Content Dam Diq Online Articles 2019 01 Vaping 1

‘Fine, I’ll just vape without the nicotine.’ Not so fast! E-cig flavorings may cause damage all by themselves

Jan. 24, 2019
The health and oral effects of vaping are being closely studied, and the excuse that it's nicotine-free is not going to work for long. Studies are showing that vaping has effects on oral health.
Early last year, we got our first confirmation that vaping—once touted as a “Get Out of Jail Free” card for smokers—isn’t all that it’s cracked up to be.

That confirmation came in the form of a 600+ page report that comprehensively analyzed 800 peer-reviewed studies. It concluded that the available evidence supports far more caution should be exercised with regard to vaping than we previously thought, especially when it comes to young people vaping.

I’ve written about the importance of dentists, hygienists, and assistants taking vaping seriously, especially in young patients. As health-care professionals with a special interest in the oral-systemic connection, dental professionals have a unique opportunity to stress to patients that we don’t know everything about how these substances can harm bodies in the long run.

However, we are rapidly learning more about the “juice” that runs the vaping industry. As new studies are released, there are rising concerns about ingredients that have absolutely nothing to do with nicotine.

Studies are showing the effects of vaping

According to an article published in the American Heart Association’s journal called “Arteriosclerosis, thrombosis and vascular biology,” flavor additives commonly used in electronic cigarettes may impair blood vessel function.

In another article titled “E-cigarette flavorings may damage blood vessel function,” by Jessica L. Fetterman, PhD, assistant professor of medicine at Boston University School of Medicine, nine chemical flavorings widely used in e-cigarettes—menthol (mint), acetylpyridine (burnt flavor), vanillin (vanilla), cinnamaldehyde (cinnamon), eugenol (clove), diacetyl (butter), dimethylpyrazine (strawberry), isoamyl acetate (banana), and eucalyptol (spicy cooling)—were tested for their short-term effects on endothelial cells, the cells that line the blood vessels and the inside of the heart.


RELATED ARTICLE:Vaping and oral health: It's worse than you think


In the in vitro (laboratory) studies , researchers found all nine flavors can damage delicate blood vessel endothelial cells at the highest levels tested, and all of the flavorings impaired nitric oxide production in endothelial cells. Several of the flavorings—menthol, clove, vanillin, cinnamon, and burnt flavoring—resulted in higher levels of an inflammatory marker called interleukin-6 (IL-6) at all concentrations tested, which suggests the endothelium is particularly sensitive to these flavors.

In addition, these flavorings were responsible for lower levels of nitric oxide, which inhibits inflammation and clotting and promotes vasodilation in response to greater blood flow. There’s also every reason to believe that flavors that were not tested may have similar properties and effects on the body, however, that’s for other researchers to test and measure in another study.

Dr. Fetterman did not leave a great deal of wiggle room when it came to interpreting the effects of the flavorings on cells in the lab setting. “Increased inflammation and a loss of nitric oxide are some of the first changes to occur leading up to cardiovascular disease and events like heart attacks and stroke, so they are considered early predictors of heart disease.”

The findings of this study will need to be replicated in vivo—in laboratory animals—but in the meantime, this research led to the American Heart Association reemphasizing its 2014 caution against vaping.

Meanwhile, a similarly designed study at the University of Rochester Medical Center reported an additional avenue for future research regarding the effects of vaping flavoring agents on overall health, this time focusing on the immune system rather than cardiovascular risks.

The article, “Inflammatory and oxidative responses induced by exposure to commonly used e-cigarette flavoring chemicals and flavored e-liquids without nicotine” was published in the open-source, non-peer-reviewed journal, Frontiers in Physiology.

In the study, researchers concluded that their data suggests that the flavoring compounds used in e-liquids appear to elevate biomarkers of damage in immune cells called monocytes, leading to potential pulmonary toxicity and tissue damage in e-cigarette users. While it turns out that some flavors were more damaging than others, the most interesting aspect of this study was that the cells showed the greatest amount of damage when flavors were combined.

The pace of investigation to regulate products to protect public health seems to proceed at a snail’s pace. It may very well take data collected from a full generation of vapers to build a bulletproof case that vaping e-liquids causes health problems beyond a reasonable doubt.

Dental professionals can make a difference sharing this knowledge

Fortunately, that is not the standard that dental professionals need to abide by. We can offer our professional opinions, advice, and all the evidence we can muster in the few minutes we have with each patient. It’s not only our professional right, it’s our duty as health advocates to share what we know with our patients and to warn them about health consequences they may not be aware of.

Don’t be afraid to ask patients whether they vape, and to point them to emerging research about the potential long-term health consequences of vaping.

With over 30 years of experience as a pharmacist, dental educator, and author, Tom Viola, RPh, CCP, has earned a reputation as an international authority on dental pharmacology. He says that knowledge of pharmacology has never been more essential to patient care. Tom is well known for his contributions to many dental journals in the areas of pharmacology, pain management, and local anesthesia. He’s served as a contributor, chapter author, and peer reviewer for several dental pharmacology textbooks and national board exam review books. For more information, visit or contact him at [email protected].
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