E-cigarette use and Barrett's esophagus: evaluating a new risk in the era of vaping

The association between electronic cigarette (e-cigarette) use and Barrett's esophagus (BE) is still unclear. While traditional, combustible cigarette smoking is a known risk factor for BE, growing evidence on e-cigarette exposure has raised concerns about potential esophageal injury. Our aim is to evaluate the relationship between e-cigarette use and BE in a large and diverse population.

We conducted a cross-sectional analysis using the All of Us Research Program to examine the association between e-cigarette use and BE. Adults aged 18 years or older with an ICD-10 diagnosis of BE (K22.7) were included. E-cigarette exposure was categorized as (1) ever vs. never use, (2) former vs. current vs. never use, and (3) dual use (concurrent e-cigarette and traditional cigarette smoking). Covariates including demographics, BMI, smoking status, alcohol use, GERD, hiatal hernia, diabetes, NSAID use, education, income, employment, and insurance status, were obtained. Multivariable logistic regression estimated adjusted odds ratios (AORs) with 95% confidence intervals.

Among the 328,022 individuals studied, 29,343 (9%) reported e-cigarette use. E-cigarette users were younger and had lower rates of diabetes and GERD. After adjusting for relevant factors, we found that ever e-cigarette use was associated with higher odds of BE (OR 1.21, 95% CI 1.06-1.39). When we stratified by patterns of use, current e-cigarette use was significantly associated with BE (OR 1.46, 95% CI 1.15-1.83), whereas former use was not (OR 1.12, 95% CI 0.96-1.31). Individuals who were dual users also had increased odds of BE (OR 1.22, 95% CI 1.05-1.41). As expected, smoking, older age, hiatal hernia, and GERD remained strong predictors across all models, with GERD showing the strongest relationship.

In this large national cohort, current and dual e-cigarette use were associated with increased odds of BE after adjustment for established risk factors, including GERD and combustible cigarette smoking. These findings suggest that e-cigarette use may represent a modifiable and underrecognized contributor to esophageal mucosal injury. Prospective longitudinal studies are needed to establish causality and clarify the mechanisms underlying this association.