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Supporting Your Practice

What You Should Know about the Changing Tobacco Landscape

This summary is based on the article published in the Journal of the American Dental Association: “The changing tobacco landscape. What dental professionals need to know” (June 2016)

  • Elizabeth T. Couch, MS, RDH
  • Benjamin W. Chaffee, DDS, MPH, PhD
  • Stuart A. Gansky, MS, DrPH
  • Margaret M. Walsh, MA, MS, EdD, RDH


  • Tobacco products in the United States and the patterns of tobacco use are changing. Although cigarette smoking prevalence has declined, dental professionals are likely to encounter substantial numbers of patients who have tried and are continuing to use new and alternative tobacco products, including cigars, water pipes (hookahs), and electronic cigarettes, as well as conventional and new smokeless tobacco products.
  • The authors reviewed conventional and new tobacco products in the United States, their adverse oral and systemic health effects, and their prevalence of use.

Key Messages


Smoking cigarettes has numerous short-term and long-term adverse health consequences for nearly every human organ system. (4, 14)

Cigarettes also affect people exposed to environmental tobacco smoke exhaled during cigarette smoking or accumulated residue on nearby surfaces, that has been linked to cancer, periodontal disease, respiratory and cardiovascular diseases, and adverse health effects among children and infants.(4, 15)

Conventional and New Smokeless Tobacco Products 

  • Associated with increased risks of oral27 and pancreatic cancer,28 oral mucosal lesions (for example, oral leukoplakia),29-31 nicotine dependence,32 and possibly cardiovascular disease.33,34
  • ST use also causes oral conditions such as gingival keratosis, tooth discoloration, halitosis, enamel erosion, gingival recession, alveolar bone damage, periodontal disease, dental caries due to sugars in the product, and tooth loss.35,36
  • Adolescent ST users are at greater risk of initiating smoking.37-40
  • Dissolvable tobacco products contain nicotine, flavoring compounds, binders, and humetcants.26 Some of these compounds have the potential to cause adverse oral and systemic health effects, although few health data related to product use are available.

Electronic Cigarettes

  • No long-term evidence related to oral and systemic health effects exist.
  • More than 460 e-cigarette brands are available in the United States, with rapidly evolving product design, little to no regulation, and inconsistent quality control.50,51
  • E-cigarette aerosols have been shown to contain nicotine, ultrafine particles, TSNAs, and other toxic compounds such as acetaldehyde, acrolein, and toluene, although at significantly lower levels than in cigarettes.46,52,56-58
  • E-cigarettes may increase the risk of experiencing adverse health effects including seizure, increased heartbeat, disorientation, airway resistance, congestive heart failure, pneumonia, and second-degree burns from faulty devices.51
  • Due to the nicotine level in most e-cigarette products, it is possible that e-cigarettes may adversely affect oral tissues and immune response.65-69
  • Further research regarding the oral and systemic health effects of e-cigarettes is needed.

Water Pipe (Hookah) Tobacco Smoking 

  • Existing evidence suggests that water pipe smoking has negative health effects similar to those of cigarettes.
  • Water pipe tobacco smoking has been associated with lung cancer, oral cancer, respiratory disease, low birth weight, and periodontal disease.76,77 Smoke generated from water pipe tobacco contains high toxic compound levels, including heavy metals, TSNAs, and carbon monoxide,78,79 as well as nicotine.
  • Investigators have shown that during a typical 60-minute water pipe smoking session,73,80 users take roughly 200 puffs with an average puff volume of 500 millilitres.81
  • Water pipe smoking may also lead to the initiation of cigarette use,83 further increasing the risk of developing disease.

Cigars, Cigarillos, and Little Cigars

  • Smoke produced from cigars contains the same, if not more, toxic and carcinogenic compounds as cigarettes.86
  • Partial inhalation is common and the lack of complete inhalation increases the environmental smoke produced, exposing those nearby to the same toxins and carcinogens as the cigar user.87
  • Due to the fermentation process, cigar tobacco has high nitrogen compound levels that, when burnt, release several TSNAs.86
  • Cigar smoke contains high concentrations of harmful substances such as nitrogen oxides, ammonia, carbon monoxide, and tar.85-87
  • Cigar smoking is associated with oral, lip, laryngeal, esophageal, pancreatic, and lung cancers.86,87,90
  • Daily cigar smokers have an increased risk of developing coronary heart disease, aortic aneurysms, chronic obstructive pulmonary disease,86,90,91 and periodontal disease.92

Implications for Dental Professionals 

  • Dentists and dental hygienists must now address a wide range of tobacco products when screening patients, documenting use of traditional and new tobacco products in health records, and providing effective tobacco-use prevention and cessation counseling.
  • Dental professionals must take caution when considering tobacco industry claims of “harmlessness” and reduced risk related to new and emerging tobacco products.
  • Accurately communicating to patients the scientific evidence related to various tobacco products will allow patients the opportunity to make informed decisions whether to continue, quit, or refrain from using.


List of references (PDF)


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