Youth E-cigarette use in the United States: carcinogenic exposure, epidemiologic trends, data gaps, and implications for cancer prevention policy
Year: 2026
Type: article
Abstract: some e-cigarette aerosol components have been reported to have a direct impact on oral cells (Ganapathy et al., 2024). According to a study by Li Q. et al., side effects believed to be linked to artificial flavors, especially cinnamon and menthol, include altered taste perception, black tongue, hairy tongue, and nicotine stomatitis.Many e-liquid flavors are available in the market targeting younger users but only 41 ecigarettes were authorized by the FDA in the USA on December 20, 2025 (Center, 2025).This article highlights the different effects of e-cigarettes on oral cancer, data availability, and long-term development and implementation of policies.E-cigarettes can be used in a wide variety of ways. For example, an occasional smoker who transitioned to e-cigarettes or an experienced smoker who is trying to quit the smoking habit, or a totally non-smoker drawn towards it out of curiosity (Weaver et al., 2024). Regardless, the false assumption that e-cigarettes can be a less harm than traditional cigarettes is false and lacks long term data. (Giovacchini, Coral X. et al., 2022). Additionally, they are designed to be sleek and easy to carry anywhere and made attractive by adding different flavors while releasing odorless vapors or smoke.A meta-analysis conducted by Wang RJ et.al in 2021 concluded that e-cigarettes in general, do not correspond to a higher smoking quit rate in the general population but are considered as a prescription drug to promote smoking cessation under clinical supervision.A study conducted by Mustaq N et al. using the Fagerstrom test, corroborated the addictive potential of e-cigarettes, like conventional cigarettes, through strong nicotine addiction pathways in the brain. The ENDS, along with providing nicotine, also produce harmful aerosols with cytotoxic and cellular immunomodulation effects, which can cause the development of clinical disease related to the lungs.Youth Exposure E-cigarettes are the most commonly used tobacco product among U.S. youth. Most e-cigarettes contain nicotine which can harm adolescent's brain thereby affecting attention, learning, mood and impulse control (CDCTobaccoFree, 2017) and is highly addictive. An article from the New England Journal of Medicine reported a 10% increase in adolescents using e-cigarettes between 2017 and 2018 alone, which is approximately 1.3 million teenagers (Farzal et al., 2019). In 2024, 1.63 million (5.9%) students in the US reported using e-cigarettes which includes 410,000 (3.5%) middle school students and 1.21 million (7.8%) high school students (Jamal et al., 2024, Park-Lee et al., 2024).Extensive advertising and marketing by the tobacco companies, availability of a wide variety of appealing flavors, social influences and the addictive effects of nicotine contribute to the reasons for vaping among youth. The most used e-cigarette brands are Elf Bar (36.1%), Breeze (19.9%), Mr. Fog (15.8%), Vuse (13.7%) and JUUL (12.6%) (U.S. Food and Drug Administration, 2025). JUUL contains approximately 5% or 59mg/ml of nicotine which is equal to the nicotine contained in 20 cigarettes (Morean et al., 2019). Despite that 39% of adolescents did not consider JUUL to be an e-cigarette at all (Morean et al., 2019) and another survey revealed that 63% of adolescents did not know that JUUL pods contained nicotine (Fadus, Smith and Squeglia, 2019). E-cigarettes can also be used to inhale marijuana and a study showed that teens who use nicotine liquid in e-cigarettes were 3.6 to 4 times more likely to use marijuana in the next 2 years (Selekman, 2019).Parents and caregivers, educators, health care providers, states and territories, communities play a very important role in educating and bringing awareness about the harmful effects of ecigarettes and helping them to reject or quit vaping and all other tobacco products.The first part of the body that comes in contact with the inhaled e-aerosol is the oral cavity and is directly exposed to the chemical components and toxins. As a result, there are changes in the oral microbiome with evidence of both compositional and functional shift in the oral microbiome and increase in opportunistic pathogens (Cameron, Hao Meng Yip and Garg, 2024). E-cigarettes are known to contain formaldehyde, acetaldehyde and heavy metal constituents.Although e-cigarettes have fewer carcinogens compared to the traditional cigarettes, the mechanism of damage to DNA is similar. Few in-vitro studies have shown that e-cigarette vapor or liquid can induce DNA damage, oxidative stress, DNA double-stranded breaks, apoptosis, necrosis and genotoxicity in various oral cells (Wilson et al., 2022, Yang, Sandeep andRodriguez, 2020) One common assumption is that nicotine in e-cigarettes is the major cause for toxicity and nonnicotine e-cigarette is inert and safe. Study by Yu et al (Yu et al., 2016) demonstrated that the vapors from e-cigarettes induced cell death through apoptosis or necrosis and caused DNA strand breaks irrespective of the presence or absence of nicotine. Although it is not clear whether the DNA strand breaks were significant enough to cause cancer, there is sufficient evidence to show that e-cigarettes with or without nicotine cannot be considered to be inert (Cameron, Hao Meng Yip and Garg, 2024).Although e-cigarettes were linked to gum diseases, dry mouth, decay, stains, most dental professionals are not fully aware of the risks (Shabani et al., 2025). Oral health professionals should be educated about the ill effects of e-cigarettes on oral health using evidence-based studies.Many oral cancers can be diagnosed using biomarker studies. Emerging research highlights the potential of salivary biomarkers, such as microRNAs, in detecting oral health issues associated with tobacco and alternative smoking devices. Pro-Inflammatory cytokines have a known association with causing inflammation and periodontal disease. An increase in cytokine levels, such as IL-1β and TNF-α, is seen in the saliva of smokers who use e-cigarettes. (Shabani et al., 2025).Clinical studies require long follow up periods to evaluate the long term effects of e-cigarettes and pose ethical concerns hence early interventions should be applied by the oral health professionals. More studies should be conducted to identify early biomarker indicators in ecigarette smokers to facilitate better care for the patients.As per the Tobacco 21 rule passed in 2019, people under 21 years are not allowed to buy ecigarettes and other tobacco products. (Tobacco, 2021). However, this policy should be implemented strictly. Flavors should be limited as some flavors like diacetyl are metabolized differently in lungs compared to gut (CDC, 2025). Another important development is the PACT agreement, which prevents the shipping of vapes with USPS (www.atf.gov, 2025). The PACT agreements should be extended to other mailing services and should be sold only in person with an ID check, like any alcohol and tobacco products that are sold in stores.E-cigarette unit sales between February 2020 and June 2024 increased from 15.7 million units to 21.1 million units (34.7% increase). In June 2024, e-cigarette sales totaled $488.9 millions. (CDC, 2024) "According to a study conducted in Kosovo in Europe, a large majority of both general dentists (77.7%) and specialists (69.8%) were unsure whether e-cigarettes are FDA-approved for safe consumption, while only 2.9% and 4.7%, respectively, affirmed FDA approval. (Shabani et al., 2025). We would recommend the following policy adaptations.• All oral health professionals, including dentists and dental hygienists, must have mandatory continuing education hours on Tobacco and e-cigarettes for their license renewal from the state and national dental associations. This allows oral health professionals to keep themselves updated with the current literature in this regard.• Inclusion of e-cigarette usage in social history questionnaires should be made mandatory during medical and dental office visits.• School children and young adults must be educated on the ill effects of e-cigarettes, as the usage is more prevalent in these age groups. Awareness and counselling should be provided in schools, colleges, hospitals and community centers.• Strict policies should be developed and adhered by agencies like the Food and Drug Administration (FDA), Centers for Disease Control and Prevention (CDC), the National Institutes of Health (NIH), and the Substance Abuse and Mental Health Services Administration.Despite the wide belief that E-cigarettes are a lower-risk alternative than traditional cigarettes more evidence is needed to support this statement. . Further research studying patients with only e-cigarette use and no prior history of other oral cancer risk factors is needed to assess ecigarettes as an independent risk factor for oral cancer.The development of interdisciplinary treatment protocols involving oral health professionals, primary care providers, nurses and oncologists is crucial to improve comprehensive care for the people using e-cigarettes.Oral health care professionals and health care providers have the responsibility to promote awareness about the toxic effects of e-cigarettes across schools, colleges, hospitals and provide resources that will help people with e-cigarette cessation.
Source: Frontiers in Oncology
Language: English
Subfield: Physiology
Field: Medicine
Domain: Health Sciences
Open Access status: gold
Estimated APC paid: $3,801
OpenAlex ID: W7155769711