Ocular Surface Implications of E-Cigarette Smoking and Vaping

Optometrists are accustomed to inquiring about smoking while taking our patient’s medical history. This helps to evaluate the patient’s general health status and assess the risk of conditions like respiratory disease, cancer, and stroke. In the field of eyecare, we also know that smoking increases the risk for age-related macular degeneration and exacerbation of conditions like thyroid eye disease and ocular surface disease. Times have changed, and it is now important to modify our inquiry and specifically include the use of e-cigarettes and vaping. Many misconceptions have accompanied the rise of these newer forms of smoking and patients don’t necessarily equate these newer vehicles with the formal definition; thus it can go unreported on an intake form or medical history. This article will pinpoint why it is so important to discuss with patients and present information to assist in patient education that hopefully encourages cessation.

Electronic cigarettes (e-cigarettes for short) involve the creation of a vapor liquid mixture consisting of nicotine, flavoring, and other chemicals. The chemical mixture is aerosolized and the vapor is inhaled (“vaping”). The vehicle usually involves a battery and a heating component and can look like a traditional cigarette (often referred to as an e-cigarette) or pen-shaped vehicle (often referred to as a “vape-pen”). There are also other variations that come in the form of a small squarish “tank” or “mod” and some that are even disguised as everyday objects like a flash drive. These devices can also be used to inhale marijuana and other drugs, in addition to nicotine substances.¹

There is very little regulation of the components included in the vapor mixture, particularly those involved in flavoring. In 2014, the FDA established that e-cigarettes are tobacco products and, as such, are subject to regulation by the Family Smoking Prevention and Tobacco Control Act. The caveat is that current flavor-regulation laws only pertain to flavors of food and drink that are ingested, leaving a loophole for flavors of products that are consumed through other modalities.²

The largest concern for e-cigarette products is within the adolescent and teen population. The CDC has reported data from 2011 to 2017 showing an increase in e-cigarette use doubling from roughly 10% to 20% over that time period.³ E-cigarettes contain nicotine and the addictive properties can lead to a transition to an addiction to traditional cigarettes. Additionally, there are major concerns on the cognitive and developmental impact of these products on the still-developing brains of teens and preteens.⁴

E-cigarettes and vaping have the misconception of being a safe tool to help with traditional cigarette smoking. They have been advertised as “safer” but still contain dangerous and carcinogenic chemicals.⁵ In fact, the CDC launched a 2018 campaign called “Safer Doesn’t Equal Safe” to expel the misconceptions about e-cigarettes.¹

A point of distinction emphasized between smoking and vaping is that a cigarette contains a known quantity of nicotine, while vapid fluid contains extracted nicotine of a quantity that is often unknown. This is a main reason that there are reports of users getting nicotine related illnesses, or “nic-sick.” This has specifically been reported in teenagers and manifests as seizures, depression, cognitive changes, and anxiety. In addition to unknown quantities of nicotine in the vaping fluid, there are other harmful chemicals.⁴

One component that has been pinpointed as related to the eye is acrolein, a chemical that prevents normal t-cell regulation (an important chemical factor in regulating the integrity of the ocular surface).⁵ Aldehydes are another chemical component involved that has been linked to increased tear film instability and the chemicals used for flavoring are thought to cause peroxidation and damage to the tear film’s lipid layer.⁶ In addition, the high heat level needed to liquify the e-cigarette product transforms some solvents into formaldehyde which is a known irritant to the conjunctiva.³

In 2019, Optometry and Vision Science published research on this topic. A study was performed comparing signs and symptoms of ocular surface disease—Shirmer testing, tear break up, surface staining, tear meniscus, and an ocular surface disease questionnaire—in nonsmokers and vapers. The qualitative portion demonstrated that patients who used vapes had a much higher level of reported moderate to severe ocular surface disease symptoms than the nonsmoking group. The examination results were consistent with this. The vaping group showed faster tear break up, reduced tear meniscus, and had more positive Shirmer tests than the nonsmoking group. A secondary leg of the research investigated the voltage level reported by each vaper and compared it to the severity of the dry eye survey and examination results. The association found that the higher the vaping voltage, the more severe the ocular surface disease signs and symptoms.⁷

Research on the long-term impact of vaping and e-cigarettes is not readily available but is underway. Currently, though, we can extend the known impacts of nicotine to the list of what is expected. This includes nicotine use being linked to nystagmus, vasoconstriction of blood vessels and reduced light adaptation of the retina.⁶ We should also cautiously assume that the established links of smoking with conditions such as macular degeneration and thyroid eye disease are similar for e-cigarette products until more research is available.

There have also been reported incidents where faulty e-cigarettes have caught fire or exploded causing direct injury to the eyes and face.¹ Multiple cases of corneal and conjunctival lacerations and burns have been reported from device malfunctions. In one case, the device explosion lacerated and ruptured a portion of the patient’s face with a ruptured choroid and blindness resulting.³

All of these ocular effects are, of course, in addition to the known association of e-cigarette and vaping devices with severe chronic pulmonary diseases. This includes thousands of cases of severe lung illness and even death reported by the FDA.⁴

Ask and educate. Consider modifying your history or intake form to specifically include vape and e-cigarette use. When discussing the ocular surface regimen for patients who are using vapes or e-cigarettes, point out that the best treatment is to discontinue the self-induced behavior and modify their personal habit and environment.

Whether it is smoking or vaping, we need to remember that for some patients it is not simply a matter of quitting; this is an addiction and it can be difficult. Dr. Lane, of the American Optometric Association, suggests that optometrists follow up and ask “why?” Finding out the reason for the patient’s smoking or vaping can direct your efforts more appropriately. Some patients may have switched to e-cigarettes as a first step to quit smoking. If the patient is using e-cigarettes to slowly eliminate their dependency, Dr. Lane states he encourages them “to continue moving forward on their journey.”⁸

All conversations of this nature should be had with care and compassion. Educate and make recommendations, but not through pressuring or shaming. Also remembering to encourage patients to seek out support of friends and family or community groups, because they don’t have to make the change alone. Here you can find a helpful fact sheet from the American Optometric Association. The CDC also provides numerous resources along with smokefree.gov.