E-Cigarette, Cigarette Use Linked to Severe, Frequent Ocular Symptoms in Youth

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An analysis of more than 4000 adolescents and young adults in the US found those who more recently used tobacco products reported more symptoms than other users.

Adolescent and young adult users of both electronic cigarettes and cigarettes experienced a higher likelihood of severe and frequent ocular symptoms compared with users of a single tobacco product, according to new research.1

Conducted in May 2020, the cross-sectional survey of more than 4000 individuals aged 13 to 24 years reported greater ocular symptoms among cigarette users than among e-cigarette users, while more recent use was associated with an increase in reported symptoms.

“These findings provide additional reasons to screen, counsel, and treat all tobacco users to prevent and reduce ocular symptoms,” wrote the investigative team, led by Albert Y. Wu, MD, PhD, department of ophthalmology at the Stanford University School of Medicine and Bonnie Halpern-Felsher, PhD, of the REACH Lab at Stanford University

Study data has found an association between cigarette use and ocular damage, as well as an increased risk of eye diseases, including age-related macular degeneration, glaucoma, and cataract. On the contrary, literature on the short- and long-term ocular effects of e-cigarette use remains limited, particularly among adolescents and young adults.

Led by Wu and Halpern-Felsher, the investigative team described the magnitude of ocular symptoms reported by young e-cigarette users, cigarette users, or dual users. Between May 6 and May 14, 2020, the observational cross-sectional survey asked 4351 participants about tobacco use, including “ever use”, “past 30-day use”, and “past 7-day use.”

The analysis examined the frequency and severity of 10 symptoms occurring in and around a patient’s eye, including ocular discomfort, pain, burning, itching, redness, dryness, glare, blurriness, strain, and headaches. For the analysis, each regression model was adjusted for sociodemographic factors, contact lens use, and the use of other combustible substances.

The total population had a mean age of 19.1 years and 63.8% identified as female. Investigators identified 2183 (50.2%) ever-users of e-cigarettes and 1588 (36.5%) ever-users of cigarettes. Among those who ever used e-cigarettes, 55.9% also used cigarettes. The population also included 1092 past 30-day users and 919 past 7-day users of e-cigarettes.

Of the ever dual users, between 1.1% and 3.9% of participants reported severe to very severe ocular symptoms, while between 0.9% and 4.3% reported daily symptoms. Investigators noted this was higher than the proportion of symptoms in e-cigarette- or cigarette-only users.

Upon analysis, investigators found past 7-day dual users had more severe symptoms compared with all other participants, including:

  • itching (adjusted odds ratio [AOR], 2.37; 95% CI, 1.36 - 4.13; P = .002)
  • redness (AOR, 2.58; 95% CI, 1.50 - 4.46; P = .001)
  • dryness (AOR, 2.89; 95% CI, 1.64 - 5.08; P <.001)
  • glare (AOR, 2.56; 95% CI, 1.50 - 4.35; P = .001)
  • blurriness (AOR, 2.47; 95% CI, 1.36 - 4.50; P = .003)
  • headaches (AOR, 2.31; 95% CI, 1.34 - 4.00; P = .003)
  • more frequent pain (AOR, 3.45; 95% CI, 2.09 - 5.68; P <.001)
  • burning (AOR, 3.08; 95% CI, 1.86 - 5.09); P <.001)
  • redness (AOR, 2.72; 95% CI, 1.69 - 4.36; P <.001)

Additionally, the past 30-day dual users had more severe dryness (AOR, 2.65; 95% CI, 1.61 - 4.36; P <.001) and more frequent pain (AOR, 3.33; 95% CI, 2.12 - 5.21; P <.001), compared with all other participants.

Participants considered dual ever-users also experienced more severe dryness (AOR, 1.60; 95% CI, 1.05 - 2.43; P = .03) and blurry vision (AOR, 1.79; 95% CI, 1.21 - 2.64; P = .003). as well as more frequent pain (AOR, 1.69; 95% CI, 1.13 - 2.53; P = .01) and blurriness (AOR, 1.63; 95% CI, 1.13 - 2.36; P = .009, compared with all other participants.

In a linked editorial, Jennifer P. Craig, PhD, of the New Zealand National Eye Centre, The University of Auckland, urged caution when interpreting the study’s findings, particularly in the absence of data quantifying the frequency and amount of e-cigarette and cigarette use.2

“...Without data quantifying the frequency and amount of e-cigarette and conventional cigarette use during these time periods, it cannot be reliably determined whether the higher rates of ocular symptoms among users of both smoking modalities might simply be attributable to a greater overall quantity of nicotine intake or whether an interaction effect may exist between the use of both modalities that risks additional adverse ocular effects,” Craig wrote.2


  1. Nguyen AX, Gaiha SM, Chung S, Halpern-Felsher B, Wu AY. Ocular Symptoms in Adolescents and Young Adults With Electronic Cigarette, Cigarette, and Dual Use. JAMA Ophthalmol. Published online August 31, 2023. doi:10.1001/jamaophthalmol.2023.3852
  2. Wang MTM, Britten-Jones AC, Craig JP. Electronic Cigarette Smoking and the Eyes. JAMA Ophthalmol. Published online August 31, 2023. doi:10.1001/jamaophthalmol.2023.4020