Electronic Nicotine Delivery Systems (ENDS) and Their Relevance in Oral Health

The number and popularity of electronic nicotine delivery systems (ENDS) and especially e-cigarettes (e-cigs) have been increasing in the last decade. Although ENDS owe their popularity to excluding the harmful chemicals that are present in tobacco smoke, there is a debate whether they are safe, regulated, and as harmless as they are assumed to be and have potential unknown long-term effects. Involvement of cigarette smoking to the progression of periodontal diseases, other adverse oral health outcomes, and its detrimental effects to oral health are well-described. ENDS producer companies claim that these products can improve oral health by providing alternatives to smoking. However, the effect of e-cigs on oral health is not fully understood and is still debated among many scientists and clinicians. The number of studies addressing the potential toxic effect of ENDS or e-cig aerosol on oral cells is limited along with the clinical studies which are still preliminary, and their sample size is limited. The long-term effects of inhaled aerosols and the potential synergistic effect of the e-cigs components are not known. It is essential and of utmost importance to determine whether exposure to ENDS aerosol contributes to the progression of periodontal diseases and how it affects periodontal ligament and gingival cells which are believed to be its first targets. This review briefly summarizes the available evidence about the effects of e-cigs on periodontal health including several pathophysiological events, such as oxidative stress, DNA damage, inflammation, cellular senescence, dysregulated repair, and periodontal diseases.

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In vitro and in vivo cardiac toxicity of flavored electronic nicotine delivery systems

AJP Heart and Circulatory Physiology ◽

10.1152/ajpheart.00283.2020 ◽

2021 ◽

Vol 320 (1) ◽

pp. H133-H143

Author(s):

Obada Abouassali ◽

Mengmeng Chang ◽

Bojjibabu Chidipi ◽

Jose Luis Martinez ◽

Michelle Reiser ◽

...

Keyword(s):

Ventricular Arrhythmias ◽

Cardiac Electrophysiology ◽

Cardiac Toxicity ◽

Delivery Systems ◽

Cardiac Safety ◽

Electronic Nicotine Delivery Systems ◽

Nicotine Delivery

The use of electronic nicotine delivery systems (ENDS) is not harm free. It is not known whether ENDS negatively affect cardiac electrophysiological function. Our study in cell lines and in mice shows that ENDS can compromise cardiac electrophysiology, leading to action potential instability and inducible ventricular arrhythmias. Further investigations are necessary to assess the long-term cardiac safety profile of ENDS products in humans and to better understand how individual components of ENDS affect cardiac toxicity.

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Explosions, Burn Injuries and Adverse Health Effects of Electronic Nicotine Delivery Systems: A Review of Current Regulations and Future Perspectives

Journal of Pharmacy & Pharmaceutical Sciences ◽

10.18433/jpps32242 ◽

2021 ◽

Vol 24 ◽

pp. 462-474

Author(s):

Ayesha Rahman Ahmed ◽

Beverly Etchey ◽

Mahiba Ahmed

Keyword(s):

Health Effects ◽

Significant Risk ◽

The United States ◽

Delivery Systems ◽

Long Term Effects ◽

Safe Alternative ◽

Electronic Nicotine Delivery Systems ◽

Adverse Health Effects ◽

Adverse Health ◽

Nicotine Delivery

Purpose: While there is a declining trend in the use of traditional methods of smoking tobacco, electronic nicotine delivery systems (ENDS) have gained popularity worldwide. ENDS are marketed as safe for the primary reason that they do not contain the well-established toxic ingredients found in traditional cigarettes. However, growing concerns over incidences of fire and explosion with specific types of ENDS, as well as their short and long-term effects, remain unaddressed. This review examines the under studied role of customized components such as batteries, e-liquid compositions, and methods of nicotine delivery that result in physical injuries and adverse health effects of ENDS. Methods: Using online reference databases (Web of Science, PubMed, Medline other, Google scholar, FDA website, FDA register), we analyzed the mechanisms through which ENDS may pose significant risk to human health. Results: An increase in the use and popularity of ENDS has been observed among youth and adults in the United States since 2007. The ENDS devices available to the public allow for custom alterations which can introduce incompatible components, resulting in overheating and explosion related injuries. Heavy metals have been found to leach from some devices into the e-liquid, and the heating of e-liquid ingredients can produce toxic byproducts. Conclusions: Overall, the current literature demonstrates that ENDS are not a safe alternative to traditional cigarettes due to explosion risks and negative health effects including addiction, adverse respiratory and cardiovascular effects, heavy metal leaching, and toxic byproducts exposure. These risks warrant regulation of ENDS devices and formulations, with urgency underscored by their increasing popularity among youth and adults.

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Electronic nicotine delivery systems: Oral health implications and oral cancer risk

Journal of Oral Pathology and Medicine ◽

10.1111/jop.12810 ◽

2018 ◽

Cited By ~ 8

Author(s):

Ahmed S. Sultan ◽

Maryam Jessri ◽

Camile S. Farah

Keyword(s):

Oral Health ◽

Oral Cancer ◽

Cancer Risk ◽

Delivery Systems ◽

Electronic Nicotine Delivery Systems ◽

Health Implications ◽

Nicotine Delivery ◽

Oral Cancer Risk

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A scoping review of studies on the health impact of electronic nicotine delivery systems

Internal and Emergency Medicine ◽

10.1007/s11739-021-02835-4 ◽

2021 ◽

Author(s):

Cother Hajat ◽

Emma Stein ◽

Saran Shantikumar ◽

Raymond Niaura ◽

Pietro Ferrara ◽

...

Keyword(s):

Mental Health ◽

Scoping Review ◽

Controlled Trial ◽

Health Impact ◽

Delivery Systems ◽

Chronic Obstructive ◽

Cross Sectional ◽

Electronic Nicotine Delivery Systems ◽

Nicotine Delivery

AbstractWe conducted a scoping review of studies on health outcomes from electronic nicotine delivery systems (ENDS). The objective was to identify, narratively synthesize, assess the strength and quality of evidence and critically appraise studies that have reported disease end points associated with the use of ENDS. We included published literature on the health impact of ENDS from 01/01/2015 until 01/02/2020 following the PRISMA guidelines using PubMed, Embase, Scopus and Google Scholar. The database search identified 755 studies, and other sources 265; 37 studies met final eligibility criteria. Levels of evidence included 24(65%) cross-sectional, one (2.7%) case–control and six (16%) case studies, four (11%) cohort studies, one (2.7%) randomized controlled trial (RCT) and one (2.7%) meta-analysis; 27(73%) studies reported only on harms, eight (22%) reported on benefits, two (2%) on benefits and harms. Quality ratings were poor in 20 (54%), fair in 9(24%) and good in 8(22%) of studies. In our review, ENDS was not shown to be causative for harmful cardiovascular disease (CVD) outcomes and shown to be beneficial for hypertensive patients. Switching from cigarettes to e-cigarettes resulted in reduced exacerbations of chronic obstructive pulmonary disease (COPD), with no evidence of long-term deterioration in lung function. Mental Health, cancer and mortality were not adequately studied to form any consensus. Our review has not demonstrated ENDS to be causative of harmful CVD outcomes; furthermore switching from cigarettes to e-cigarettes was associated with improved hypertensive control and reduced exacerbations of COPD, with no evidence of increased asthma risk or long-term respiratory harm. Mental health, cancer and mortality outcomes have not been adequately studied to form a conclusion. Overall, the findings of our review did not provide evidence to counter the consensus held by many that ENDS use is safer than the risks posed from smoking cigarettes.

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Beliefs and Self-reported Practices of Health Care Professionals Regarding Electronic Nicotine Delivery Systems: A Mixed-Methods Systematic Review and Synthesis

Nicotine & Tobacco Research ◽

10.1093/ntr/ntz046 ◽

2019 ◽

Vol 22 (5) ◽

pp. 619-629 ◽

Cited By ~ 6

Author(s):

Daniel A Erku ◽

Coral E Gartner ◽

Kylie Morphett ◽

Kathryn J Steadman

Keyword(s):

Health Care ◽

Mixed Methods ◽

Health Care Professionals ◽

Delivery Systems ◽

Potential Health ◽

Electronic Nicotine Delivery Systems ◽

Nicotine Delivery ◽

Patient Health ◽

Training And Support

Abstract Aims This review explores the (1) beliefs and attitudes of health care professionals (HCPs) toward electronic nicotine delivery systems (ENDS) including use as a smoking cessation aid and/or harm reduction, safety and regulation, and (2) the extent and content of patient–HCP communication about ENDS. Methods PubMed, Embase, CINAHL, and PsycINFO were searched to identify articles published since 2003. The Mixed Methods Appraisal Tool and Strengthening the Reporting of Observational Studies in Epidemiology checklists were used to assess the quality of studies. Thematic synthesis was used to analyze qualitative data. Results A total of 45 articles (32 quantitative, 12 qualitative, and 1 mixed) were included. There was wide variation regarding beliefs about the efficacy of ENDS as a cessation aid. Although the majority of HCPs believes that ENDS are safer than combustible cigarettes, they also have concern about the short and long-term safety of ENDS, uptake by adolescents, and the potential for ENDS to act as a “gateway” to smoking cigarettes. Beliefs about ENDS are influenced by media stories and experiences provided by patients. Although most HCPs do not proactively recommend ENDS, they are more likely to support ENDS use among patients with smoking related comorbidities, heavy smokers with previous unsuccessful quit attempts, or patients who express interest in trying them. Conclusions Overall, HCPs hold diverse views about the efficacy of ENDS and expressed wariness over their potential health effects. HCP endorsement of ENDS use seems to depend largely on patient health status, the presence of other competing risk factors and patient preferences. Implication Although evidence on safety and efficacy of ENDS is emerging, HCPs should be honest with their clients, stating that the long-term safety is not yet established but what is known is that they appear to be a lower risk alternative to cigarettes. Our review highlights a need for further training and support for HCPs regarding ENDS use, which would enable them to guide their clients in making evidence-based decisions.

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Electronic nicotine delivery system-induced alterations in oral health via saliva assessment

Experimental Biology and Medicine ◽

10.1177/1535370220941258 ◽

2020 ◽

Vol 245 (15) ◽

pp. 1319-1325

Author(s):

Saeed Alqahtani ◽

Bruce Cooper ◽

Claire A Spears ◽

Christa Wright ◽

Jonathan Shannahan

Keyword(s):

Risk Factor ◽

Oral Health ◽

Pilot Study ◽

Periodontal Disease ◽

Health Effects ◽

Inflammatory Cytokines ◽

Delivery Systems ◽

Disease Development ◽

Electronic Nicotine Delivery Systems ◽

Nicotine Delivery

Use of electronic nicotine delivery systems (ENDS) is becoming increasingly prevalent. ENDS aerosols contain a variety of toxic components that may adversely impact health. Although exposure to traditional cigarette smoke is a risk factor for periodontal disease, the effects of ENDS on oral health have not been adequately examined. To evaluate potential oral health effects associated with ENDS use, a pilot study was performed with 14 current ENDS users and 16 never tobacco users. Participants completed questionnaires about their ENDS use and overall health. Saliva samples were assessed for differential biomarkers of inflammation, toxicity, and disease development. This included evaluation of specific inflammatory cytokines and the global assessment of alterations in metabolites. ENDS users were determined to have elevated saliva levels of interleukin-1β and tumor necrosis factor-α indicative of inflammation. Metabolite profiling determined 368 metabolites were differentially expressed in the saliva of ENDS users versus never tobacco users. Cotinine, the primary metabolite of nicotine, was the most significantly altered metabolite between the groups. Increased levels of prostaglandins and leukotrienes indicated that ENDS users exhibited increased arachidonic acid metabolism compared to never tobacco users. Additionally, a variety of other metabolites known to be involved in immune signaling such as gangliosides, ceramides, angiotensin, and others were also different between groups. Overall, our pilot study demonstrates differential saliva component profiles in current ENDS users, which may contribute to periodontal disease development. These alterations suggest specific pathways of oral disease induced by ENDS use and could be utilized as potential future biomarkers. Impact statement The use of traditional tobacco products is a known risk factor for the development of diseases including periodontal disease. To date, the potential oral health effects related to electronic nicotine delivery systems (ENDS) use is unknown. This study collected saliva from ENDS users and never tobacco users to examine differences in the oral cavity of inflammatory cytokines and metabolites. The identification and measurement of these ENDS-related changes provide insight into disease pathways potentially associated with ENDS use. The utilization of saliva samples collected from human participates enhances the application of the findings compared to the majority of studies using cell culture and animal models. In addition, these foundational findings can inform future studies to examining specific pathways identified, interventional approaches, and application of translatable biomarkers of ENDS use.

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Stealth-vaping: a new era of illicit substance misuse? a systematic review and meta-analysis of the prevalence of electronic nicotine delivery systems for the consumption of illicit substances

BJPsych Open ◽

10.1192/bjo.2021.686 ◽

2021 ◽

Vol 7 (S1) ◽

pp. S256-S257

Author(s):

Tim Hicks ◽

Rebecca Arrowsmith ◽

Susannah Keill ◽

Eleni Papadakou

Keyword(s):

Random Effects ◽

Delivery Systems ◽

Significant Heterogeneity ◽

Random Effects Model ◽

Total Study Population ◽

Electronic Nicotine Delivery Systems ◽

Nicotine Delivery ◽

Study Population ◽

Illicit Substances

AimsTo estimate the prevalence of using Electronic Nicotine Delivery Systems (ENDS) for the consumption of illicit Substances (illegal under UK Law). We hypothesised that this is an increasingly common mode of delivery.BackgroundUsing ENDS to consume nicotine is increasing in popularity worldwide with a prevalence in the UK of 6% and in the USA 4%-6%. Existing studies have reported that people are switching to vaping because it is felt to be safer than smoking.However there is also emerging evidence that this mode of consumption is increasingly being used as it is discreet and much less easy to detect, hence sometimes referred to as stealth-vaping. This appears to be driving a switch to vaping to administer substances other than nicotine, notably, but not exclusively cannabis, including concentrated forms of Tetrahydrocannabinol (THC) and synthetic cannabinoids. Anecdotally this practice is known to be occurring in psychiatric inpatient settings.This is against a backdrop of the uncertain long-term effects of vaping and the emergence of case reports of the death of otherwise healthy young persons after using ENDS to consume cannabis.MethodSearch strategy: MEDLINE , EMBASE, Cochrane Database of Systematic Reviews, Grey Literature using Medical Subject Headings (MeSH), text words relating to vaping of drugs and hand searching journals.Statistical methods: Synthesis of data was performed using inverse variance with double arcsine transformation in MetaXL. Heterogeneity was assessed with the Cochran's Q and I2.ResultFrom 970 abstracts, 61 papers were selected for full text review, 18 met the inclusion criteria. The total study population for the outcome of ENDS nicotine users who also use ENDS for the consumption of illicit substances was 9098. There was significant heterogeneity with a random effects model prevalence of 17% (95%CI 7%-32%). The total study population for the outcome of cannabis users who use ENDS to consume cannabis was 52708. There was significant heterogeneity with a random effects model prevalence of 23% (95%CI 12%-37%).ConclusionThe use of ENDS to consume illicit substances is concerning as it appears to be relatively common practice. This was most notable in studies of existing cannabis users, younger people and medical marijuana users.Given the uncertainty of long term health consequences and poor understanding of sudden death in some users, this study highlights an emerging and substantial public health concern.Currently there is a paucity of primary studies to elucidate the impact on health.

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International Randomized Controlled Trial Evaluating Changes in Oral Health in Smokers after Switching to Combustion-Free Nicotine Delivery Systems: SMILE Study protocol

10.1101/2020.12.12.20240143 ◽

2020 ◽

Author(s):

Gianluca Conte ◽

Sebastiano Antonio Pacino ◽

Salvatore Urso ◽

Pasquale Caponnetto ◽

Francesca Benfatto ◽

...

Keyword(s):

Oral Health ◽

Cigarette Smoking ◽

Electronic Cigarettes ◽

Periodontal Diseases ◽

Delivery Systems ◽

Randomized Controlled ◽

Nicotine Delivery ◽

Never Smokers ◽

The Impact

ABSTRACTAlthough the well-known detrimental effects of conventional cigarette smoking on oral health, there are still lack of evidences about the impact of less harmful alternatives (such as electronic cigarettes or heat not burn products), especially in young smokers with clinical absence of signs of periodontitis.SMILE will be a prospective, multicenter, interventional, open label, randomized, controlled, three parallel-arms study assessing oral health parameters and teeth appearance of 18 months duration.This study aims to compare short- and long-term impact on oral health between smokers continuing with conventional cigarette smoking, those switching to combustion-free nicotine delivery systems (C-F NDS), and never-smokers by objectively evaluating changes in gingival response, as a proxy for periodontal/gingival.The total number of participants in the study planned of the trial is 606 (505 regular smokers and 101 never-smokers).Regular smokers not intending to quit will be randomized in the ratio 1:4 either in continuing to smoke commercially manufactured conventional cigarettes (n = 101; Study Arm A) or switching to C-F NDS (n = 404; Study Arm B), never-smokers will be assigned in Arm C (n= 101).The primary outcome will be to assess and compare the percentage mean change in Modified Gingival Index (MGI) score between Baseline and 18 months follow-up between the Study Arms A and B.Secondary outcomes include the assessment of within- and between-group (Arm A, Arm B and Arm C) variations from baseline to 18 months follow-up of several endpoints, such as MGI, Tooth Stains Assessment, Dental Discolorations, Plaque Score Imaging, Oral Health Quality of Life (OHQOL) assessment and EuroQoL Visual Analog Scale (EQ VAS – QoL) assessment.Patient recruitment will start in January 2021 and enrolment is expected to be completed by June 2021.This will be the first study determining overall oral health impact of using CF-NDS in smokers without sign of periodontitis. Data from this study will provide valuable insights into the overall potential of C-F NDS to reduce the risk of periodontal diseases.

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