To Vape or Not to Vape? That Is the Question

The management of diabetic foot ulcers is always a challenge because of the underlying disease and patient comorbidities. One of the comorbidities that is particularly concerning and frequently encountered is smoking. Smoking has been documented as a significant risk factor for the development of diabetic ulcers and associated with delayed healing of diabetic ulcers as well as a marker for increased foot amputation in those with diabetic ulcers.^1-4 Cigarette smoking is thought to increase the morbidity of diabetic ulcers mainly due to its effect on the circulation. Smoking is known to increase oxidative stress and result in apoptosis of the vascular endothelial cells, which leads to endothelial dysfunction and accelerated atherosclerosis in the vascular system. The vasoconstriction caused by the nicotine in the cigarette smoke further worsens blood flow. The carbon monoxide in the smoke combines with hemoglobin, resulting in carboxyhemoglobin (known to displace oxygen from the blood cells) and reducing the delivery of oxygen to the tissues.⁵ When the tissues do not receive enough oxygen, formation of new blood cells is stimulated, thus increasing blood viscosity and potentially reducing blood perfusion.⁶ Other work has suggested smoking affects cell mediators of healing such as vascular endothelial growth factor (VEGF), which influences new blood vessel formation; transforming growth factor beta 1, which is involved in extracellular matrix and granulation tissue formation; and matrix metalloproteinase-1 (MMP-1), which is involved in extracellular matrix remodeling.^7-9 The influence on these mediators can lead to reduced wound healing.

Because we know the negative effects of smoking, as health care providers, we encourage our patients to cease smoking with varying degrees of success. As a result, many patients have changed to electronic cigarette vaping as a perceived safer alternative than cigarette smoking. It has been questioned whether vaping is truly safer than cigarette smoking as well as whether vaping has the same ill effects on wound healing.^10,11 Reports show the levels of nicotine in vaping fluid are higher than in cigarettes and that some vaping fluids contain ethylene glycol, glass, and heavy metals.^11,12 Recent studies show that vaping reduces the expression of VEGF, and subsequently, blood vessel density in the healing wound was significantly affected, leading to loss of tissue in experimental wounds. In wounds where flaps were created then replaced to heal, 52% of the flaps in the control group did not heal while 72% of the flaps in the smoking group and 70% of the flaps in the vaping group did not heal.¹¹ Interestingly, the expression of VEGF was decreased in healthy tissue compared with the control group. This difference was not noted in the smoking group.¹¹ The density of small blood vessels was significantly decreased in healthy tissue in the vaping and smoking groups compared with the control group.¹¹ This suggests that these effects could be responsible for other changes seen in the tissues of patients with chronic use of these products.

The expression of MMP-1 was reduced in the cigarette smoking and vaping groups. This leads to dysregulation of the healing extracellular matrix and fibrotic tissue formation.¹¹ For these reasons, the patient with a healing wound—whether associated with diabetes or another etiology—should not substitute vaping for smoking. It is not considered to be a safer alternative.

So, to address the topic of to vape or not to vape in wound care—from my professional experience, the answer is definitely not.