1. e-cigarettes
WHAT TO
TELL YOUR
PATIENTS
T
he jury is still out on e-cigarettes, also
known as electronic nicotine delivery
systems (ENDS). Are they safe? Are they an
effective aid to assist with tobacco cessation? What
about health concerns surrounding second-hand
vapour emissions? Although the research is not
currently available to answer all of these questions,
we are starting to get some preliminary insight into
how ENDS can affect oral health.

2. Supporting Your Practice
| Volume 2 Issue 450
E-cigarettes have been around for some time, but have only become mainstream
in North American culture over the past few years. Comprised of 3 major
components—a battery, a cartridge and an atomizer (heating element)—
electronic cigarettes allow to replicate smoking behaviours without the use of
many harmful chemicals and tobacco. However, the benefits of e-cigarettes may
be nullified by an increased exposure to chemicals due to extended use. ENDS can
also potentially be equally as harmful to your mouth as traditional cigarettes as
they contain varying concentrations of nicotine, depending on the brand.
E-cigarettes use either disposable or replaceable cartridges,
and provide between 150 and 300 puffs per cartridge—
the equivalent to 40 cigarettes worth of drags. A 10-mL
liquid solution used to refill many e-cigarettes is equiv-
alent to 200 cigarettes worth of nicotine. According to
Dr. Deepak Saxena, researcher at the New York University
College of Dentistry, a cartridge can be fully consumed in
2 hours. Although the contents of the vapour may be fa-
vourable compared to traditional inhaling from cigarettes,
early indications suggest prolonged exposure to nicotine
can have troubling effects on gum tissue. Dr. Saxena uses
the example of smokers on a “smoke break” knowing it’s
time to get back to work once their cigarette is finished.
Yet with e-cigarettes, many smokers can puff away for
hours—even inside the office—without paying attention
to how much nicotine is going into their system.
Oral Issues
According to Dr. Saxena, initial research indicates regular
e-cigarette usage puts users at a significantly higher
risk of periodontal disease from increased exposure to
nicotine. Other known side effects include persistent dry
mouth.1
Based on initial in vitro research conducted by his
team, Dr. Saxena also believes gum tissue and microflora
are being affected by the e-cigarette liquid solution, as
the resulting vapour can create an oral cavity environment
conducive to gum tissue mutation and changes in the
microflora.
This article was a collaboration between Dr. John O'Keefe of CDA
and Eliot Coles of the Nova Scotia Dental Association.
We would like to acknowledge the efforts of Dr. Deepak Saxena
and his team at New York University College of Dentistry.
A version of this article originally appeared in the December/January 2015
edition of Nova Scotia Dentist Magazine.
Nova Scotia
Dental
Association
 The long-term safety of e-cigarettes is not yet
established.3
 E-cigarettes are likely to be less harmful than tobacco
cigarettes,3
but not without their own risks.
 The effectiveness of e-cigarettes as either a smoking
cessation tool or a harm reduction tool is not yet
established.3
 At present no e-cigarettes are licensed as a medicine
and patients are recommended to use licensed nicotine
replacement therapy products to quit smoking or
reduce tobacco consumption.3
 Early indications suggest e-cigarettes can have harmful
effects on gum tissue and microflora.
 Advise patients that referral to a smoking cessation
service is an option to consider.
 E-cigarettes can act like a gateway to cigarette smoking
by youth, and can often entice young smokers through
the use of flavoured ENDS.
Key Messages

3. 51Volume 2 Issue 4 |
Supporting Your Practice
Additionally, Dr. Saxena is concerned about hookah
smoking, which is a growing trend in North America.
There appears to be a common misconception that
having the nicotine or tobacco smoke pass through
water during the inhaling process somehow cleans the
vapour. According to Dr. Saxena, hookah smoking may
be the worst smoking means of all, as charcoal is used
to burn the tobacco.
Advice for Your Patients
With so little clinical evidence available on e-cigarettes,
it may be difficult to answer all of your patients’
questions regarding the safety and validity of
vaporizing. Currently, e-cigarette use as a smoking
cessation tool is not supported by the federal
government in Canada. And the results of a recent
study comparing the effectiveness of e-cigarettes
and nicotine patches over a 6-month period were
inconclusive.2
This suggests e-cigarettes may not be
a superior smoking cessation aid compared to more
traditional forms of medication like
nicotine patches, with e-cigarettes
also potentially posing additional
oral health risks. a
References
1.GoniewiczML1,KnysakJ,GawronM,KosmiderLetal.Levelsofselectedcarcinogensandtoxicantsin
vapourfromelectroniccigarettes.TobControl.2014Mar;23(2):133-139.
2.[noauthorslisted]E-cigarettes–aidtosmokingcessationorsmokescreen?Lancet2014Sept
6;384(9946):829.
3.WorsleyDJ,JonesK,MarshmanZ.Patientsareaskingaboute-cigarettes.Whatdowetellthem?Br
DentJ.2014Jul;2017(2):91-5.
e-Cigarettes:OtherSources
❚ Government of Canada [Internet]. Canadian Tobacco,
Alcohol and Drugs Survey, 2013; 2015 Feb 3 [accessed 2015
Feb 6]. Available: healthycanadians.gc.ca/science-research-
sciences-recherches/data-donnees/ctads-ectad/index-
eng.php
❚ Canadian Cancer Society [Internet]. Our perspective on
e-cigarette; 2014 Dec 12 [accessed 2015 Feb 2]. Available:
cancer.ca/en/about-us/news/national/2014/perspective-
on-e-cigarettes/
❚ Smoke-Free Nova Scotia [Internet]. Smoke-Free Nova Scotia
Position Statement on E-cigarettes and Electronic Nicotine
Delivery Systems; 2014 Jan [accessed 2015 Feb 2]. Available:
smokefreens.ca/site-media/documents/sfns-e-cig-
position-statement-january-2014.pdf
❚ Canadian Medical Association [Internet]. Electronic
cigarettes [accessed 2015 Feb 11]. Available: cma.ca/
En/Pages/electronic-cigarettes.aspx