A University of Central Florida professor has been researching vaping’s impact on the balance of bacteria in the mouth to illustrate that the habit isn’t the safe alternative to smoking many believe it to be.

From the American Lung Association to the surgeon general, reports indicate that youth e-cigarette use is a significant public health concern, calling for parents, educators and policymakers to step up and proactively discourage children and adolescents from picking up a vaping habit that’s come to be regarded as less dangerous than the traditional cigarettes.

But Dr. Claudia Andl is among those diligently working to illustrate that a comparative lack of nicotine, tar and well-studied history of proven health risks doesn’t mean that vaping should be considered a safer smoking alternative—or even safe at all. Last year, the associate professor at UCF’s College of Medicine broadened her research on throat and mouth cancer to discover that, in addition to the lung damage and cancer correlation that others have already studied, vaping affects its first point of contact, too.

Building on the “large collection of literature that has been published [that] gave a really good look into what vaping does to the lungs,” Dr. Andl and her team turned their attention to the mouth. They soon discovered that vaping wreaks havoc on the oral cavity’s delicate bacterial balance, allowing two types of always-present harmful bacteria—including Streptococcus mutans, largely associated with tooth decay and gum disease—to thrive, unaffected by the vapors that drastically hinder the growth of healthy bacteria.

A mother herself, Dr. Andl knows that it’s tough getting through to youngsters who think they’re invincible and are more interested in fitting in than listening to well-meaning parents, even when that parent has a Ph.D. in cell biology. But, as she told Orlando Family Magazine, the need for impactful messaging and sobering discoveries increased her drive to produce the kind of research that helps educate kids and parents alike, pushes for better regulation and more effective product labeling, and will eventually start chipping away at a pernicious misconception that downplays the dangers of youth vaping.

What made you want to advance this research?

With the e-cigarette vape in general, I realized that, all of a sudden, it was all over the place. And we have always been interested in studying mechanisms of oral cancer, the different signaling pathways that are involved. In terms of risk factors, e-cigarette vaping was definitely something new, and it also seemed like it was something that is really not that well understood yet, even to this day: There is that pretty large body of literature out there but I still don’t think it really answers all the questions.

Part of the problem, I believe, is there’s such little regulation in purchasing, for example, a JUUL pod. You could purchase something similar from a different company, and you really don’t know if they’re the same. And they’re not, because everything that’s in there is really not fully tested, so a JUUL pod that you bought today and then one that you may buy two months down the road may be slightly different. So we were also interested in what all these different components do. You obviously have nicotine in there, and that’s very bad for addiction. Usually, once the nicotine gets heated up, a different breakdown product forms: That incredible temperature that it is heated to can actually also form other chemicals that are known to cause cancer, and so that is really where we started. We tested just the e-cigarette liquids with a carrier, and then the ones with the nicotine, and we had some with menthol, and also straight from the bottle without heating it in an actual e-cigarette device. It is pretty clear that the high temperature causes a lot of these probably rather harmful and toxic chemicals.

Even though the long-term impact of vaping is still too new to be fully understood, how do you help young vapers realize the health consequences?

That’s hard! You obviously can’t say with guarantee that all of these kids will eventually develop cancer.

We have new, preliminary data that are not published yet. We’re currently working on where we look for cancer markers, something that could help you, for example, diagnose cancer, and we see that some of these markers are already present in our model longer term. That shows me that, eventually, there is a higher risk that some of these kids eventually may develop cancer—maybe it’s not cancer right away, but a lesion that could eventually become a cancer, especially if it’s frequently and continuously exposed to those same chemicals, because a lot of those cause DNA damage, and we know that can cause mutation, and mutation causes cancer. It’s a pretty linear progression if you look at it.

They already tried to regulate it so it doesn’t get in the hands of teens and, as we all know, even middle schoolers can get their hands on something they are not able to purchase legally. So they still get it, they still use it, and they think “Oh, it’s not going to happen to me.” My biggest hope is that there will be better regulation and obvious labeling on the product itself, same as with tobacco products. I hope that, if we have some of our data peer-reviewed and published, that maybe some of the labeling will change. Vaping products aren’t directly marketed to kids, but at the same time, yes they are: The sleek packaging is super cute, it’s pink little boxes that say something like “Awesome piña colada flavor!”

I do hope there will be something like a big, scary toxic face on the packaging to make it less appealing. Because kids are kids, right? That’s why education is a big piece of this, and that includes educating the parents. With vaping, there’s no stink [like cigarette smoke], so some parents may not even be aware their kid is vaping. I think just starting that discussion at home can get that conversation going. At the same time, kids are hooked and a lot of them have very bad withdrawal when they try to quit. So when their parents know that they’re trying to quit, they can hopefully benefit from someone supporting them through it.

What kind of surprises have you encountered over the course of your research?

We all thought nicotine is the bad guy. I think a lot of people assumed, “Oh, if I have the e-cigarette vape without the nicotine, then it’s fine.” But it’s not fine. That really was the biggest surprise to us: It doesn’t even matter if there’s no nicotine in what you’re vaping because the actual damage can come from any of the ingredients in there. One, propylene glycol, is also in your windshield wiper fluid. It is known to be antibacterial, so you will find plenty of websites where people claim it’s good for you because it kills the bacteria in your mouth—but it kills the good bacteria so the bad ones can still occupy your entire oral cavity.

As a mom, is it hard to balance what you know about vaping with the reality that kids are more swayed by peer pressure than parental concern?
Oh, absolutely! It’s very hard if you try to convince them and they don’t come to that conclusion themselves, and that’s why I think warnings have to be a lot more graphic. They need to see all the nasty data that goes with vaping. When they start vaping, they may have a terrible sore throat in the beginning, but then it goes away—but one day, it won’t just go away.

They have to really, really want to quit, they probably won’t just one day say, “Oh, I’ll do what Mama says now.” Because they do surround themselves with friends who, one way or another, support vaping themselves. That’s another issue, too: It looked like the numbers went down for a while, especially during COVID when people were at home and kids had a lot less access to vapes, but then everybody went back and everybody is with their friends again vaping in the high school bathroom. These, to me, are the big challenges, even trying to provide education. Kids won’t stop vaping until they really are ready for it, and hopefully it won’t be too late when they do.

What’s next for your research and goals?

We definitely aim to get better models. There are different models out there, there are these cells that we can culture that come originally from the mouth, and we grow them, we expose them to all these different things. But then there’s other literature that has described using, for example, animal models and in a lot of those, they develop other cancers like lung cancer and bladder cancer, probably because a lot of the toxins eventually have to get expelled from the body. Some of these pre-lesions, pre-cancers in the bladder seem to be very common—but none of [the mice] really got cancers in the mouth, probably because mice don’t breathe through the mouth, they breathe through their noses. Everything is connected, so there’s still obviously some exposure in the mouth as well but, of course, its concentrations will be much lower, not like direct exposure since most of it goes to the lungs. So we will be trying to think about better models so we can identify some of the other chemical components.

Eventually, we will have some more hard data. We always do hope that we may acquire some funding, then we could do studies where we literally swab the mouth and sample bacteria; you could also, based on the cells you scrub off, look at changes in DNA status for mutations and things like that. Vaping really isn’t all that new anymore: Some college kids may have already vaped for five, six years by now, so maybe we would actually be able to identify some of these things. And we are still continuing with the models that we already have. As they get more solid evidence and ultimately as that gets published and peer-reviewed, people can see that there are more precancerous pathways activated by vaping than you’d think.