Electronic Nicotine Delivery Systems and Oral Health: Emerging Risks and Concerns

Sir, The introduction of electronic cigarettes (ECs) also known as Electronic Nicotine Delivery Systems (ENDS) has disrupted the tobacco control efforts, shifting from traditional smoking to the inhalation of aerosolized nicotine. Initially marketed as smoking cessation tools, ECs have gained popularity as socially acceptable recreational devices. Oral health is particularly affected due to direct exposure with ENDS use linked to caries, periodontal disease, mucosal damage and altered microbiomes. Toxic chemicals in e-liquids and their base ingredients (propylene glycol and vegetable glycerine) foster colonization of bacteria like Streptococcus mutans, Porphyromonas gingivalis. Some of the major components in ENDS include propylene glycol, glycerine, diacetyl, benzaldehyde, acrolein, formaldehyde etc that leads to health hazards such as respiratory tract irritation, bronchiolitis etc.[1] The flavours (menthol, bubble-gum etc.,) enhance oxidative stress, inflammation, while nicotine metabolites (cotinine, anabases) and prostaglandins (PGD2, PGE2) are elevated altering metabolic pathways. High cobalt and manganese levels are found in plasma after ENDS explosion with 62% occurring in pockets and 8% injuries to face.[2] Also, higher frequency of hyperplastic candidiasis, virulent strains of Candida like SAP2, SAP3 and SAP9 are found. Considering the several health hazards, the Ministry of Health and Family Welfare, Government of India banned the use of e-cigarettes, Production, Manufacture, Import, Export, Transport, Sale, Distribution, Storage, and Advertisement Act, 2019 (PECA).[3] But despite the ban and the penalties in place to prevent e-cigarette availability, a 2023 survey among young adults revealed that around one in ten being a current vaper and a further 14% reported having used e-cigarette in the past.[4] In India, the prohibition on e-cigarettes may not have curbed ENDS consumption but instead pushed the market underground. Despite the nationwide ban on e-cigarette sales, the Indian market still offers covert online purchasing options, highlighting the need to clarify the Act’s provisions to effectively curb illegal sales. Effective enforcement of India’s e-cigarette ban requires a complete restriction on advertisements and promotional content across online platforms, including blocking foreign-generated advertisements and prohibiting cross-border promotions, particularly social media posts originating from other countries. The rampant marketing of e-cigarettes has the potential to reverse the progress made in tobacco control efforts in India, necessitating decisive action to enforce the provisions of PECA 2019. This includes the establishment of an Inter-Ministerial committee, stringent enforcement including international borders through customs authorities, and enhancing cyber enforcement.[5] Hence, authorities should identify violation and direct social media platforms ensuring, which such content is not accessible to the Indian audience. Thus, a comprehensive approach to effectively uphold the ENDS ban includes enforcing a restrictive environment, creating public awareness campaigns and stringent digital monitoring.[5] Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.