Vaping & Nicotine Pouches vs. Smoking: Oral Health Risks Compared

German Review Finds Vaping and Pouches Are Easier on Gums Than Cigarettes, But Quitting Nicotine is Safest

A new comprehensive review of 52 human studies has shed more light on the comparative oral health risks of modern nicotine products like e-cigarettes (vaping) and nicotine pouches versus traditional combustible cigarettes. The German research, which analyzed papers published up to August 2024, confirms that while vaping and other tobacco harm reduction methods are significantly less damaging to oral health than smoking, the best outcomes are seen in individuals who quit nicotine altogether. This study provides crucial context for adult smokers considering switching to alternatives and for public health discussions surrounding harm reduction.

The researchers systematically reviewed 199 separate findings from the 52 studies, categorizing them into four broad areas of oral health: pre-cancerous changes, inflammation (like swelling and bleeding gums), everyday clinical signs (plaque, bone loss), and shifts in the oral microbiome (the ecosystem of bacteria in the mouth). They compared users of modern nicotine products (e-cigarettes, heated tobacco sticks, and nicotine pouches) with both traditional cigarette smokers and people who used no nicotine at all.

Key Findings: A Clear Hierarchy of Harm

The review established a clear hierarchy of oral health risks among the different groups. Across all measures, individuals who vaped showed significantly reduced negative effects in their mouths compared to those who smoked combustible cigarettes. However, their oral health outcomes were still worse than those of non-users.

This trend was consistent across several key indicators:

Inflammation and Gum Health: In 76 comparisons between vapers and non-users, inflammatory markers like swelling and bleeding gums were more common in the vaping group. However, when these same indicators were compared between vapers and smokers in 69 instances, the vaping group consistently appeared healthier.
Clinical Dental Check-up Items: The results from everyday dental examinations were particularly clear. Measures like bleeding on probing, plaque index, and probing depth (a measure of gum pocket depth) were all worse in people who vaped compared to those who had never used nicotine. Yet, in a six-month study cited in the review, the smoking group saw their probing depth and bone loss deteriorate, while these measures remained stable in the vaping group.
Pre-Cancerous Changes: While long-term data is still needed, the short- and medium-term signals suggest a lower risk of pre-cancerous oral changes for vapers compared to smokers.

In one clinical study mentioned, plaque, calculus, and gum disease improved fastest in patients who had never used nicotine, with vapers landing in the middle, and smokers trailing behind both groups, demonstrating a clear risk continuum.

The Invisible Impact: Changes to the Oral Microbiome

One of the most significant findings related to the oral microbiome. The review found that vaping caused frequent and significant changes to the invisible ecosystem of bacteria in the mouth, scoring higher on a disruption scale than both smoking and non-use. Scientists are concerned that upsetting this delicate bacterial balance may set the stage for future problems, including infections, gum disease, and potentially even cancer down the road. Another six-month cohort study showed that while each group’s mouth bacteria settled into its own stable pattern, the ecosystem was healthiest in non-users, most disrupted in smokers, and somewhere in between for vapers.

Several factors in vaping may contribute to these changes. Propylene glycol (PG) and vegetable glycerin (VG), the base liquids in e-cigarettes, are known to be hygroscopic, meaning they soak up water. This can lead to a drier mouth, which may encourage plaque build-up. Furthermore, while vaping avoids the thousands of toxins from combustion, the review notes that prolonged, low-level exposure to various irritants in the aerosol, including formaldehyde, acetaldehyde, and trace metals, may lead to chronic tissue inflammation over time. Nicotine itself constricts blood vessels, which can mask the early signs of gum disease (like bleeding) and delay healing, even at the lower doses sometimes delivered by vaping and nicotine pouches.

Limitations and the “Dual Use” Problem

The authors of the review stress that their meta-study is qualitative, not a traditional number-crunching meta-analysis, due to the wide variation in the design, duration, and testing methods of the 52 papers they examined. This “mixing of apples and oranges” means the findings should be interpreted as strong indicators of probable outcomes rather than hard risk estimates.

A significant challenge in this field of research is “dual use.” Nearly 30% of American adults who vape also smoke cigarettes. Many of the reviewed studies relied on self-reporting or short-term carbon monoxide breath tests to screen out smokers, meaning some dual users could have slipped through and inadvertently inflated the apparent harm attributed to vaping alone.

Another key limitation is time. E-cigarettes were only introduced to retail stores in 2007, with heated tobacco and nicotine pouches following later. This means no study in the review could track users for the two decades or more typically needed to see certain long-term health outcomes, such as oral cancers, emerge.

Conclusion: A Harm Reduction Tool, Not a Health Product

This comprehensive review reinforces the public health consensus in countries like the UK and Canada: while vaping is not harmless, it is significantly less harmful to oral health than smoking traditional cigarettes. For the millions of adults who continue to smoke, switching completely to a less harmful alternative like vaping or nicotine pouches can lead to measurable improvements in oral health and a reduction in the risk of serious diseases.

However, the study also clearly shows that the best outcome for oral health is to be free from all nicotine products. As lead author Gerhard Scherer stated, “There is a need for further research into the long-term effects of these products … as well as the underlying biological mechanisms.” The researchers call for longer-term studies that track exclusive users of each product type, verify nicotine exposure with biomarkers, and control for other lifestyle factors like diet, alcohol use, and oral hygiene habits.

This study will not settle the ongoing policy debates, but it provides valuable evidence for adult smokers. Switching to e-cigarettes or nicotine pouches may lower some significant oral health risks associated with smoking, but leaving nicotine behind entirely remains the safest and healthiest choice.

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Matthew Ma

Marketing at Ecigator

With over a decade of experience in the e-cigarette industry, Matthew Ma is a seasoned expert in both the manufacturing and usage aspects of vaping products. His extensive background has provided him with a deep understanding of the intricacies and evolving dynamics of e-cigarettes.