Oral Cancer: Emerging Risk Factors

Oral cancer is often described as a “silent killer” because, in the early stages, it can be painless and leave few physical marks. However, according to the Oral Cancer Foundation (2016), one person in the U.S. dies of oral cancer every single hour of every single day. Of those diagnosed with oral cancer, only about 57% are alive after five years. According to the CDC (2013), some minorities experiencing mortality at almost twice the rate. While the statistics are astounding, the good news is that one can mitigate the risks of oral cancer through the adoption of healthy lifestyle choices. This month, we highlight Oral Cancer Awareness to educate people about ways to reduce risks of developing this dangerous disease and encourage them to access oral cancer screening programs in their community!

According to the Oral Cancer Foundation (2016), 7% of oral cancers come from unknown causes; some may be due to a genetic predisposition. The vast majority of oral cancers are due to tobacco and alcohol use, as well as exposure to the human papilloma virus version 16 (HPV-16) (see: HPV’s Impact on the Mouth). About 80% of people with oral cavity and oropharyngeal cancers use tobacco, while about 70% of people diagnosed with oral cancer are heavy drinkers. For people who smoke and drink heavily, the risk of oral cancer may be as high as 100% more than the risk for people who do not smoke or drink (Cancer Treatment Centers of America, 2016).

Therefore, preventing high risk behaviors is critical in preventing oral cancers. These include avoidance of all tobacco products, including cigarettes, cigars, pipes and smokeless tobacco. Thanks to the U.S. Surgeon General’s seminal report (1964), the toxic effects of tobacco have long been known.  The report was a catalyst for a legion of anti-smoking campaigns that have succeeded in steadily reducing smoking rates.

A new danger has recently emerged threatening to overturn the decades of advocacy efforts that discouraged this deadly habit. E-cigarettes are devices that do not burn tobacco leaves but instead vaporize a solution that the user inhales, a distinction that many marketing companies laud as a healthy alternative to smoking.  Marketing, colorful packing and array of fruit flavors has succeeded in turning 2.4 million middle and high school students into current users of e-cigarettes (CDC, 2014). In fact, e-cigarettes have surpassed the current use of every other tobacco product. Among those who have never smoked, young adults, aged 18-24, are more likely to have tried e-cigarettes; current smokers who have tried to quit are more likely to use e-cigarettes than those who have not tried quitting (Schoenborn & Gindi, 2015).

The Tobacco Free Initiative of the World Health Organization is tasked with focusing international resources and action on the global tobacco epidemic. After reviewing current research on e-cigarettes, the group released a report (2014), in which they stated that e-cigarettes do inflame the eyes and respiratory tract, but found that well-regulated electronic cigarettes are likely to be less toxic than are conventional cigarettes or other combusted tobacco products. However, they do caution that most e-cigarettes contain nicotine, which may affect brain development and pregnancy outcomes; may lead to cardiovascular disease and neurodegeneration; cause addiction and may lead to continued tobacco product use. Because cancer has a long latency period, conclusive evidence about the carcinogenic properties of electronic cigarettes are not yet available; however, the aerosol is known to contain carcinogenic compounds like formaldehyde in the ultrafine range.

To fill in the research gap and clarify the effect of electronic-cigarettes on oral health, the National Institute of Dental and Craniofacial Research has launched an initiative to encourage studies aimed at assessing the effects of aerosol mixtures produced by electronic cigarettes on oral and periodontal epithelial cells.While the effects of long term exposure to e-cigarettes are currently unknown, they present a potential oral cancer and periodontal disease risk for users due to their higher exposure to chemical mixtures.

While more research needs to be done to satisfactorily elucidate the effects and uncertainties of e-cigarettes on health, the lack of regulation of e-cigarettes by the FDA has led to wide variations in the nature of the toxicity of contents and emissions of e-cigarettes. Different battery voltage and unit circuitry can impact the amount of toxicant delivery to the body, as well as contribute to the formation of additional toxicants. Products also vary in the ease with which they can be modified to increase nicotine delivery. Large doses of nicotine can lead to nicotine poisoning that can lead to seizures and respiratory depression. The number of calls to poison centers involving e- rose from one per month in September 2010 to 215 per month in February 2014 (Chatham-Stephens et. al., 2014). In one tragic case, a one-year-old child died from nicotine poisoning. The WHO calls on public health officials to regulate e-cigarettes to minimize content and emissions of toxicants, ensure use of nicotine of pharmacological quality, standardize nicotine delivery to known levels, and minimize acute nicotine toxicity.

Primary care providers and dentists can contribute to curbing oral cancer and e-cigarette use by teaming up to engage their patients in oral health promotion, risk reduction behaviors and oral cancer screening programs. Healthcare providers must adopt a non-confrontational approach to speaking with teenagers and young adults about their e-cigarette use. As more research evidence becomes available, healthcare teams can educate their patients about the potential impact that e-cigarettes have on health, as well as provide parents with guidance on measures to adopt in order to prevent nicotine poisoning in their young children.


Cancer Centers of America. Oral Cancer Risk Factors. http://www.cancercenter.com/oral-cancer/risk-factors/

Center for Disease Control (2016). E-cigarettes Ads and Youth. http://www.cdc.gov/vitalsigns/ecigarette-ads/

Center for Disease Control (2013). Oral Cancer. http://www.cdc.gov/oralhealth/oral_cancer/

Chatham-Stephens, K., Law, R., Taylor, E., Melstrom, P., Bunnell, R., Wang, B., … & Schier, J. G. (2014). Notes from the field: calls to poison centers for exposures to electronic cigarettes–United States, September 2010-February 2014. MMWR Morb Mortal Wkly Rep, 63(13), 292-293. http://www.ncbi.nlm.nih.gov/pubmed/24699766

Schoenborn, C. A., & Gindi, R. M. (2015). Electronic cigarette use among adults: United States, 2014. NCHS data brief, 217, 1-8. http://www.cdc.gov/nchs/data/databriefs/db217.pdf

Terry, L., & Woodruff, S. (1964). Smoking and health: report of the Advisory Committee to the Surgeon General of the United States. U-23 Department of Health, Education and Welfare. Washington DC: Public Health Service Publication, (1103). http://profiles.nlm.nih.gov/NN/B/B/M/Q/

Oral Cancer Foundation. Oral Cancer Facts. http://www.oralcancerfoundation.org/facts/

World Health Organization (2014).Electronic nicotine delivery systems. http://apps.who.int/gb/fctc/PDF/cop6/FCTC_COP6_10Rev1-en.pdf?ua=1

4 thoughts on “Oral Cancer: Emerging Risk Factors

  1. Thank you for bringing attention to this very deadly cancer that too few people know about. Lack of awareness means lack of knowledge of risk factors some of which could be avoided, and lack of awareness of early signs and symptoms that may mean less damaging treatments and even survival. There are a few minor errors in this piece that do not take a large amount of value away from it, but I think should be corrected for the record. OCF does not say that 7% come from genetics. It says that 7% come from unknown causes. Some of that may very well have to do with a genetic predisposition. But it is just as likely that a some or all of those share a lifestyle risk factor yet unidentified. The web site clearly states on the first page http://www.oralcancer.org that at five years from diagnosis there is a death rate of about 43%, meaning a survival rate of about 57%. Of course depending on how you parse the SEER data base, and many variables possible such as over ten years vs. the last year that there is complete data from only that percentage will change as the survival advantage in HPV origin cancers is driving survival up particularly in oropharyngeal cancers. So it is safer to say about 60% ( given all the ways this can be manipulated ) survival at 5 years. BY most cancers standards, that is really bad. Over all though you guys did a good job.


    1. Dear Mr. Hill– thank you so much for your thorough reading of our piece. We very much appreciate your input! Please also accept our congratulations on your recent Innovation Leadership Award and for the excellent work that you do with the Oral Cancer Foundation!


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