Literature Review: Vaping and Your Health

Vaping is gaining popularity, particularly among youth. Some people believe that vaping is a safe alternative to smoking. But is it truly safe? Read on to learn what research, medical and dental literature has reported about the Vaping and Health.

What is vaping?

An e-cigarette is a battery-operated device or ‘cigarette’ that delivers flavored nicotine using vapors instead of smoke. The device uses a power source (e.g. lithium ion battery) to heat a metal element. The element aerosolizes the flavored e-liquids, and the user inhales the resulting aerosol.

Most e-liquids contain four base chemicals: propylene glycol, vegetable glycerin, nicotine, and flavorings. In the U.S., over 400 companies distribute thousands of e-liquids through local ‘vape shops’ and online stores.1

The exact ingredients in e-cigarettes aren’t all known, because the Food and Drug Administration does not require vape manufacturers to provide a full list.

In 2014, there were over 7,700 different e-liquid formulations available on the market and it is estimated that more than 200 new flavors are being introduced monthly.1

What is in e-cigarette aerosol?

The e-cigarette aerosol that users breathe from the device and exhale can contain potentially harmful substances, including:

• Nicotine
• Ultrafine particles that can be inhaled deep into the lungs
• Flavoring such as diacetyl, a chemical linked to a serious lung disease
• Volatile organic compounds
• Cancer-causing chemicals
• Heavy metals such as nickel, tin, and lead

It is difficult for consumers to know what e-cigarette products contain. For example, some e-cigarettes marketed as containing zero percent nicotine have been found to contain nicotine.

Is vaping harmful?

“Studies suggest e-cigarette fluids contain cancer causing chemicals, such as formaldehyde. Others show vaping pens can release heavy metals, chemicals and glass particles found in the welding material and tubing for the device,” states Dr. Jeffrey Spiegel, who is chief of facial plastic surgery at Boston Medical Center.

Medical effects of vaping

“Based on our findings, e-cigarettes are not a safe alternative to traditional cigarettes as it relates to timely wound healing and this should be considered before and after surgery,” said Spiegel. Based on experiments on rats, he said, “Smoking and vaping appear to be equally detrimental to wound healing and associated with a statistically significant increase in tissue death.”

One Boston University study says patients should be banned from vaping for two months before surgery to avoid complications. Nicotine, the addictive ingredient, is known to restrict blood flow and raise the risk of complications for cigarette smokers.

“Vaping just once – even when it doesn’t contain nicotine or THC – can damage a person’s blood vessels,” according to a study published in the Journal of Radiology. Researchers observed reduced blood flow and oxygen in the participants’ legs after each one ‘took 16 puffs of an e-cigarette that contained tobacco flavorings and sweeteners like propylene glycol and glycerol, but no nicotine’. The participants had never used an e-cigarette before. This studied has shown an immediate effect on the body’s vascular function.

Over time, however, “This kind of damage to the body can become cumulative,” said Dr. S. Christy Sadreameli, a pediatric pulmonologist at the Johns Hopkins Hospital in Baltimore, and volunteer spokesperson for the American Lung Association. That cumulative damage is what could increase the risk of heart problems.

“It may not mean that you are going to have a heart attack soon,” Sadreameli said. “But while we all get some damage to our blood vessels with aging, this means it could start happening younger and in a more accelerated fashion.” Author Felix Wehrli, a professor of radiologic science and biophysics at the University of Pennsylvania told NBC News that the effect is similar to what’s known about conventional tobacco smoking.

Vaping and Nicotine

“Nicotine is a highly addictive substance and, in excess amounts, can be lethal. A single Juul pod can have as much nicotine as twenty cigarettes. Nicotine can adversely affect adolescent brain development, which continues until young adults are in their mid-twenties,” reports Sucharita Kher, assistant professor at the School of Medicine and director of the Tufts Medical Center Outpatient Pulmonary Clinic.2

• Nicotine, has known health effects.
• Nicotine is highly addictive.
• Nicotine is toxic to developing fetuses.
• Nicotine can harm adolescent brain development, which continues into the early to mid-20s.
• Nicotine is a health danger for pregnant women and their developing babies. 1

Vaping and the lungs

“Vaping continues to be at the forefront of the public health dialogue—multiple people have been hospitalized as a result of severe lung damage from vaping, and e-cigarette use has also been linked to seizures among those who vape. Now, vaping is also being linked to a severe type of pneumonia,” Maggie O’Neil writes in August 2019 in Explore Health.4

Vaping is linked to lipoid pneumonia, which is caused when lipids, essentially, fatty acids, enter the lungs, causing the lungs to become inflamed.

Lipoid pneumonia seems to be one more reason that vaping isn’t necessarily safer than smoking cigarettes.

Is vaping addictive?

An e-cigarette, which heats up nicotine, is addictive. “The nicotine goes into your bloodstream and releases substances in your brain that can initially give you a pleasure sensation,” Humberto Choi, MD, a pulmonary medicine specialist at Cleveland Clinic, tells Health.

That pleasure sensation comes from nicotine stimulating the release of dopamine, feel-good chemicals, in your brain, according to the National Institute on Drug Abuse. Those feel-good chemicals keep you coming back for more and even change your brain’s sensitivity to dopamine, leading to your body needing more and more nicotine to satisfy it.

“Vaping addiction can also lead to withdrawal once you stop. Over time, your brain starts to crave it,” says Dr. Choi, “and once you stop, your body goes through withdrawal symptoms like typical nicotine withdrawal, including weight gain, irritability, and restlessness.”

But, while experts know vaping is addictive, they’re not sure how addictive — or if it’s any more addictive than smoking regular cigarettes. According to Dr. Choi, “The scientific data isn’t there yet,” but, he explains, “when you vape you could be inhaling a higher concentration of nicotine than you would from a regular cigarette, since levels of nicotine can vary between vape juices—and more nicotine could mean a quicker, stronger addiction.”

Therefore vaping can be just as addictive, if not more than, regular cigarettes. “Previous research has shown that it takes the average smoker 30 or more attempts to quit smoking,” says Brian Barnett, MD, who works at Cleveland Clinic’s Center for Behavioral Health, tells Health. “We shouldn’t expect vaping to be any different from that.”

Vaping and Youth

The U.S. Centers for Disease Control and Prevention reported that an estimated two million U.S. middle and high school students used e-cigarettes in the past thirty days. The percentage of high school students who reported using e-cigarettes in the previous month has increased from 1.5 percent in 2011 to 11.7 percent in 2017. The U.S. Surgeon General issued a report saying that e-cigarette use among the young is a “public health concern.”

Sophisticated packaging for candy-flavored e-liquids, which targets youth, can be indistinguishable from real candies is, in part, responsible for accidental ingestion. The American Association of Poison Control Centers receives on average 10 calls a day from people regarding children who were accidently exposed to e-cigarette devices and liquid nicotine.5

Nicotine liquids, also referred to as e-juices, come in thousands of flavors often with playful names such as fried cream cakes, booger sugar, candy cane and sundae drizzle.

Teenage Target Demographic

Teenagers, specifically — who are often the target demographic for e-cigarettes — are more at risk for succumbing to this nicotine addiction since their brains aren’t fully developed, says Dr. Choi. “Teenagers especially — their brains are still developing. They’re more susceptible to this kind of stimulation.”

It may also take less time to become addicted to vaping—especially in teenagers. “It may not take a lot of exposure to begin the cycle of vaping addiction,” says Dr. Choi. In fact, teenagers specifically may cycle through the addiction process at a faster rate, becoming hooked on e-cigarettes, going through withdrawal, and then turning to e-cigarettes again “within only a matter of weeks after vaping for the first time,” Dr. Barnett tells Health.

Currently we do not have long-term data to understand the physiological, psychological, and developmental effects of e-cigarette on youth. Some researchers consider e-cigarettes as ‘gateway devices,’ in that kids are introduced to tobacco products via vaping and once addicted to nicotine, ‘graduate’ to traditional products such as cigarettes, cigars, chewing tobacco and hookah. 6,7

Children Obtain Tobacco Products

E-cigarette products are easier for children to obtain compared to regular tobacco products.8 Studies show e-cigarettes have surpassed combustible cigarettes as the most commonly used tobacco product among middle school and high school students.9-11 Marketing, internet availability and sweet flavorings may have contributed to this shift. In a 2016 report, the U.S. Surgeon General states that e-cigarette usage among youth and young adults has become a public health concern.6.

Nicotine negatively affects adolescence brain developmental processes and may lead to psychiatric disorders and cognitive impairment in later life.12-13

“Nicotine is a highly addictive substance and in excess amounts can be lethal. It can adversely affect adolescent brain development, which continues until young adults are in their mid-twenties,” explains Sucharita Kher, assistant professor at the School of Medicine and director of the Tufts Medical Center Outpatient Pulmonary Clinic. “Nicotine exposure in adolescents is associated with problems with mood, attention, and learning. It can make it harder to control impulses. It also has adverse effects on development of heart disease, aortic aneurysms, and is associated with peptic ulcer.”

What happens to the mouth and teeth in people who vape?

Vaping is bad for your dental health. American Dental Association spokesperson, Dr. Matthew Messina, in an article discussing how vaping may affect oral health, says that, “Heat in the mouth changes the bacterial presence in the mouth. It dries the mouth out.” Dr. Messina adds, “The rate of tooth decay can increase dramatically, if we dry the mouth out. In addition, vaping can lead to tooth discoloration because of the presence of nicotine, inflamed gum tissue, and bone loss. It’s important to stress the fact that while vaping is new and is being actively studied, we have to consider vaping and cigarette smoking relatively the same, as far as the effects on the teeth and gum tissues,” he says.

Dr. Messina explains that the warmer mouth temperature that is caused by vaping creates an environment favorable to harmful bacteria. Vaping can lead to dental decay, bone loss, and inflamed gum tissue. Deepak Saxena, PhD and associate professor at NYU College of Dentistry, adds that vaping can make your mouth more susceptible to infection.

Research findings reported in Dentistry IQ suggest that vaping negatively affects gum tissue, even more than smoking. Vaping has been shown to contribute to several pathophysiological effects including oxidative and carbonyl stress, inflammatory dysfunction, presence of apoptotic necrotic epithelial cells, and impaired fibroblastic activity. Evidence-based research has shown the use of electronic nicotine devices leads to changes in cellular activity, which manifests as a strong risk factor for periodontal disease and fibrosis of the oral submucosa.

Is vaping safer than cigarette smoking?

Tobacco use is associated with higher rates of tooth decay, receding gums, periodontal disease, mucosal lesions, bone damage, tooth loss, jaw bone loss and more.

Well, are e-cigs better for you teeth than normal cigarettes?

“While vaping is new and is being actively studied, we have to consider vaping and cigarette smoking relatively the same, as far as the effects on the teeth and gum tissues,” says Dr. Messina. That’s because there’s still a heat element. “The rate of tooth decay increases, sometimes dramatically, if we dry the mouth out.”

Vaping will also “cause a darkening of the teeth,” says Dr. Messina. That’s because, while e-cigarettes don’t contain tar, they do still contain nicotine—and nicotine adds to tooth discoloration. “Nicotine will stain teeth. It also sticks to the enamel and makes it rougher, so that plaque and other colored things will stick more readily and build up.”

Tufts School of Dental Medicine

“Smoking and vaping take a toll on oral health, including increasing the risk of oral cancer.” Tufts Now talked with Natalie Hagel, assistant professor of comprehensive care at Tufts School of Dental Medicine who teaches dental students about interventions and tobacco-cessation techniques for their patients. She is a faculty advisor to the Tufts student chapter of the American Association for Public Health Dentistry and is active in the oral-health section of the American Public Health Association.

With any tobacco, including regular cigarettes and vapes, the chance of oral cancer increases. So do the chances of getting periodontal disease, and dry mouth. With the higher rate of vaping, we are seeing a higher rate of dental decay, because the aerosols that are bombarding the mouth are filled with sweeteners. Research shows an increase in dry mouth. And with dry mouth comes an increase in the risk for dental decay. Many medications have dry mouth as a side effect, so if you’re taking any of those, smoking can amplify that.

Vaping marijuana

Juul, a vape pen for tobacco use, also manufactures a popular marijuana pen-and-pod device called the Pax Era. Tech-savvy teens are learning how to refill their Juul pods with different blends, including marijuana oils.

Experts and educators say young people are one step ahead of the adults, experimenting with this new way to consume weed.

“It’s only a matter of time before adolescents are vaping nicotine and pot in equal measure, ” said Mila Vascones-Gatski, a substance abuse counselor at Arlington Public Schools in Virginia. “Anything in liquid form can go into a vape, and that’s scary.”

Among California high school students who have used an electronic smoking device, 27 percent said they used it with some form of cannabis, according to a report by the state Department of Public Health, based on 2016 data.

More Research Needed

The California Department of Public Health says researchers do not fully understand how using cannabis oils and waxes with vapes affect health. What they do know is that vaporized cannabis can contain a lot more THC, the cannabis ingredient responsible for psychoactive effects such as anxiety and paranoia.

“When you make it into an oil or wax, the THC concentration can be very high,” Vascones-Gatski said. “This is when psychotic symptoms are intensified.”

Recreational marijuana use is illegal among children in all states. In California, such use was legalized for adults beginning this year. Critics argue the change could make marijuana more accessible to young people.

Some popular cannabis oil flavors include mint, jasmine, banana smoothie, pumpkin spice and gummy fish. Even if the cannabis industry says its target is not youth, there is no denying that fruity smells attract kids, said Stanton Glantz, professor of medicine and director of the Center for Tobacco Control Research and Education at University of California-San Francisco.

Lambert said, “They’re learning how to refill their Juul pods, the cartridges that contain e-juice, with different blends, including marijuana oils, with the help of video tutorials on YouTube. These oils are becoming mainstream and easy to access.”

What has the ADA stated?

The ADA is especially concerned about efforts to characterize some nicotine-containing products as less harmful than cigarettes, particularly electronic nicotine delivery systems such as vapes, vaporizers, vape pens, hookah pens, e-cigarettes and e-pipes.

While the oral health effects of vaping are not fully studied, there is some evidence that vaping increases the likelihood that tobacco users will not be able to quit. There have also been reports of orofacial damage when these devices have suddenly overheated, sometimes to the point of exploding.

Aside from the intended use of approved nicotine cessation products, the ADA discourages the use of all nicotine products made or derived from tobacco.14

The ADA continues to educate and inform its membership and the public about the many health hazards attributed to the use of traditional and non-traditional tobacco products, including e-cigarettes, e-cigarette cartridges, dissolvable tobacco, tobacco gels, and other products made or derived from tobacco. The Association does not consider the marketing of some tobacco products as safer or less harmful to an individual’s health than others to be a viable public health strategy to reduce the death and disease associated with tobacco use.

FDA Regulations

Effective August 8, 2016, FDA regulates e-cigarettes under the “Deeming Tobacco Products Amendment” (Docket No. FDA2014-N-0189). The rule extends the FDA’s regulatory authority to all tobacco products, including e-cigarettes, cigars, hookah, pipe tobacco, nicotine gels, and dissolvables. The FDA states the rule will help prevent young people from starting to use these products help consumers better understand the risks of using these products, prohibit false and misleading product claims, and prevent new tobacco products from being marketed unless a manufacturer demonstrates that the products meet the relevant public health standard. The new rule is well-received and welcomed by most U.S. health care professionals and organizations.15

The CDC says that e-cigarettes are dangerous for people who don’t smoke. “If you’ve never smoked or used other tobacco products or e-cigarettes, don’t start,” the CDC warns.

The evidence is clear that vaping impairs wound healing and is bad for your dental health. Vaping contributes to caries, periodontal disease, and tooth loss. Nicotine in many vaping products has been proven to be addictive and unhealthy. Aggressive marketing has enticed many young people to experiment with vaping. The long term effects of vaping are not fully understood, so don’t make yourself a test subject for vaping products. While research continues, there is ample proof that vaping is harmful.

Footnotes:

1. Zhu SH, Sun JY, Bonnevie E, et al. Four hundred and sixty brands of e-cigarettes and counting: implications for product regulation. Tob Control. 2014;23 Suppl 3:iii3-9.
2. US Department of Health and Human Services. E-cigarette use among youth and young adults: a report of the Surgeon General pdf icon[PDF–8.47 MB]. Atlanta, GA: US Department of Health and Human Services, CDC; 2016.
3. Goniewicz ML, Gupta R, Lee YH, et al. Nicotine levels in electronic cigarette refill solutions: a comparative analysis of products from the U.S., Korea, and Poland. Int J Drug Policy. 2015;26(6):583–588.
4. https://www.health.com/smoking/lipoid-pneumonia-vaping
5. http://www.aapcc.org/alerts/e-cigarettes/
6. Barrington-Trimis JL, Berhane K, Unger JB, et al. The E-cigarette Social Environment, E-cigarette Use, and Susceptibility to Cigarette Smoking. J Adolesc Health. 2016;59(1):75-80.
7. Barrington-Trimis JL, Urman R, Berhane K, et al. E-Cigarettes and Future Cigarette Use. Pediatrics. 2016;138(1).
8. https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6349a1.htm
9. https://www.cdc.gov/mmwr/volumes/65/wr/mm6514a1.htm
10. https://www.drugabuse.gov/trends-statistics/monitoring-future/monitoring-futurestudy-trends-in-prevalence-various-drugs
11. https://www.cdc.gov/mmwr/volumes/65/wr/mm655051a2.htm
12. https://www.surgeongeneral.gov/library/2016ecigarettes/index.html
13. https://www.surgeongeneral.gov/library/reports/50-years-of-progress/full-report.pdf
14. http://www.fda.gov/TobaccoProducts/Labeling/RulesRegulationsGuidance/ucm32094909.htm)