenting may be used for disease at the aorto-iliac level
• Bypass surgery — a vein or synthetic graft reroutes blood around a blocked artery
• Endarterectomy — surgical removal of plaque from an artery

The choice between endovascular (catheter-based) and open surgical approaches depends on lesion anatomy, patient fitness, and center expertise — a decision made jointly by the vascular team and the patient.

Prevention: Daily Steps That Protect Your Leg Arteries

1. Stop smoking and vaping. There is no safe level of nicotine for your arteries. Ask your GP about pharmacological cessation support (varenicline, nicotine replacement therapy).
2. Walk every day. Even 30 minutes of brisk walking five days per week significantly reduces cardiovascular risk (WHO Physical Activity Guidelines, 2020).
3. Adopt a Mediterranean-style diet. Rich in olive oil, fish, vegetables, and legumes; associated with reduced atherosclerosis progression.
4. Control blood pressure. Target below 130/80 mmHg in most patients with PAD (AHA/ACC 2017 Hypertension Guidelines).
5. Manage blood sugar. Diabetes doubles PAD risk; tight glycemic control matters.
6. Inspect your feet daily. Small cuts or sores that fail to heal may be the first sign of critical ischemia.
7. Know your numbers. Ask your doctor for a lipid panel, fasting glucose, and ABI if you are over 50 and have ever smoked or vaped.

For more evidence-based prevention strategies, explore our prevention section.

When to See a Doctor — Clear Criteria

See a physician or vascular specialist promptly if you:

• Experience calf, thigh, or buttock pain that consistently appears during walking and disappears with rest
• Notice that one foot is persistently colder or paler than the other
• Have a sore or wound on your leg or foot that is not healing normally
• Feel a weak or absent pulse in your foot
• Are a current or former smoker or vaper over the age of 50 with any cardiovascular risk factor (diabetes, hypertension, high cholesterol)

Seek emergency care immediately if you:

• Develop sudden, severe leg pain with coldness and pallor (possible acute limb ischemia — a vascular emergency)
• Notice rapidly spreading redness, black discoloration, or foul-smelling wounds on the foot

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Sources

1. Franzen KF, Willig J, Cayo Talavera S, et al. E-cigarettes and cigarettes worsen peripheral and central hemodynamics as well as arterial stiffness: A randomized, double-blinded pilot study. Vascular Medicine. 2018;23(5):419–425. PMID: 30025506

2. Tsai MC, Byun MK, Shin J, et al. Effects of e-cigarettes and vaping devices on cardiac and pulmonary physiology. Journal of Physiology. 2020;598(22):5039–5062. PMID: 32030788

3. Rezk-Hanna M, Williamson E, Perez-Pinzon MA, et al. Cardiopulmonary impact of electronic cigarettes and vaping products: a scientific statement from the American Heart Association. Circulation. 2023;148(8):703–728. DOI: 10.1161/CIR.0000000000001128

4. Aboyans V, Ricco JB, Bartelink MEL, et al. 2017 ESC/ESVS Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases. European Journal of Vascular and Endovascular Surgery. 2018;55(3):305–368. PMID: 28851596

5. Gerhard-Herman MD, Gornik HL, Barrett C, et al. 2016 AHA/ACC Guideline on the Management of Patients with Lower Extremity Peripheral Artery Disease. Circulation. 2017;135(12):e726–e779. PMID: 27840333

6. Fowkes FGR, Rudan D, Rudan I, et al. Comparison of global estimates of prevalence and risk factors for peripheral artery disease in 2000 and 2010. Lancet. 2013;382(9901):1329–1340. PMID: 23915883

Medical Disclaimer: This article is produced by the Petit Veinard Editorial Board for informational and educational purposes only. It does not constitute medical advice, diagnosis, or a treatment recommendation. All content is based on published scientific literature and clinical guidelines available at the time of writing. Individual medical situations vary; always consult a qualified physician or vascular specialist before making any decision about your health or treatment. In the event of a medical emergency, contact your local emergency services immediately.