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Many people seem to think that inhaling e-cig vapor is harmless or, at least, not nearly as dangerous as smoking tobacco. More and more studies, however, suggest that e-cigs do pose health risks, and those recent risks are not trivial. One recent study found that, compared to people who don’t use tobacco or vape, e-cigarette users have twice the risk of having a heart attack.

Meanwhile, people who smoked “normal”, tobacco cigarettes had nearly a tripled risk of having a heart attack compared to non-smokers. What was truly surprising was that in people who both smoked tobacco and e-cigs, the risk of a heart attack was five times greater than in non-smokers/non-vapers — so the two risks seem to stack together somewhat. According to the study published in the American Journal of Preventive Medicine by researchers at the University of California San Francisco along with a team from George Washington University, nearly 66% of e-cigarette users also smoke tobacco.

The study relied on two datasets involving more than 69,000 people 18 and older, who were surveyed in 2014 and 2016. The findings stood even after the researchers controlled for variables such as age, sex, body mass index, high blood pressure, high cholesterol, and diabetes.

Of the 9,352 participants who were current or former e-cigarette users, 333 (3.6%) had experienced a heart attack at some point. The highest percentage of heart attacks (6.1 percent) was among those who used e-cigarettes daily.

“Most adults who use e-cigarettes continue to smoke cigarettes,” said senior author Stanton Glantz, PhD, a UCSF professor of medicine and director of the UCSF Center for Tobacco Control Research and Education.

“While people may think they are reducing their health risks, we found that the heart attack risk of e-cigarettes adds to the risk of smoking cigarettes,” Glantz said. “Using both products at the same time is worse than using either one separately. Someone who continues to smoke daily while using e-cigarettes daily increases the odds of a heart attack by a factor of five.”

The good news is that once people quit smoking tobacco or inhaling e-cig vapor, a person’s health quickly and dramatically improves.

“The risk of heart attack starts to drop immediately after you stop smoking,” said Glantz. “Our results suggest the same is true when they stop using e-cigarettes.”

An electronic cigarette works by delivering an aerosol of nicotine and usually other flavors by heating a liquid. These products are marketed as the safer alternative to smoking conventional cigarettes, which generate nicotine by burning tobacco. However, e-cigs aren’t harmless. While they deliver lower levels of carcinogens than tobacco, e-cigs generate ultrafine particles (up to 100th the thickness of a human hair) that can hurt the lung and airways, as well as toxins that have been linked to cardiovascular and non-cancer lung diseases.

The was only an observational study, so no direct causality was established. Nevertheless, the association between e-cig use and heart disease is significant, suggesting that vaping isn’t really a healthy alternative to smoking. The best thing a smoker can do is stop both.