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Update on flavoring-induced lung disease

Holden, Van K.; Hines, Stella E.

Current Opinion in Pulmonary Medicine: March 2016 - Volume 22 - Issue 2 - p 158–164
doi: 10.1097/MCP.0000000000000250

Purpose of review Since the initial report of bronchiolitis obliterans in microwave popcorn workers, exposures to flavoring substances have been identified in a variety of food and flavor manufacturing facilities and in the consumer market. Attempts to decrease the risk of lung disease have included the use of flavoring substitutes; however, these chemicals may cause similar injury. This article reviews recent flavoring exposures and data on the pathogenesis, clinical characteristics, and surveillance of flavoring-induced lung disease.

Recent findings Diacetyl and 2,3-pentanedione exposures have occurred in food production facilities that make cookies, cereal, chocolate, and coffee. Airborne levels often exceed proposed occupational exposure limits. Cases of biopsy-proven bronchiolitis obliterans in heavy popcorn consumers have also been reported. New data demonstrate the presence of diacetyl and 2,3-pentanedione in flavored nicotine liquids used in electronic nicotine delivery systems.

Summary Diacetyl substitutes cause similar peri-bronchiolar fibrotic lesions in animal studies. Their use may continue to place workers at risk for flavoring-induced lung disease, which may present in forms beyond that of fixed airflow obstruction, contributing to delays in identifying and treating patients with flavoring-induced lung disease. Engineering controls, medical surveillance and personal protective equipment can limit flavorings exposure and risk for lung disease.

aDivision of Pulmonary and Critical Care Medicine

bDivision of Occupational and Environmental Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA

Correspondence to Stella E. Hines, MD, MSPH, Division of Occupational and Environmental Medicine, University of Maryland School of Medicine, 11 S. Paca Street, Suite 200, Baltimore, MD 21201, USA. Tel: +1 410 706 7464; e-mail:

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