A Cloud of Danger

A Cloud of Danger

With the rise in use of electronic cigarettes, especially among youth, researchers and clinicians – including those at Creighton – are sounding alarms on the negative health effects of vaping, from dental disease to altered lung function.

By Margaret Bumann

The photos are pretty gruesome. A 55-year-old woman in distress makes an emergency visit to a dental clinic. The inside of her mouth is blanketed with painful, peeling white lesions that look like burns. A former smoker, she was using electronic cigarettes for about two years, but only developed mouth sores after purchasing a new bottle of vape juice.

The diagnosis: oral lesions related to e-cigarette liquid.

It is difficult to know precisely what caused the dental patient’s mouth sores, but the most likely culprit is propylene glycol, which is commonly used in cosmetics, pharmaceuticals and as a food additive.

E-cigarette juice is a mixture of propylene glycol, glycerol, a choice of nicotine levels, benzoic acid (a common food preservative) and food-grade flavoring.

“Propylene glycol is an irritant in the mouth and throat,” says Hardeep Chehal, DDS’15, a professor and board-certified oral and maxillofacial pathologist who holds the Dr. Oscar S. Belzer Endowed Chair in Dentistry.

Because vaping is still relatively new, we still don’t know the long-term consequences of using e-cigarettes, but cases such as this are a red flag, and “there are definitely similar cases being reported,” according to Chehal.

What is Vaping?

E-cigarettes come in a variety of shapes, sizes and designs, but work in the same way; the battery-powered devices heat the liquid, or “juice,” to make an aerosol that is inhaled and exhaled.

Chinese pharmacist Hon Lik is credited with patenting the first e-cigarette device, and creating it when his father was dying of lung cancer. The devices were first introduced to the U.S. mass market in 2007 as a way for tobacco smokers to replace or supplement nicotine.

At the time, they were not covered by existing tobacco regulations, and their popularity grew slowly.

Then manufacturers began adding flavorings to e-cigarette juice, a practice recently targeted by the Food and Drug Administration, with varieties reaching the thousands — from blueberry cheesecake to mango, cinnamon, gummy bear, cookies ’n cream and cotton candy. By 2014, a congressional report had already accused e-cigarette companies of marketing their flavors to youth.

Vaping and Dental Disease

It is a well-known fact that cigarette smoking can contribute to periodontal disease and other adverse oral outcomes. E-cigarette companies claim that switching from smoking to vaping is a less harmful alternative, but that may not be true, according to a review of the latest research by two Creighton dental students.

Emily Johnson, BSCHM’19, who is working on a Master of Oral Biology degree, says studies show that flavoring agents used in e-cigarettes produce a more acidic environment in the mouth, making the user more susceptible to irritable gums and gum disease. In addition, she says, studies have found that for patients receiving dental implants, rejection is more likely in e-cigarette users compared to nonusers.

Dental student Emily Snodgrass says her review of the literature showed a similar negative correlation between vaping and dental health.

The Creighton Dental Clinic has taken note. The health-history form that patients fill out when they visit the clinic now asks if they have a history of vaping.

“That simple addition may help us identify patients who could be at greater risk of (dental) disease,” Snodgrass says.

Teens and Vaping

Health officials nationwide are especially concerned about the rise of vaping among teens and younger children. Among the e-cigarette brands on the market, Juul is so ubiquitous on high school and college campuses that “to Juul” has become synonymous with vaping.

The Centers for Disease Control and Prevention (CDC) calls youth vaping a health concern of unmatched proportions: “The United States has never seen an epidemic of substance use arise as quickly as our current epidemic of youth use of e-cigarettes.”

The 2019 National Youth Tobacco Survey, conducted by the Food and Drug Administration (FDA) and the CDC, shows that 5 million U.S. middle and high school students use e-cigarettes, and more than 1 in 4 high school seniors reported vaping in the last 30 days. The number of e-cigarette users who began vaping at age 14 or younger has more than tripled in the last five years, according to University of Michigan research.

What’s the appeal of vaping for young people? One, sophisticated technology, and two, the flavors used in e-cigarette juice. Fruit flavors such as banana and blue raspberry. Dessert flavors such as chocolate truffle. Sophisticated flavors such as espresso. Once initiated, the nicotine fix can result in an addictive habit.

Vaping Alters Lung Function

Charles Bockman, PhD, assistant professor of pharmacology and neuroscience at Creighton and part of Creighton’s Cancer and Smoking and Disease Research Program, says health concerns over youth vaping include  impaired brain development, nicotine addiction and e-cigarettes leading to cigarette and other drug use.

Like alcohol and heroin, nicotine affects the brain’s reward system. The CDC says that using nicotine in adolescence can harm the parts of the brain that control attention, learning, mood and impulse control.

When Bockman began studying vaping two years ago, with the help of undergraduate student Michael Franco, very little research had been done on the health effects of e-cigarettes. In fact, the duo had to build their own vaping chamber to study the effects of vaping on mice.

What have they found? Chronic exposure to vaping alters lung function. At least in mice; they have not conducted any human trials.

“We are finding that mice exposed to daily vaping are developing airways that are hypersensitive to contractile stimuli like allergens. This change can increase one’s risk for dangerous bronchospasms and respiratory distress,” Bockman says.

Vaping and Smoking Cessation

A growing body of evidence, including the study from Bockman’s lab, confirms that vaping is far from harmless, but a question remains: Is it the lesser of two evils when compared to cigarettes?

“There is a lot of evidence that answers this already, that it is not the lesser of two evils,” says Kate Nolt, MPH, PhD, assistant professor in the Department of Interdisciplinary Studies at Creighton, and co-chair of the Alcohol, Tobacco and Other Drugs Section Policy Committee for the American Public Health Association (APHA). “It is in some ways worse because we know it can cause acute lung injury in the short term.”

For decades, reducing tobacco use has been a major U.S. public health initiative. According to the CDC, cigarette smoking kills more than 480,000 Americans annually. In addition, smoking-related illness in the United States costs more than $300 billion a year, including nearly $170 billion in direct medical care for adults and $156 billion in lost productivity.

“There was, and still is, interest in the medical community about the possibility that vaping could be even more effective (than nicotine gum or patches),” in terms of smoking cessation, Bockman says. “In addition to nicotine, it may supply the oral sensation and rapidity of action of smoking and thus be more effective in suppressing the urge to smoke.”

Health Threat?

In 2019, an outbreak of severe lung illnesses tied to vaping was experienced across the United States and accounted for nearly 3,000 lung injuries and 60 deaths, according to the CDC.

The CDC says most of these cases were linked to vaping products that: (1) contained tetrahydrocannabinol (THC), the active ingredient in cannabis; (2) came from sources such as friends or online dealers, and; (3) contained vitamin E acetate, which was found in product samples tested by the FDA.

“From my professional perspective, vaping is as much a threat to the public’s general health as regular tobacco products and anything else that is addictive, and should be prevented (or stopped, if started),” says Nolt, who was part of the group that wrote a policy statement from APHA following the rash of acute, vaping-related lung injuries in 2019. That policy statement supports tighter regulation and restriction of e-cigarettes, which is now occurring.

Recent federal legislation, passed in December 2019, prohibits the sale of tobacco products, including e-cigarettes, to anyone under the age of 21. In January, the FDA issued a policy prioritizing enforcement against certain unauthorized flavored e-cigarette products nationwide. At the time of this writing, however, the FDA guidelines did not apply to disposable e-cigarettes, which are sold in a variety of flavors.

“Your health is based on the decisions you make,” says Nolt, a behaviorist who specializes in prevention, treatment and addiction, and is the mother of two teenage sons.

“I’m shaking my head, realizing we have a lot of work to do to help young people understand their choices.”