Smoking, vaping, and the connection to COVID-19 severity is yet another developing link, adding to the dangers that e-cigarette users face. The vaping epidemic that dominated the news for a time has since resulted in severe lung injury and death for many users nationwide. However, while the vaping issue still exists, it has recently taken a back seat to other news stories. Studies and warnings are now emerging about the increased risk of severe COVID-19 reactions in individuals who vape or use traditional cigarettes.
Anewly released study from the Stanford School of Medicine, published on August 11, 2020, makes the connection between vaping and the likelihood of contracting COVID-19.1 Results reveal a startling increase in the odds of smokers contracting COVID-19 with more severe onset of symptoms. The study included 4,351 participants, ranging in age from 13 to 24, with all 50 states represented. A notable statistic is that individuals who had ever used e-cigarettes had a greater risk (by five times) of contracting COVID-19 than their nonsmoking counterparts. Further, those who smoked in the previous 30 days were 6.8 times more likely to contract the disease.1
Lead researcher Shivani Mathur Gaiha, PhD, states: “This study tells us pretty clearly that youth who are using vapes or are dual-using [e-cigarettes and cigarettes] are at elevated risk, and it is not just a small increase in risk; it’s a big one.”1
It has also been determined that vaping or smoking can increase the risk of disease severity if an individual contracts SARS-CoV-2. Multiple studies, including research from the University of Rochester Medical Center, confirm that, on average, COVID-19 affects all smokers worse than the general population.2 Irfan Rahman, who runs the lab at the university, goes on to state that use of tobacco and vaping products increases the receptors on cells in the lungs for an enzyme called ACE2. More receptors allow for a higher viral load exposure, which can lead to a more severe infection.2 This was also reiterated by Jason Sheltzer, a scientist at Cold Spring Harbor Laboratory, who has been studying the role of ACE2 enzymes as a correlation in disease progression.2
New York-Presbyterian is one of many hospitals that have issued warnings and statements that point to smoking and vaping as factors that increase the risk of complications from a COVID-19 infection.3 Notably, use of these products can lead to a malfunction of the immune system within the lungs.3 While the World Health Organization has yet to confirm this, it is well known that inhaling tobacco and vaping substances into the lungs causes inflammation, which can increase one’s susceptibility to disease.
Looking back over the past few years when vaping became widely popular, especially among teens and young adults, the boiling point came in 2019 when many began to fall seriously ill for reasons unknown at the time. To date, nearly 3,000 people have been hospitalized. The Centers for Disease Control and Prevention (CDC) stopped tracking cases of e-cigarette or vaping-associated lung injury (EVALI) in February 2020, as cases had drastically dropped off from their peak in September 2019.4
One contributor to the decrease in cases was identification of vitamin E acetate that had been added to tetrahydrocannabinol (THC)-containing e-cigarettes.4 We are still seeing a rise in vape users, but consumers are a little more aware of what is in the vaping e-liquids.
Vitamin E acetate additives were not the exclusive cause of EVALI, however. According to the CDC, tobacco is the leading cause of preventable disease and death in the US, with nearly 40 million Americans using cigarettes and nearly 4.7 million teens using at least one form of tobacco.4 Every day approximately 1,600 youths smoke for the first time, starting a potentially deadly habit.5
EVALI symptoms often mirror COVID-19–related symptoms. With a worldwide focus on the COVID-19 pandemic, multiple sources state that testing and reporting of vaping-associated lung disease have taken a back seat. Symptoms that both COVID-19 and EVALI may share include nausea, vomiting, shortness of breath, cough, headache, and dizziness.6
A newly reported and notable sign of COVID-19 that presents orally is a rash described as “erythematous and petechial.” Some COVID-19 patients are reported to have a skin rash, while others have a mucous membrane rash consistent with many viral infections. In a patient who may be an e-cigarette user, this oral rash may look similar to stomatitis.7 This is just one more anomaly that we, as dental professionals, must be aware of during patient examinations as the fight against COVID-19 continues.
Patients who are traditional cigarette smokers are often easy to identify by the malodor and staining that is present. At this point, we can have those conversations about risk and provide cessation advice if needed.
But can you identify patients who use e-cigarettes and vaping devices as easily? My guess is no. There is no distinct odor and many of us are not trained to identify the signs of e-cigarette use that may differ from that of a traditional cigarette smoker. Take staining, for example. In my experience, traditional smokers will usually present with dark staining; e-cigarette users often present with an orange line stain at the gingival margins.
Side effects of e-cigarettes can lead to more than just acute or chronic lung injury. It has been well documented that vaping increases the risk of periodontal disease, similar to traditional smoking. Periodontal disease has been shown to have a correlation between multiple detrimental health concerns, including cardiovascular disease, chronic kidney disease, diabetes, insulin resistance, and, most recently, an association in the brains of Alzheimer’s patients.8
A large case study of more than 18,000 participants was conducted to assess the risk factor of e-cigarette use associated with periodontal disease diagnosis to reflect the national population.9 Study findings revealed an increased risk of periodontal disease associated with vaping, even when accounting for the use of tobacco and other confounding variables.9 Notably, in vitro studies have shown “e-cigarette vapor can lead to inflammation of gingival epithelial cells similar to that observed in cells exposed to conventional cigarette smoke.”9
The oral effects of vaping may also include stomatitis or evidence of burns, which is not surprising when you realize that the heat necessary to vaporize the liquid can reach up to 420 degrees Fahrenheit.10 The liquid does cool some before passing over the tongue and oral cavity, but high temperatures may explain why some e-cigarette users complain of a sore or burning tongue sensation. Xerostomia caused by smoking or vaping may also contribute to the oral irritation.
Did you know that the use of vaping products increases caries risk and decreases enamel hardness by 27%?11 In addition to the increased caries risk, one study states that “certain e-liquid ingredients interact with hard tissues of the oral cavity in such a way that resembles high-sucrose candies and acidic drinks.”11 The e-liquids made with propylene glycol and glycerin increase attachment and provide additional food sources for bacteria, including Streptococcus mutans.
E-cigarette users show an increase in biofilm formation over those who do not use e-cigarettes, and vaping is noted to increase the microbial adhesion by four times.11 Combined with less-than-stellar home care, this combination can create an atmosphere primed for decay, along with an expensive restorative bill for the patient.
January 2020 brought a new national ban on flavored refillable cartridges and raised the minimum age of those who can purchase tobacco from 18 to 21.12 However, that did little to curb the way teens were still getting the attractive flavored devices. Going from the popular replaceable cartridges like JUUL, teens turned toward disposable cigarettes like Puff Bar that could still be sold in various flavors. This continued until July 20, 2020, when the FDA issued a warning letter to remove flavored disposable e-cigarettes and e-liquids from the market for illegal marketing.13
An important part of our role as dental providers is to educate our patients. We can discuss the risks of tobacco and smoking and document that education and counseling with a CDT code. Starting in 2021, there will be a CDT code for “high-risk substance use,” which encompasses not only education about the risks of vaping but also any risks with illicit drugs, alcohol, and prescription drugs. The Dental Coding Consortium—a group of hygienists and industry leaders who provide proposals and testimony at the ADA regarding CDT coding—identified the need for a CDT code to track patient education and metrics. The ADA concurred and adopted a proposal regarding the new code that will take effect in 2021.
Dental disease will always be with us, ensuring the need for dental care, but what we recognize and look for will continue to evolve as science does. Even though we are faced with a pandemic and the risk of infection is high in the case of dental professionals, we must continue to treat and educate our patients about the benefits of oral-systemic health and the risks associated with certain adverse behaviors. The new resources and codes associated with vaping will continue to push the conversation forward.
- Digitale E. Vaping linked to COVID-19 risk in teens and young adults. Stanford School of Medicine. August 11, 2020. https://med.stanford.edu/news/all-news/2020/08/vaping-linked-to-covid-19-risk-in-teens-and-young-adults.html
- Dahlberg B. Researchers uncover links between COVID-19 and smoking, vaping. WBFO NPR. June 30, 2020. https://news.wbfo.org/post/researchers-uncover-links-between-covid-19-and-smoking-vaping
- Vaping and COVID-19: Can vaping increase complications? New York-Presbyterian Health Matters. https://healthmatters.nyp.org/vaping-and-covid-19-can-vaping-increase-complications/
- Outbreak of lung injury associated with the use of e-cigarette, or vaping, products. Centers for Disease Control and Prevention. Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion. Updated February 25, 2020. https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html
- Youth and tobacco use. Centers for Disease Control and Prevention. Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion. Updated September 9, 2020. https://www.cdc.gov/tobacco/data_statistics/fact_sheets/youth_data/tobacco_use/index.htm
- Armatas C, Heinzerling A, Wilken JA. Notes from the field: e-cigarette, or vaping, product use—associated lung injury cases during the COVID-19 response—California, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(25):801-802. doi:10.15585/mmwr.mm6925a5
- Betsaida A. A new sign of COVID-19: a rash in the mouth. News Medical. July 21, 2020. Accessed September 10, 2020. https://www.news-medical.net/news/20200721/A-new-sign-of-COVID-19-a-rash-in-the-mouth.aspx
- Kim J, Amar S. Periodontal disease and systemic conditions: a bidirectional relationship. Odontology. 2006;94(1):10-21. doi:10.1007/s10266-006-0060-6
- Atuegwu NC, Perez MF, Oncken C, Thacker S, Mead EL, Mortensen EM. Association between regular electronic nicotine product use and self-reported periodontal disease status: population assessment of tobacco and health survey. Int J Environ Res Public Health. 2019;16(7):1263. doi:10.3390/ijerph16071263
- Construction of electronic cigarettes. Wikipedia. Accessed September 10, 2020. https://en.wikipedia.org/wiki/Construction_of_electronic_cigarettes
- Kim SA, Smith S, Beauchamp C, et al. Cariogenic potential of sweet flavors in electronic-cigarette liquids. PLoS ONE. 2018;13(9):e0203717. doi:10.1371/journal.pone.0203717
- FDA finalizes enforcement policy on unauthorized flavored cartridge-based e-cigarettes that appeal to children, including fruit and mint. US Food and Drug Administration. January 2, 2020. https://www.fda.gov/news-events/press-announcements/fda-finalizes-enforcement-policy-unauthorized-flavored-cartridge-based-e-cigarettes-appeal-children
- FDA notifies companies, including Puff Bar, to remove flavored disposable e-cigarettes and youth-appealing e-liquids from market for not having required authorization. US Food and Drug Administration. July 20, 2020. https://www.fda.gov/news-events/press-announcements/fda-notifies-companies-including-puff-bar-remove-flavored-disposable-e-cigarettes-and-youth
JAMIE COLLINS, RDH-EA, is a practicing clinical hygienist in Idaho and Washington states. She has been in the dental field for nearly 20 years, both as an assistant and hygienist. With a passion for patient care, especially for those with higher risk factors, she enjoys sharing the tips and tricks of the dental profession through speaking and writing. In addition to being in clinical practice, Collins is also an educator, has contributed to multiple textbooks and curriculum development, and is a key opinion leader. She can be contacted at [email protected].