Tobacco Induced Diseases

Review Paper

Effects of tobacco product use on oral health and the role of

oral healthcare providers in cessation: A narrative review
Sangeeta Gajendra1, Scott McIntosh2, Sucharu Ghosh1,3

ABSTRACT
Tobacco use has detrimental effects on health, including oral health. The AFFILIATION
1 Eastman Institute for
emergence and increasing popularity of newer tobacco and nicotine products Oral Health, University of
make tobacco use one of the major public health problems in the world. Rochester, Rochester, United
States
Tobacco use increases the risk of oral diseases such as oral cancer, oral mucosal 2 Department of Public
lesions, periodontal disease, and dental caries, among many other oral diseases Health Sciences, University of
and conditions. The dental office is an excellent venue for providing cessation Rochester, Rochester, United
States
intervention. However, there is a lack of knowledge and training in tobacco use 3 Arthur A. Dugoni School of
prevention among dental professionals. More efforts are needed for smoking Dentistry, University of the
Pacific, San Francisco, United
cessation interventions in the dental office. Smoking cessation interventions States
provided by oral healthcare providers include brief educational, behavioral, and
CORRESPONDENCE TO
pharmacological interventions. This review provides an overview of the ill effects Sangeeta Gajendra.
of tobacco use on oral health and the role of oral healthcare providers in managing Department of Community
Dentistry, Eastman Institute
and preventing tobacco dependence. for Oral Health, University
of Rochester, Box 683, 625
Elmwood Avenue, Rochester,
Tob. Induc. Dis. 2023;21(January):12 [Link] NY 14620, United States.
E-mail: sangeeta_gajendra@
[Link]
ORCID ID: [Link]
org/0000-0002-7323-1374
INTRODUCTION
The World Health Organization reported that 23.6% of the global adult population KEYWORDS
pharmacotherapy, dentist,
(aged ≥15 years) were current tobacco users in 2018, down from 33.3% in 2000 tobacco cessation, brief
and projected to decline further to 20.9% by 20251. In the United States in 2018, intervention, oral health
while an estimated 20% of US adults currently used any tobacco product, 13.7%
Received: 1 May 2022
of US adults (34.2 million people) were current cigarette smokers2. From 1965 to Revised: 11 October 2022
2017, the prevalence of current smoking declined from 52.0% to 15.8% (relative Accepted: 6 December 2022
percent change: 69.6%) among men and from 34.1% to 12.2% (relative percent
change: 64.2%) among women.
Tobacco and tobacco-related products recently were found to have been used
as far back as 12300 years ago3. Cigarette smoking is the most popular method of
using tobacco. While each cigarette contains 10–14 mg of nicotine, 1–1.5 mg is
absorbed into the body when smoked4. Tobacco addiction is driven by nicotine,
which is the primary reinforcing component of tobacco. Nicotine is generally
delivered through the skin, lungs, and mucous membranes.
Smoked tobacco, and in particular, cigarette smoking, is the most popular
method of using tobacco. Smoked tobacco is the most common method for
nicotine delivery. Smoked tobacco is available in various forms, such as cigarettes,
cigars, pipes, bidis, hookah, and others 5. According to the American Lung
Association, a burning cigarette produces more than 7000 chemicals, of which
69 are carcinogens6.
Smokeless tobacco is an umbrella term, which includes chewing tobacco,

Published by European Publishing. © 2023 Gajendra S. et al. This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 International
License. ([Link]

1
 Tobacco Induced Diseases
Review Paper

dry snuff, moist snuff, Swedish-style snus, betel of every use of e-cigarettes among adults (>18
quid, gutkha, zarda, toombak, and other products5. years) was 20%. Compared with adults aged ≥55
These products are generally made from a mixture years, odds of e-cigarette use were 4.77 times (95%
of tobacco, nicotine, sweeteners, abrasives, salts, and confidence interval, CI: 3.63–6.27) higher among
chemicals, and contain a mix of 4000 chemicals, more those aged 18–34 years and 2.16 times (95% CI:
than 30 of which are known carcinogens7. Smokeless 1.49–3.14) higher among people aged 35–54 years17.
tobacco delivers 3–4 times more nicotine than smoked The use of e-cigarette use has been associated with
tobacco. The amount of nicotine in 8–10 chews/dips respiratory illnesses and other health effects18. The
per day is equivalent to 30–40 cigarettes per day8. evidence base for the harms caused by e-cigarette
Studies from North America, Sweden, and South Asia liquids, their flavors, and their intensity of use has
have linked smokeless tobacco use with pancreatic been established and is continuing to grow19.
cancer, oral cancer, cardiovascular, and other Currently, 16 million Americans are living with a
diseases9-12. Swedish snus, a steam-pasteurized form smoking-related disease. In addition to the human
of tobacco, contains a lower amount of nitrosamine costs, smoking places a significant financial burden
than traditional products and has been promoted on US citizens, as smoking-attributable healthcare
as a potential harm-reduction product. Levy et al.13 spending exceeds $170 billion per year20. Clearly,
estimated low nitrosamine smokeless tobacco (LNST) there is a strong evidence base supporting smoking
to be 90% less hazardous than cigarette smoking and as a risk factor for non-communicable diseases such
promoting LNST could reduce smoking prevalence as cardiovascular diseases and cancer21. Evidence
by 1–3%. However, simulation models failed to show has linked smoking with lung diseases as well
any significant public health benefits of promoting as impacting the immune system and increased
smokeless tobacco14. susceptibility to infections. Smoking, including
Other forms of non-cigarette tobacco include e-cigarette use, increases the risk and severity of
nicotine products like nicotine-containing pulmonary infections because of structural damage
medications or nicotine replacement therapy (NRT) to the upper airways and a decrease in pulmonary
(examples are transdermal patches, gum, lozenge, immune function22.
sublingual tablet, inhaler, and nasal spray) and The evidence is also strong and growing regarding
electronic nicotine delivery systems (ENDS) or the association between smoking and infectious
e-cigarettes5. Transdermal patch is a slow sustained- diseases, including increasing the prevalence of HIV,
release form of nicotine delivery. Other products tuberculosis, and COVID-19 due to the alteration
like gum, nasal spray, oral inhaler, and tablets, are of the structural, functional, and immunologic host
acute dosing forms of nicotine. They provide general defenses23. For example, the novel coronavirus SARS-
craving relief and breakthrough craving relief with CoV-2 that causes COVID-19 affects the respiratory
the immediate release of nicotine15. E-cigarette, a system from mild to severe respiratory symptoms.
non-combustible tobacco product, comes in several A recent systematic review and meta-analysis of 40
formats resembling for example traditional cigarettes, studies concluded that there is an increased risk of
pens, or USB flash drives using an e-liquid that may severe COVID-19 disease among current smokers and
contain nicotine and various flavorings, propylene former smokers compared to non-smokers (OR=1.58;
glycol, vegetable glycerin, and other ingredients. The 95% CI: 1.16–2.15, p=0.004; and OR= 2.48; 95% CI:
device generates an aerosol that the user inhales. 1.64–3.77, p<0.001). Furthermore, the study found
According to the National Youth Tobacco Survey an increased risk of death among COVID-19 patients
2021, an estimated 2.06 million youths in the US who are current or former smokers (OR=1.35; 95%
reported using e-cigarettes within the past 30 days CI: 1.12–1.62, p=0.002; and OR=2.58; 95% CI:
(current use) with 84.7% using flavored e-cigarettes, 2.15–3.09, p<0.001)24. Another systematic review of
including 85.8% of high school users and 79.2% of 73 articles and 863331 patients found a significant
middle school users16. Analysis of the National Health association between smoking and mortality among
and Nutrition Examination Survey (NHANES) for COVID-19 patients with a relative risk of 1.19 (95%
the years 2015–2016 found the weighted prevalence CI: 1.12–1.27)25.

Tob. Induc. Dis. 2023;21(January):12

[Link]

2
 Tobacco Induced Diseases
Review Paper

For oral healthcare providers, it is imperative to a 5-year relative survival rate of 66.9% from 2011
keep abreast of the latest research on the general and to 201726. Oral squamous cell carcinoma (OSCC)
oral health effects of smoked and smokeless tobacco accounts for 80–95% of all oral cancers27,28. Tobacco,
and nicotine products. This can be translated into smoked or smokeless, causes oral squamous cell
clinical practice to successfully deliver counseling and carcinoma (OSCC)29. Cigarettes and other combusted
tobacco use cessation strategies in the dental office. tobacco products are dangerous nicotine delivery
The purpose of this study is to provide a practical devices that contain a complex mixture of tumor
review of the literature and discussion of the effects promoters, co-carcinogens, and various toxicants
of tobacco-related products on oral health and the role that exacerbate the effects of the carcinogens30. In a
of oral healthcare providers in preventing tobacco- narrative review of 32 selected articles, Jiang et al.29
related illness. proposed a plausible carcinogenic pathway attributing
tobacco as the major risk factor for OSCC. Tobacco
DEVELOPMENTS may cause epigenetic alteration of oral epithelial cells
An electronic search was performed between October and inhibit multiple systemic immune functions of the
2021 and February 2022. Electronic databases host. Its toxic metabolites may also cause oxidative
including PubMed, EMBASE, and Google Scholar stress on tissues releasing reactive oxygen species
were searched for systematic reviews, controlled that can damage, cause mutations and induce OSCC.
clinical trials, and observational studies using specific Studies of e-cigarette chemicals in vaping liquid have
keywords. Articles that reported the ill effects of also been shown to cause oxidative stress on tissues31,
tobacco on oral health (including dental, periodontal, including oral tissues 32. Oral cancer is the eighth
mucosal, salivary glands, implants, and oral cancer) most common type of cancer and one-third of oral
and tobacco cessation interventions used by oral cancer-related mortality in the world is attributable
health providers (including educational, behavioral, to tobacco smoking33. In a meta-analysis of 15 case-
and pharmacological) were included. Searches control studies, Sadri et al.34 found that smokers are
were also conducted of websites of leading national 4.65 (95% CI: 3.19–6.77) times more likely to have
organizations such as the American Dental Association, oral cancer. Oral cancer related to smokeless tobacco
the Centers for Disease Control and Prevention, the is most prevalent in Asia and Africa. A meta-analysis
US Food and Drug Administration, the National of 12 systematic reviews found that the estimated risk
Cancer Institute, the Office of Disease Prevention for oral cancer ranged from 1.36 to 7.90 with a higher
and Health Promotion, the National Institute on Drug risk for the South-East Asia Region (4.44–7.90)35.
Abuse, the National Cancer Institute, the Agency for Another systematic review found tobacco chewing
Healthcare Research and Quality, the American Lung increased the risk of oral cancer by 4.7 (95% CI: 3.1–
Association, and the American Psychiatric Association. 7.1) times and paan (betel leaf and areca nut) with
tobacco increases the risk by 7.1 (95% CI: 4.5–11.1)
Effects of tobacco-related products on oral times36.
health Exposure to secondhand smoke or passive smoking
In addition to associations between tobacco product is a risk factor for several adverse health effects. A
use and many diseases, cigarettes, smokeless tobacco systemic review of 1179 cases and 5798 controls
(e.g. chewing tobacco and snus), and other tobacco found that people exposed to secondhand smoke
uses cause specific oral health issues such as oral (SHS) are 1.51 (95% CI: 1.20–1.91) times more likely
cancer, oral mucosal lesions, periodontal disease, to have oral cancer. When the duration of exposure
implant failure, salivary gland hypofunction, dental was more than 10–15 years, the odds ratio increased to
caries among many other oral diseases and conditions. 2.07 (95% CI: 1.54–2.79). This systematic review and
meta-analysis supports a causal relationship between
Oral cancer SHS and oral cancer and provides guidance to develop
Oral cancer is the eighth most common cause of policy and appropriate prevention programs37.
cancer-related mortality in the world. An estimated Smoking and alcohol have a synergistic effect on
54010 new cases were reported in the US in 2021with oral cancer development. A systematic review of 33

Tob. Induc. Dis. 2023;21(January):12

[Link]

3
 Tobacco Induced Diseases
Review Paper

articles by Mello et al. 38 concluded the following and gingival crevicular fluid samples were collected
synergistic effects: alcohol and tobacco smoking from cigarette smokers (CS), e-cigarette smokers
(OR=4.74; 95% CI: 3.51–6.40), alcohol and smokeless (EC), dual smokers (DS), and non-smokers (NS).
tobacco (OR=7.78; 95% CI: 2.86–21.14), and alcohol, The samples were analyzed to compare biomarkers of
tobacco smoking, and smokeless tobacco (OR=16.17; inflammation, oxidative stress, anti-inflammatory lipid
95% CI: 7.97–32.79) increased the risk for oral cancer. mediators, tissue injury and repair, and growth factors
Smokers who are at high risk for cancer need to be with immunoassay (enzyme-linked immunosorbent
identified early to prevent the onset of this disease. assay and Luminex) in the four groups. Levels of
inflammatory mediators and oxidative stress were
Oral mucosal lesions statistically significantly higher in EC versus NS
A strong association has been found between as well as in DS versus EC32. Additionally, smokers
tobacco use and mucosal lesions such as leukoplakia, had approximately 80% higher risk of periodontitis
smokeless tobacco keratosis at the site of tobacco than quitters (RR=1.79; 95% CI: 1.36–2.35) and
placement, nicotinic stomatitis, smoker’s melanosis39 never smokers (RR=1.82; 95% CI: 1.43–2.31)45. On
and erythroplakia40. While some of the oral mucosal a positive note, a systematic review found that those
lesions are non-malignant, it is necessary to further who quit after a smoking cessation program have a
investigate leukoplakia associated with tobacco with similar risk of periodontal disease as those who never
a biopsy for the presence of epithelial dysplasia or smoked (RR=0.97; 95% CI: 0.87–1.08). This finding
carcinoma. About 3 to 6% of leukoplakias undergo was supported by a meta-analysis of longitudinal
malignant transformation, with this frequency studies that found former smokers and never smokers
increasing with longer follow-up periods41. Epithelial have a similar risk of tooth loss. However, smokers
dysplasia may appear clinically white or red due to have 2.6 (95% CI: 2.29–2.96) times more risk of tooth
hyperkeratosis or epithelial atrophy, respectively. loss46.
Epithelial dysplasia that involves the full thickness of The deleterious effects of tobacco smoking on
epithelium but does not invade the connective tissue dental implants have been extensively studied and
is termed carcinoma in situ39. Heavy smokers may also multiple systematic reviews were published in the last
have a condition called the black hairy tongue. The few years. Smoking has been attributed as the primary
dorsal surface of the tongue has a hair-like appearance patient-centered risk factor for endosseous implant
due to hypertrophy of filiform papillae and retardation loss 47. The implant failure rate was found to be
of the normal rate of desquamation39. Assessment of higher among smokers48. A systematic review found
oral mucosal lesions along with the risk factors is a dose-response effect between cigarette smoking
important for their appropriate management. and implant failure. The patients who smoked more
than 20 cigarettes per day had a significantly higher
Periodontal disease and dental implants risk of implant failure than non-smokers49. Negative
Periodontal disease is a preventable disease in which effects of smoking might be through both systemic
tobacco use is considered the strongest modifiable and local routes. The heat from smoking and its toxic
risk factor. As early as the 1940s, studies have found by-products such as nicotine, carbon monoxide, and
a relationship between tobacco use and periodontium. hydrogen cyanide may impair healing. In addition,
Smokers have higher gingival recession, tooth loss, arteriolar vasoconstriction and decreased blood flow
and pocket depths. compared to non-smokers42. A may affect the success of surgical procedures involving
recent systematic review found that tobacco smoking implants50. Smoking cessation may be an effective
increases periodontitis by 85% (RR=1.85; 95% CI: strategy to improve the success rate of implants.
1.5–2.2)43. Tobacco smokers display an increased
gingival microvascular density with considerable Effects on salivary glands
gingival inflammation, suppressed angiogenesis due Even though the available literature is sparse,
to local immune suppression, and oxidative stress tobacco smoking has been associated with increased
leading to periodontal disease and increased risk of sialolithiasis (stones within salivary ducts) formation
complications44. In a cross-sectional pilot study32, saliva and decreased salivary flow rate. A cross-sectional

Tob. Induc. Dis. 2023;21(January):12

[Link]

4
 Tobacco Induced Diseases
Review Paper

study of 947 cases and 3788 controls, found a an odds ratio of 1.84 (95% CI:1.64–2.07). The study
statistically significant association between smoking also found that smoking prevention can lead to a 7%
and sialolithiasis with an odds ratio of 1.31 (95% CI: potential reduction in dental caries57. Thus, dental caries
1.08–1.59). Multiple studies have concluded that and other oral health findings attributed to tobacco use
smoking is associated with thick saliva with reduced should be part of the discussion for quitting.
salivary flow compared to non-smokers51. Smoking
has been found to decrease saliva pH52 and alter Impact of socioeconomic factors on the use of
secretory immunoglobulin A (sIgA) levels53. All these tobacco-related products and oral health
factors could lead to an increase in periodontal disease Smokers are at increased risk for oral diseases. With
and dental caries. the advent of new combustible, noncombustible,
and electronic tobacco products being available in
Dental caries the US, it is imperative to determine the impact of
Dental caries is a multi-factorial disease. Its etiology socioeconomic factors on tobacco product use and
is mostly related to poor eating habits, oral hygiene, oral health. This will help in designing targeted
and compliance with treatment. Studies have interventions in concert with the regulation of
shown a relationship between smoking and caries- tobacco products to reduce tobacco-related diseases62.
causing bacteria54. Nicotine may cause an ecological Profound oral health disparities are seen in specific
imbalance and promote colonization and metabolism subpopulations in the US. Untreated decay, tooth
of Streptococcus mutans, a significant bacterium loss, and periodontal disease are disproportionately
contributing to dental caries. Smoking influences higher among racial and ethnic minorities, low-
saliva by lowering the buffer capability, altering income individuals, those with limited education,
its chemical agent and bacterial components54, and with public dental insurance or without any dental
reducing salivary flow rate55 thereby promoting the insurance, and smokers63. Smokers have lower rates of
formation of a caries-susceptible environment54. dental care utilization compared to non-smokers64,65.
Several epidemiological studies have linked tobacco Participants of the OralHealth4Life trial, eligible
use and increased dental caries prevalence54,56,57. callers to the Louisiana, Nebraska, and Oregon state
Findings from the National Health and Nutrition tobacco quitlines, mostly low-income individuals
Examination Survey (NHANES) from 2011 to 2016 with high school or lower education, cited cost and
found that 40–50% of adult smokers aged 20–64 no dental insurance as barriers to receiving dental
years have untreated dental decay, specifically among care. After controlling for these financial factors, the
non-Hispanic Black, Mexican American, or poor and following baseline characteristics were significantly
near-poor, combined as well as those who had a high associated with a higher likelihood of dental care
school education or lower. The prevalence was twice utilization at 6 months: higher motivation (relative
that of adults who were non-Hispanic White or not- risk, RR=2.16) and self-efficacy (RR=1.80) to visit the
poor, who had more than high school education, and dentist, having a disability (RR=1.63), having a higher
who had never smoked. Smokers aged ≥65 years are education level (RR=1.52), and having perceived gum
twice as likely to have untreated caries than those disease (RR=1.49)66. Data from a large, population-
who never smoked56. Studies from Italy and Finland based case-control study of oral cancer risk factors
have shown smokers have higher decayed, missing, conducted in four areas of the US found that various
filled teeth (DMFT) scores than non-smokers58,59. environmental or lifestyle determinants of oral cancer
Two systematic reviews, published in 2013 and 2019, may contribute to the higher oral cancer rates in
have found a positive correlation between tobacco Blacks than in Whites in the US, but that patterns and
smoking and increased dental caries. However, both risks associated with alcohol consumption, particularly
studies concluded that the present evidence is poor among current smokers, are the most important
and there is a need for more prospective studies60,61. A contributors to the excess risk in Blacks67. Indeed, the
3-year epidemiological surveillance open cohort study use of tobacco-related products contributes to health
of 22009 patients found that 36.6% had dental caries disparities and inequalities and needs to be addressed
with smoking as a risk indicator for dental caries with in cessation programs.

Tob. Induc. Dis. 2023;21(January):12

[Link]

5
 Tobacco Induced Diseases
Review Paper

Role of oral healthcare providers in cessation cessation should prioritize increasing dental providers’
Quitting tobacco use greatly reduces the risk of relevant knowledge, skills, and sense of professional
developing many diseases20. Dependence on tobacco responsibility 75. A randomized controlled trial of
or nicotine is a chronic condition that warrants a smoking cessation intervention (combination of
interventions by all healthcare providers, including brief counseling using the 5As model and NRT)
oral healthcare providers. Patients need multiple delivered by dental hygienists found that a statistically
attempts to successfully achieve abstinence. A study by higher percentage of intervention participants had a
Babb et al.68 found that 68% of adult smokers wanted quit attempt of at least 1 week at 3 months (15%
to stop smoking, 55% made a past-year quit attempt, intervention group vs 9% controls) and 6 months
and about 7% quit smoking. The study also found (10% intervention group vs 5% controls). This
that 57.2% had been advised by a health professional feasibility study has shown the potential that trained
to quit, and 31.2% used cessation counseling and/or dental hygienists could have in delivering smoking
medication when trying to quit. The goal for Healthy cessation advice76.
People 2030 is to increase past-year attempts to quit A study involving analysis of national data NHANES
smoking in adults from 56% in 2018 to 65.7% and (2015–2018) in which 1024 adult respondents who
increase successful quit attempts from 8.3% in 2018 were current or former smokers who quit smoking
to 10.2%69. Understanding the role that barriers play within the past 12 months, and reported a dental
in quitting tobacco use is helpful. Cessation programs visit within the past 12 months, were included in
need to address barriers to improve the success rates the study. Among the study subjects, only 44.6%
for quitting. A two-wave survey to explore self- received smoking-cessation advice from a dental
reported barriers to quitting among young adult care professional. The authors found no significant
smokers found that low SES smokers reported several association between smoking-cessation advice
barriers. The risk of gaining weight was statistically and any attempt to quit smoking. Although the
significant between low SES and high SES. Other respondents who received smoking-cessation advice
barriers like the cost of classes or programs, craving reported 18% more quit attempts, the advice was not
or withdrawal from nicotine, loss of a way to handle associated with abstinence of 6 months or longer.
stress, and friends’ smoking were prevalent but not Thus, receiving smoking-cessation advice from a
significant70. dental care professional was associated with more
The dental office is an excellent venue for providing attempts to quit smoking77.
cessation intervention as 46.6% of patients who smoke Based on an extensive review of the existing
make an annual visit to the dentist71. There are more scientific literature, the most recent Surgeon General’s
than 200000 professionally active dentists in the US72. Report of 2020 on smoking cessation20, concluded
On average, a dentist sees more than 68 patients per that proven smoking cessation treatments are widely
week (including hygiene appointments)73 and the available today. However, the reach and use of
hygienist sees approximately 45–50 patients per existing smoking cessation interventions remain low.
week74. The entire dental team needs to be involved There are gaps in the utilization of programs, policies,
in tobacco cessation, including dental hygienists and and resources that can improve cessation rates and
assistants. Patients tend to have a better rapport with help smokers quit. The report also stated that the
dental hygienists and pay more attention to their oral evidence is sufficient to infer that the development
health educational messages. Integration of tobacco and dissemination of evidence-based clinical
cessation by the electronic health record system with practice guidelines increase the delivery of clinical
automated clinical reminders is a useful tool. A recent interventions for smoking cessation. Thus, more
study reported that although dental professionals ask efforts are needed for smoking cessation interventions
for and document patient tobacco use (hygienists: in the dental office.
80%; dentists: 73%), they did not frequently assist Tobacco cessation in oral health settings is both
in tobacco cessation (hygienists: 27–49%; dentists: feasible and effective. Incorporating behavioral
10%–31%). The findings from this study suggest interventions for tobacco cessation within routine
that efforts to engage dental professionals in tobacco oral examinations help tobacco users quit78. Tobacco

Tob. Induc. Dis. 2023;21(January):12

[Link]

6
 Tobacco Induced Diseases
Review Paper

cessation interventions provided by oral healthcare limitations such as lack of time and expertise 81.
providers can be classified into three categories, A recent systematic review 82 was conducted to
which include brief educational, behavioral, and determine if dental professionals could help people
pharmacological interventions. The interventions can to stop using tobacco by offering them advice and
be used alone or in combination78. support. All studies used behavioral programs aimed
to boost motivation and offer advice to help people
Brief educational interventions stop using tobacco. The study found that behavioral
Brief interventions involve raising awareness about the programs involving dental professionals and NRT
harmful effects of tobacco products on general health. or e-cigarettes probably help more people to stop
The 5As model is the most recognized and widely smoking. On average, 74 out of 1000 people stopped
accepted framework for brief smoking cessation compared with 27 out of 1000 people who did not
intervention. This model was developed by the receive behavioral support. However, the authors were
United States Department of Health’s Clinical Practice moderately confident about the benefit of support
Guideline in 2000 and is based on the transtheoretical from dental professionals plus NRT or e-cigarettes.
model of behavior change, or the stages of change To overcome the common barriers of the 5As model,
model79. It proposes that smokers should be given a a three-step model was proposed, Ask, Advise, and
brief intervention to address smoking at every health Refer: Ask every patient about tobacco use; Advise
consultation. This model is based on five strategies: all tobacco users to quit; and Refer tobacco users
1. Ask about the duration of tobacco use, amount, and to nationally available tobacco cessation quitlines79.
type of tobacco use (1 min). The New South Wales (NSW) Oral Health Promotion
2. Advise all smokers to quit in a clear, strong, and Network developed an abbreviated 3As model: Ask
personalized manner (30 sec). about and record smoking status; Approach smokers
3. Assess the subject’s willingness to quit smoking using about their interest in quitting (using the stages of
the Prochaska Stages of Change model80. Assess the change model); and advise of NSW Quitline and refer
patient’s willingness to quit within the next 30 days. to appropriate services81.
If a patient is willing to try to quit within the next 30
days, move to the Assist step. If not, use the 5Rs to Behavioral interventions
try to increase their motivation (30 sec). Behavioral interventions aim to motivate, guide, and
4. Assist the subject with a plan for quitting and set a psychologically assist smokers to quit83. A specific
quit date (3–5 min). taxonomy for classifying Behavior Change Techniques
5. Arrange a follow-up one month after the quit date (BCT) targeted to smoking cessation is called
either in person or via telephone (5 min). Behavior Change Techniques Taxonomy for Smoking
For patients who are not ready to make a quit (BCTTsm)83. This taxonomy includes 44 BCTs and
attempt in the next 30 days, the oral health providers classifies them into four groups84:
may use the 5Rs strategy79: 1. Directly addressing motivation (e.g. boosting
1. Relevance – encourage the patient to indicate why motivation and self-efficacy);
quitting is personally relevant. 2. Maximizing self-regulatory capacity and skills (e.g.
2. Risks – ask the patient to identify potential negative facilitating relapse prevention and coping);
consequences of tobacco use. 3. Promoting adjuvant activities (e.g. advice on stop-
3. Rewards – ask the patient to identify the potential smoking medication); and
benefits of stopping tobacco use. 4. Supporting other BCTs (e.g. focus on the delivery
4. Roadblocks – ask the patient to identify barriers or of the intervention).
impediments to quitting. Hartmann-Boyce et al.85 conducted a meta-analysis
5. Repetition – the motivational intervention should of 33 Cochrane Reviews and found that behavioral
be repeated every time an unmotivated patient has interventions for smoking cessation such as any
an interaction with a clinician. form of counseling along with guaranteed financial
Even though the 5As model remains the most incentives provided the most motivation to quit for
accepted model for brief intervention, there are six months or longer85. Another systematic review

Tob. Induc. Dis. 2023;21(January):12

[Link]

7
 Tobacco Induced Diseases
Review Paper

concluded that goal setting has a unique effect Pharmacotherapy

across a range of behaviors and it is particularly Smoking cessation advice for even a few minutes
effective when the goal is in a group, difficult, and increases long-term smoking abstinence rates by
set publicly86. A recent Cochrane Review found that 5%, which can be increased by 50–70% with the
behavioral support provided by dental professionals use of adjunctive pharmacotherapy, e.g. nicotine
is beneficial for smoking cessation at six months replacement therapy for withdrawal symptoms 90.
compared to brief or no intervention. Multiple- The US Preventive Services Task Force found a
session programs have a higher quit rate than substantial benefit of FDA-approved pharmacological
single-session programs82. Systematic reviews did and behavioral interventions, both individually and
not find any harmful effects as a result of behavioral in combination to increase smoking cessation among
intervention by the dentist82,85. non-pregnant adults91. Pharmacological interventions
A systematic review84 published in 2021 evaluated help to reduce withdrawal symptoms associated with
BCTs used for tobacco cessation in dental practices cessation attempts by curbing nicotine cravings 92.
and their effects on intervention. They found that They include nicotine replacement therapies (NRTs),
16 out of 44 BCTTsm were used in general and varenicline, cytisine, and bupropion SR.
2–11 BCTs were included in the interventions. The
authors did not find any association between the Nicotine replacement therapy
number of BCTs and intervention effectiveness. Among the various pharmacotherapies, nicotine
The most commonly used BCTs are: facilitating goal replacement therapy (NRT) is the most commonly
setting, offering/directing towards appropriate written used. Nicotine is a chemical that acts as an agonist
materials, assessing current readiness and ability to of nicotinic acetylcholine receptors in the ventral
quit, assessing current and past tobacco-use behavior, tegmental area of the brain. When stimulated, the
advising on/facilitating the use of social support, nicotinic receptors release dopamine in the nucleus
providing feedback on current behavior and advice accumbens leading to a sense of reward. NRT
on stop-tobacco medication. products contain pure nicotine and aim to reduce the
Telephone quitlines are a cost-effective 87 , desire for smoking by increasing nicotine levels in
evidenced-based approach for providing behavioral the bloodstream through sources other than cigarette
counseling across large geographical areas and smoke92. Several types of NRT products are available
populations. The first quitline was established in in the market.
California in 1992 and is now available in all 50 US Nicotine gum, an easily accessible NRT product,
states, the District of Columbia, Guam, and Puerto is prescribed for 6–12 weeks for a maximum of 6
Rico. Quitline services are also available through the months. Patients are advised to chew intermittently for
National Asian Smokers’ Quitline. Since its launch 30 minutes and then place it in the oral vestibule for
in 2004, 1-800-QUIT-NOW has received more than transmucosal absorption. After 2–3 months the dose is
10 million calls. Quitlines not only offer counseling tapered or the chewing time is gradually decreased93.
but also offer free nicotine replacement therapy88. Generally, gums with 4 mg of nicotine have a higher
A United States Public Health Service-sponsored success rate than gums with 2 mg of nicotine. In a
Clinical Practice Guideline meta-analysis in 200879 recent randomized clinical trial, Hansson et al.94 found
found that quitlines increased overall quit rates by that 6 mg nicotine gums provide a faster and greater
about 60% when compared to minimal counseling, reduction of urges than 4 mg gums. Some side effects
no counseling, or self-help. The guidelines also of nicotine gum include soreness, hiccups, dyspepsia,
reported that healthcare providers are more likely and jaw pain95.
to provide smoking cessation interventions if state Nicotine lozenges come in two sizes (regular
quitlines are conveniently available as a referral and mini) and two strengths (2 mg and 4 mg). It is
source. A systematic review of smokeless tobacco recommended to use 1 lozenge every 1–2 hours for
cessation intervention studies conducted globally the first six weeks of the quit attempt96. The dose is
found regular telephone support/quitlines also proved then tapered and then stopped. Chronic overuse of
to be beneficial89. NRT, specifically nicotine lozenges are associated with

Tob. Induc. Dis. 2023;21(January):12

[Link]

8
 Tobacco Induced Diseases
Review Paper

hyperkeratotic lesions97. Oral healthcare providers healthcare providers motivate those wishing to quit
need to be aware of the oral effects associated with smoking. Oral healthcare providers have a unique
NRT products. opportunity to educate the public about the safety of
Nicotine patches are transdermal patches that NRT products by debunking the misconception of the
release nicotine slowly over time. Two forms of carcinogenic effects of nicotine102.
patches are available which can be worn either for 16
hours or 24 hours. The 16-hour patches are available Varenicline (CHANTIX/CHAMPIX)
in the form of 5, 10, and 15 mg doses, and the 24- Varenicline is a smoking cessation aid, which is
hour patches are available in 7, 14, and 21 mg doses98. used in combination with education and counseling.
In a randomized placebo-controlled trial, Schnoll et Studies have shown varenicline to have more efficacy
al.99 found that the 24-week patch treatment may be than bupropion SR and nicotine patches. It acts
more effective in reducing the chances of relapse and as a partial agonist of the alpha-4-beta-2 nicotinic
the weight gain than the 8-week patch treatment. acetylcholine receptors and inhibits the activation
Insomnia and local skin irritations have been reported of the dopaminergic pathway which is linked to the
as side effects of nicotine patches98. withdrawal syndrome during cessation attempts105.
Nicotine inhalers mimic cigarettes and consist of Varenicline comes as a tablet and is only given to
a mouthpiece and a plastic cartridge98. Each inhaler adult patients. The therapy starts 1 week before the
contains 10 mg of nicotine which can be sprayed target quit date with a tapered increase dose (Days
in the mouth without touching the lips93. Nicotine 1–3: 0.5 mg once daily; days 4–7: 0.5 mg twice daily;
nasal sprays were designed for the rapid delivery days 8–11: 1 mg twice daily). Patients are advised
of nicotine. Multiple studies have shown that nasal to take the tablet with a full glass of water after a
sprays can deliver nicotine more rapidly than other meal to avoid stomach upset. In patients with renal
NRT products98. CDC recommends patients take 1–2 impairment, a maximum dose of 0.5 twice daily and
doses per hour with a maximum of 40 doses per day. with end-stage renal disease maximum dose of 0.5 mg
However, in a randomized trial, Rubinstein et al.100 once daily is recommended106.
did not support the use of nasal sprays as an adjunct to Common side effects of varenicline include nausea,
counseling for adolescent smokers due to unpleasant insomnia, abnormal vivid dreams, and headaches105.
adverse effects, poor adherence, and consequent lack It also increases the risk of pancreatitis, and kidney
of efficacy. stones and failure. Patients using varenicline should
Oral healthcare providers can use the Fagerström be under close supervision for behavioral changes
scale to assess the severity of tobacco addiction. On as there is an FDA-mandated warning for severe
this scale, patients are asked 6 scored questions and psychiatric symptoms including suicidal symptoms106.
based on the total score, NRT can be prescribed101. Furthermore, it contains N-nitroso-varenicline
Oral health providers can use various methods to impurity which is carcinogenic. However, the health
help their patients with NRT. The NRT sampling benefits of stopping smoking outweigh the cancer risk
(NRTS) method is a short starter course of NRT from the nitrosamine impurity in varenicline107.
prescribed to all eligible smokers regardless of their
motivation to quit102. Carpenter et al.103 found that Bupropion SR
a free 2-week starter kit of NRT (both patch and Bupropion has been widely used as an antidepressant.
lozenge) increased quit attempts, use of smoking It is also used as a smoking cessation aid. The
cessation medications and abstinence, compared to mechanism of action is not fully understood but it
standard care and the effects were consistent despite seems that bupropion weakly inhibits norepinephrine
the smoker’s motivation to quit103. NRT products and dopamine. Also, it has some action on nicotinic
with stain removal or tooth-whitening activity can and serotonin receptors108.
be useful for oral healthcare providers to show early Bupropion SR tablets can be regular or extended-
measurable benefits of smoking cessation102. Whelton release (12- or 24-hour) and are available from 75
et al.104 found that the tested nicotine replacement to 522 mg forms. Patients are advised to take the
gum can help in stain reduction and can help oral whole tablet once daily with or without a meal. Newly

Tob. Induc. Dis. 2023;21(January):12

[Link]

9
 Tobacco Induced Diseases
Review Paper

prescribed patients should be closely monitored for a total of 3200 participants found that combination
behavioral changes as bupropion SR is known to NRT has a significantly higher quit rate at 6 months
cause suicidal tendencies108. or longer than single or no NRT114.
Common side effects of bupropion SR are Second, a combination of NRT and non-NRT
tachycardia, rhinitis, pharyngitis, insomnia, headache, drugs such as bupropion SR and NRT, nortriptyline
agitation, dizziness, diaphoresis, weight loss, and NRT, and varenicline and NRT, has proven to
constipation, dry mouth, nausea, tremor, and blurred be effective. The only FDA-approved combination
vision. More than 10% of the patients suffer one or therapy for smoking cessation is bupropion SR and
more side effects108. nicotine patches113. In general, studies suggest that
bupropion SR in combination with NRT increases the
Cytisine quit rates in the short-term but long-term benefits
Cytisine is a plant-based alkaloid and has been used are insignificant according to the United States Public
in eastern Europe for smoking cessation since 1964. Health Service Guideline meta-analysis79.
It acts as a partial agonist of alpha-4-beta-2 nicotinic
acetylcholine receptors and inspired the development Barriers to smoking cessation interventions
of varenicline109. Oral cytisine has a shorter half-life There is a lack of studies focusing on the perceived
(4.8 vs 17 hours) and treatment course (3.5 vs 12 barriers to oral health providers while providing
weeks) than varenicline110. tobacco cessation interventions. In their systematic
A recent systematic review and meta-analysis found review, Carr and Ebbert78 cite several barriers across
that patients on cytisine had 1.74 (95% CI: 1.38–2.19) studies they reviewed, including: 61.5% of dentists
times higher successful continuous abstinence at believe patients do not expect tobacco cessation
the longest follow-up than those using a placebo111. resources, in spite of the fact that 58.5% of patients
Nausea, vomiting, dyspepsia, upper abdominal pain, felt these resources should be provided; concern for
and dry mouth were reported as the side effects of patient resistance; lack of knowledge; lack of time;
cytisine111. lack of financial reimbursement; and concern for
unsuccessful patient follow-up to tobacco cessation
Combination therapy resources. A more recent systematic review115, by Goel
Combination therapy of drugs with a distinct et al.116 in 2020, found that dental practitioners lacked
mechanism of action or therapeutic properties helps satisfactory knowledge, confidence and training,
to achieve therapeutic synergism112. A meta-analysis and were unaware of existing referral pathways to
of five clinical trials of pooled 2204 patients found specialist smoking cessation services.
that combination therapy was significantly better than In a study on general dentists in California,
monotherapy (p<0.05). The relative risk of abstinence Pennsylvania, and West Virginia, the barriers to
comparing combination with single treatment groups cessation counseling included: patient resistance
was 1.42 (95% CI: 1.21–1.67), 1.54 (95% CI: 1.19– (66%); lack of insurance reimbursement (56%);
2.00), and 1.58 (95% CI: 1.25–1.99) at 3, 6, and 12 not knowing where to refer (49%); and lack of
months, respectively. Primarily, two following types time (32%). Similar barriers were identified among
of combination therapy include a combination of dental hygienists75. The authors found that perceived
different NRTs or NRTs with non-NRT drugs113. patient resistance (per the hygienists) and lack
First, a combination of NRTs with different of training (per the dentists) were the most cited
pharmacokinetic profiles such as nicotine patch + barriers to providing tobacco cessation. The authors
nicotine gum, patch and inhaler, patch and nasal spray, also found that greater confidence and willingness
etc. Withdrawal symptoms can be better managed with to assist were positively associated with providing
combination NRTs as sustained-release NRTs (e.g. assistance in multivariable models, but perceived
nicotine patch) to maintain a stable baseline nicotine barriers (e.g. lack of time and remuneration) were
level in addition to immediate release NRTs (e.g. gum, not. The authors concluded that greater dental
spray, inhaler, etc.) that can intermittently increase professional engagement in tobacco cessation will
blood nicotine level113. A systematic review including require expanding providers’ self-efficacy, perceived

Tob. Induc. Dis. 2023;21(January):12

[Link]

10
 Tobacco Induced Diseases
Review Paper

professional scope, and motivation and likely will Implications

require system and organizational change75. A similar Dental treatment involves several visits to the dental
study found that dental hygienists reported greater office providing multiple opportunities for the dental
levels of activity and confidence, fewer barriers, and team to manage and prevent tobacco product use and
longer consultation times compared to dentists. All nicotine dependence. Tobacco product use should be
participants indicated high rates of advising patients to addressed with every patient at every dental visit.
quit smoking, but low rates of assisting and referring Integration of tobacco cessation by the electronic
patients117. Identifying barriers to tobacco cessation health record system with automated clinical
counseling may enhance effectiveness, and should reminders is a useful tool. The evidence is strong
be addressed in the American Dental Hygienists’ for the effectiveness of tobacco cessation involving
Association’s ‘Ask, Advise, Refer’ initiative79. brief behavioral interventions complemented by
Adequate reimbursement for providing tobacco pharmacological treatment and referral to state
cessation is essential to incentivize health professionals, quitlines and quitsites. The entire dental team needs
including dental professionals to promote tobacco to promote tobacco product cessation to their patients
cessation among smokers. Considering the prohibitive to ensure successful quit attempts.
costs associated with tobacco-related illnesses,
both public (Medicaid and Medicare) and private CONCLUSION
insurance (individual purchased and employer- Tobacco has detrimental effects on oral health. Tobacco
sponsored) should cover tobacco cessation programs. users have significantly higher rates of oral cancer,
The prevalence of current cigarette smoking is oral mucosal lesions, periodontal disease, dental
approximately twice as high among adults enrolled in caries, and implant failure. Dental practice settings
Medicaid (23.9%) as among privately insured adults provide a unique opportunity in providing tobacco
(10.5%), placing Medicaid enrollees at increased risk cessation assistance. Oral health providers can refer
for smoking-related disease and death2 . There is patients to free evidence-based treatment options such
strong evidence that comprehensive, barrier-free state as telephone quitlines, quitsites, and telehealth, and
Medicaid cessation coverage could reduce smoking, they can use brief educational interventions, behavior
smoking-related disease, and healthcare expense counseling, and pharmacotherapy including nicotine
among Medicaid enrollees. While all 50 states and replacement therapy. Lack of time and training are
the District of Columbia covered some cessation the most common barriers faced by dentists while
treatments, only 15 states, as of 31 December 2018, providing tobacco counseling services. Considering
covered all nine cessation treatments with some the myriad of roles oral healthcare providers can play
barriers (copayment, prior authorization, counseling in tobacco cessation, more conferences, workshops,
required for medications, limits on duration, etc.) and research are needed to motivate and educate oral
in place for some treatments118. Both Medicaid and healthcare providers on tobacco cessation services and
Medicare have started reimbursing dental practitioners develop interventions geared towards dental practices.
for tobacco cessation. New York State in particular has
been the front-runner for this119. However, a survey of REFERENCES
1. World Health Organization. World Health Statistics
New York State dentists and dental hygienists found
2021: Monitoring Health for the SDGs. World
that only 26.7% of dentists were aware that dentist Health Organization; 2021. Accessed October
smoking cessation counseling is covered and 15.5% 11, 2022. [Link]
of hygienists were aware that hygienist smoking handle/10665/342703/9789240027053-eng.
cessation counseling is covered by Medicaid 120. pdf?sequence=1&isAllowed=y
Among private insurers, adults are more likely to visit 2. Creamer MR, Wang TW, Babb S, et al. Tobacco Product Use
a dentist annually for routine preventive care. Thus, and Cessation Indicators Among Adults - United States,
2018. MMWR Morb Mortal Wkly Rep. 2019;68(45):1013-
coverage for tobacco cessation by private insurance 1019. doi:10.15585/mmwr.mm6845a2
would be beneficial. More studies are needed to assess 3. Tobacco-Free Life. History of Tobacco. Accessed October
barriers and facilitators to deliver tobacco cessation 11, 2022. [Link]
interventions successfully in the dental office. history/

Tob. Induc. Dis. 2023;21(January):12

[Link]

11
 Tobacco Induced Diseases
Review Paper

4. Benowitz NL, Hukkanen J, Jacob P 3rd. Nicotine E-Cigarette Use Among Middle and High School Students
chemistry, metabolism, kinetics and biomarkers. — National Youth Tobacco Survey, United States, 2021.
Handb Exp Pharmacol. 2009;(192):29-60. MMWR Morb Mortal Wkly Rep. 2021;70:1387-1389.
doi:10.1007/978-3-540-69248-5_2 doi:10.15585/mmwr.mm7039a4
5. O’Connor RJ. Non-cigarette tobacco products: what have we 17. Stallings-Smith S, Ballantyne T. Ever Use of E-Cigarettes
learnt and where are we headed? Tob Control. 2012;21(2):181- Among Adults in the United States: A Cross-
190. doi:10.1136/tobaccocontrol-2011-050281 Sectional Study of Sociodemographic Factors. Inquiry.
6. American Lung Association. What’s In a Cigarette? 2019;56:46958019864479. doi:10.1177/0046958019864479
Updated November 17, 2022. Accessed December 14, 18. American Lung Association. The Impact of E-Cigarettes
2022. [Link] on the Lung. Updated November 17, 2022. Accessed
facts/whats-in-a-cigarette January 19, 2023. [Link]
7. National Cancer Institute, Centers for Disease Control smoking/e-cigarettes-vaping/impact-of-e-cigarettes-
and Prevention. Smokeless Tobacco and Public Health: on-lung#:~:text=E%2Dcigarettes%20produce%20a%20
A Global Perspective. U.S. Department of Health and number,as%20cardiovascular%20(heart)%20disease
Human Services. Centers for Disease Control and 19. S o u l e E , B a n s a l - Tr av e r s M , G r a n a R , e t a l .
Prevention, National Institutes of Health. National Cancer Electronic cigarette use intensity measurement
Institute; 2014. Contract No.: 14-7983. Accessed October c h a l l e n g e s a n d r e g u l a t o r y i m p l i c a t i o n s . To b
11, 2022. [Link] Control. 2021:tobaccocontrol-2021-056483.
files/2020-06/[Link] doi:10.1136/tobaccocontrol-2021-056483
8. University of Rochester. Smokeless Tobacco. 20. United States Public Health Service Office of the Surgeon
Accessed October 11, 2022. [Link] General; National Center for Chronic Disease Prevention
[Link]/encyclopedia/content. and Health Promotion (US) Office on Smoking and
aspx?contenttypeid=1&contentid=2947 Health. Smoking Cessation: A Report of the Surgeon
9. Luo J, Ye W, Zendehdel K, et al. Oral use of Swedish moist General. US Department of Health and Human Services;
snuff (snus) and risk for cancer of the mouth, lung, and 2020. Accessed October 11, 2022. [Link]
pancreas in male construction workers: a retrospective [Link]/books/NBK555591/
cohort study. Lancet. 2007;369(9578):2015-2020. 21. National Center for Chronic Disease Prevention and
doi:10.1016/S0140-6736(07)60678-3 Health Promotion (US) Office on Smoking and Health.
10. Boffetta P, Straif K. Use of smokeless tobacco and The Health Consequences of Smoking—50 Years of
risk of myocardial infarction and stroke: systematic Progress: A Report of the Surgeon General. Centers for
review with meta-analysis. BMJ. 2009;339:b3060. Disease Control and Prevention (US); 2014. Accessed
doi:10.1136/bmj.b3060 October 11, 2022. [Link]
11. Boffetta P, Hecht S, Gray N, Gupta P, Straif K. Smokeless NBK179276/
tobacco and cancer. Lancet Oncol. 2008;9(7):667-675. 22. Huttunen R, Heikkinen T, Syrjänen J. Smoking and the
doi:10.1016/S1470-2045(08)70173-6 outcome of infection. J Intern Med. 2011;269(3):258-
12. Sapkota A, Gajalakshmi V, Jetly DH, et al. Smokeless 269. doi:10.1111/j.1365-2796.2010.02332.x
tobacco and increased risk of hypopharyngeal and 23. Jiang C, Chen Q, Xie M. Smoking increases the risk of
laryngeal cancers: a multicentric case-control study infectious diseases: A narrative review. Tob Induc Dis.
from India. Int J Cancer. 2007;121(8):1793-1798. 2020;(July)18. doi:10.18332/tid/123845
doi:10.1002/ijc.22832 24. Umnuaypornlert A, Kanchanasurakit S, Lucero-Prisno
13. Levy DT, Mumford EA, Cummings KM, et al. The potential DEI, Saokaew S. Smoking and risk of negative outcomes
impact of a low-nitrosamine smokeless tobacco product among COVID-19 patients: A systematic review and
on cigarette smoking in the United States: estimates of a meta-analysis. Tob Induc Dis. 2021;19(February).
panel of experts. Addict Behav. 2006;31(7):1190-1200. doi:10.18332/tid/132411
doi:10.1016/[Link].2005.09.010 25. Hou H, Li Y, Zhang P, et al. Smoking Is Independently
14. Mejia AB, Ling PM, Glantz SA. Quantifying the effects Associated With an Increased Risk for COVID-19
of promoting smokeless tobacco as a harm reduction Mortality: A Systematic Review and Meta-analysis
strategy in the USA. Tob Control. 2010;19(4):297-305. Based on Adjusted Effect Estimates. Nicotine Tob Res.
doi:10.1136/tc.2009.031427 2021;23(11):1947-1951. doi:10.1093/ntr/ntab112
15. Wadgave U, Nagesh L. Nicotine Replacement Therapy: 26. National Cancer Institute. Cancer Stat Facts: Oral Cavity
An Overview. Int J Health Sci (Qassim). 2016;10(3):425- and Pharynx Cancer. Accessed October 11, 2022. https://
435. Accessed October 11, 2022. [Link] [Link]/statfacts/html/[Link]
[Link]/pmc/articles/PMC5003586/pdf/ijhs-10-3-425. 27. DeVita VT Jr, Lawrence TS, Rosenberg SA, eds. Cancer:
pdf Principles and Practice of Oncology. 10th ed. Wolters
16. Park-Lee E, Ren C, Sawdey MD, et al. Notes from the Field: Kluwer; 2015.

Tob. Induc. Dis. 2023;21(January):12

[Link]

12
 Tobacco Induced Diseases
Review Paper

28. Dhanuthai K, Rojanawatsirivej S, Thosaporn of Smoking on Periodontitis: A Systematic Review and

W, et al. Oral cancer: A multicenter study. Med Meta-regression. Am J Prev Med. 2018;54(6):831-841.
Oral Patol Oral Cir Bucal. 2018;23(1):e23-e29. doi:10.1016/[Link].2018.02.014
doi:10.4317/medoral.21999 44. Silva H. Tobacco Use and Periodontal Disease-The
29. Jiang X, Wu J, Wang J, Huang R. Tobacco and oral Role of Microvascular Dysfunction. Biology (Basel).
squamous cell carcinoma: A review of carcinogenic 2021;10(5):441. doi:10.3390/biology10050441
p a t h ways . To b I n d u c D i s . 2 0 1 9 ; 1 7 ( A p r i l ) . 45. Leite FRM, Nascimento GG, Baake S, Pedersen LD,
doi:10.18332/tid/105844 Scheutz F, López R. Impact of Smoking Cessation on
30. Hecht SS. Biochemistry, biology, and carcinogenicity Periodontitis: A Systematic Review and Meta-analysis of
of tobacco-specific N-nitrosamines. Chem Res Toxicol. Prospective Longitudinal Observational and Interventional
1998;11(6):559-603. doi:10.1021/tx980005y Studies. Nicotine Tob Res. 2019;21(12):1600-1608.
31. Lerner CA, Sundar IK, Yao H, et al. Vapors produced by doi:10.1093/ntr/nty147
electronic cigarettes and e-juices with flavorings induce 46. Souto MLS, Rovai ES, Villar CC, Braga MM, Pannuti
toxicity, oxidative stress, and inflammatory response CM. Effect of smoking cessation on tooth loss: a
in lung epithelial cells and in mouse lung. PLoS One. systematic review with meta-analysis. BMC Oral Health.
2015;10(2):e0116732. doi:10.1371/[Link].0116732 2019;19(1):245. doi:10.1186/s12903-019-0930-2
32. Ye D, Gajendra S, Lawyer G, et al. Inflammatory 47. Kasat V, Ladda R. Smoking and dental implants. J
biomarkers and growth factors in saliva and gingival Int Soc Prev Community Dent. 2012;2(2):38-41.
crevicular fluid of e-cigarette users, cigarette smokers, doi:10.4103/2231-0762.109358
and dual smokers: A pilot study. J Periodontol. 48. Chrcanovic BR, Albrektsson T, Wennerberg A.
2020;91(10):1274-1283. doi:10.1002/JPER.19-0457 Smoking and dental implants: A systematic review
33. Nocini R, Lippi G, Mattiuzzi C. The worldwide burden of and meta-analysis. J Dent. 2015;43(5):487-498.
smoking-related oral cancer deaths. Clin Exp Dent Res. doi:10.1016/[Link].2015.03.003
2020;6(2):161-164. doi:10.1002/cre2.265 49. Naseri R, Yaghini J, Feizi A. Levels of smoking and dental
34. Sadri G, Mahjub H. Tobacco smoking and oral cancer: a implants failure: A systematic review and meta-analysis.
meta-analysis. J Res Health Sci. 2007;7(1):18-23. J Clin Periodontol. 2020;47(4):518-528. doi:10.1111/
35. Asthana S, Vohra P, Labani S. Association of jcpe.13257
smokeless tobacco with oral cancer: A review of 50. Levin L, Schwartz-Arad D. The effect of cigarette smoking
systematic reviews. Tob Prev Cessat. 2019;5(October). on dental implants and related surgery. Implant Dent.
doi:10.18332/tpc/112596 2005;14(4):357-361. doi:10.1097/[Link].0000187956.59276.f8
36. Khan Z, Tönnies J, Müller S. Smokeless tobacco and 51. Petrušić N, Posavac M, Sabol I, Mravak-Stipetić M. The
oral cancer in South Asia: a systematic review with Effect of Tobacco Smoking on Salivation. Acta Stomatol
meta-analysis. J Cancer Epidemiol. 2014;2014:394696. Croat. 2015;49(4):309-315. doi:10.15644/asc49/4/6
doi:10.1155/2014/394696 52. Grover N, Sharma J, Sengupta S, Singh S, Singh N,
37. Mariano LC, Warnakulasuriya S, Straif K, Monteiro L. Kaur H. Long-term effect of tobacco on unstimulated
Secondhand smoke exposure and oral cancer risk: a systematic salivary pH. J Oral Maxillofac Pathol. 2016;20(1):16-19.
review and meta-analysis. Tob Control. 2021;31(5):597-607. doi:10.4103/0973-029X.180907
doi:10.1136/tobaccocontrol-2020-056393 53. Arbabi-Kalati F, Salimi S, Nabavi S, Rigi S, Miri-Moghaddam M.
38. Mello FW, Melo G, Pasetto JJ, Silva CAB, Warnakulasuriya Effects of Tobacco on Salivary Antioxidative and Immunologic
S, Rivero ERC. The synergistic effect of tobacco and Systems. Asian Pac J Cancer Prev. 2017;18(5):1215-1218.
alcohol consumption on oral squamous cell carcinoma: a doi:10.22034/APJCP.2017.18.5.1215
systematic review and meta-analysis. Clin Oral Investig. 54. Wu J, Li M, Huang R. The effect of smoking on caries-
2019;23(7):2849-2859. doi:10.1007/s00784-019-02958-1 related microorganisms. Tob Induc Dis. 2019;17(April).
39. Mirbod SM, Ahing SI. Tobacco-associated lesions of the doi:10.18332/tid/105913
oral cavity: Part I. Nonmalignant lesions. J Can Dent 55. Rad M, Kakoie S, Niliye Brojeni F, Pourdamghan
Assoc. 2000;66(5):252-256. N. Effect of Long-term Smoking on Whole-mouth
40. Villa A, Villa C, Abati S. Oral cancer and oral erythroplakia: Salivary Flow Rate and Oral Health. J Dent Res
an update and implication for clinicians. Aust Dent J. Dent Clin Dent Prospects. 2010;4(4):110-114.
2011;56(3):253-256. doi:10.1111/j.1834-7819.2011.01337.x doi:10.5681/joddd.2010.028
41. Silverman S Jr, ed. Oral Cancer. 4th ed. B.C. Decker; 56. Centers for Disease Control and Prevention. Oral
1998. Health Surveillance Report: Trends in Dental Caries
42. Krall EA, Garvey AJ, Garcia RI. Alveolar bone loss and and Sealants, Tooth Retention, and Edentulism, United
tooth loss in male cigar and pipe smokers. J Am Dent Assoc. States, 1999–2004 to 2011–2016. Centers for Disease
1999;130(1):57-64. doi:10.14219/[Link].1999.0029 Control and Prevention, US Dept of Health and Human
43. Leite FRM, Nascimento GG, Scheutz F, López R. Effect Services; 2019. Accessed October 11, 2022. [Link]

Tob. Induc. Dis. 2023;21(January):12

[Link]

13
 Tobacco Induced Diseases
Review Paper

[Link]/oralhealth/pdfs_and_other_files/oral-health- tobacco-use
[Link] 70. Carlson S, Widome R, Fabian L, Luo X, Forster J.
57. de Araújo Nobre M, Maló P. Prevalence of periodontitis, Barriers to Quitting Smoking Among Young Adults: The
dental caries, and peri-implant pathology and their Role of Socioeconomic Status. Am J Health Promot.
relation with systemic status and smoking habits: 2018;32(2):294-300. doi:10.1177/0890117117696350
Results of an open-cohort study with 22009 patients in 71. Centers for Disease Control and Prevention. 2020 BRFSS
a private rehabilitation center. J Dent. 2017;67:36-42. Survey Data and Documentation. Accessed October
doi:10.1016/[Link].2017.07.013 11, 2022. [Link]
58. Campus G, Cagetti MG, Senna A, et al. Does smoking annual_2020.html
increase risk for caries? a cross-sectional study in an 72. American Dental Association. Supply of dentists in the
Italian military academy. Caries Res. 2011;45(1):40-46. U.S.: 2001-2021. Accessed October 11, 2022. https://
doi:10.1159/000322852 [Link]/resources/research/health-policy-institute/
59. Bernabé E, Delgado-Angulo EK, Vehkalahti MM, Aromaa dentist-workforce
A, Suominen AL. Daily smoking and 4-year caries 73. Statista. Average number of yearly patient visits per U.S.
increment in Finnish adults. Community Dent Oral dentist from 1990 to 2018. Accessed October 11, 2022.
Epidemiol. 2014;42(5):428-434. doi:10.1111/cdoe.12101 [Link]
60. Jiang X, Jiang X, Wang Y, Huang R. Correlation between visits-among-all-dentists-us-per-year/
tobacco smoking and dental caries: A systematic review 74. Management Experts. How Many Patients Should a
and meta-analysis. Tob Induc Dis. 2019;17(April):34. Hygienist See Per Day?. Accessed October 11, 2022.
doi:10.18332/tid/106117 [Link]
61. Benedetti G, Campus G, Strohmenger L, Lingström should-a-hygienist-see-per-day/#:~:text=In%20a%20
P. Tobacco and dental caries: a systematic review. typical%20practice%2C%20a,8%2D10%20patients%20
Acta Odontol Scand. 2013;71(3-4):363-371. per%20day
doi:10.3109/00016357.2012.734409 75. Chaffee BW, Urata J, Couch ET, Silverstein S.
62. Cornelius ME, Wang TW, Jamal A, Loretan CG, Neff LJ. Dental Professionals’ Engagement in Tobacco,
Tobacco Product Use Among Adults - United States, 2019. E l e c t r o n i c C i g a r e t t e , a n d C a n n a b i s Pa t i e n t
MMWR Morb Mortal Wkly Rep. 2020;69(46):1736-1742. Counseling. JDR Clin Trans Res. 2020;5(2):133-145.
doi:10.15585/mmwr.mm6946a4 doi:10.1177/2380084419861384
63. Centers for Disease Control and Prevention. Disparities 76. Binnie VI, McHugh S, Jenkins W, Borland W,
in Oral Health. Updated February 5, 2021. Accessed Macpherson LM. A randomised controlled trial of a
October 11, 2022. [Link] smoking cessation intervention delivered by dental
oral_health_disparities/[Link] hygienists: a feasibility study. BMC Oral Health. 2007;7:5.
64. Bloom B, Adams PF, Cohen RA, Simile C. Smoking and doi:10.1186/1472-6831-7-5
oral health in dentate adults aged 18-64. NCHS Data 77. Yadav S, Lee M, Hong YR. Smoking-cessation advice
Brief. 2012;(85):1-8. Accessed October 11, 2022. https:// from dental care professionals and its association with
[Link]/nchs/data/databriefs/[Link] smoking status: Analysis of National Health and Nutrition
65. Drilea SK, Reid BC, Li CH, Hyman JJ, Manski RJ. Examination Survey 2015-2018. J Am Dent Assoc.
Dental visits among smoking and nonsmoking US adults 2022;153(1):15-22. doi:10.1016/[Link].2021.07.009
in 2000. Am J Health Behav. 2005;29(5):462-471. 78. Carr AB, Ebbert JO. Interventions for tobacco cessation
doi:10.5555/ajhb.2005.29.5.462 in the dental setting. Cochrane Database Syst Rev.
66. Blasi PR, Krakauer C, Anderson ML, et al. Factors 2006;(1):CD005084. doi:10.1002/14651858.CD005084.pub2
associated with future dental care utilization among 79. Clinical Practice Guideline Treating Tobacco Use and
low-income smokers overdue for dental visits. BMC Oral Dependence 2008 Update Panel, Liaisons, and Staff.
Health. 2018;18(1):183. doi:10.1186/s12903-018-0646-8 A clinical practice guideline for treating tobacco use
67. Day GL, Blot WJ, Austin DF, et al. Racial differences in and dependence: 2008 update. A U.S. Public Health
risk of oral and pharyngeal cancer: alcohol, tobacco, and Service report. Am J Prev Med. 2008;35(2):158-176.
other determinants. J Natl Cancer Inst. 1993;85(6):465- doi:10.1016/[Link].2008.04.009
473. doi:10.1093/jnci/85.6.465 80. Prochaska JO, Velicer WF. The transtheoretical model
68. Babb S, Malarcher A, Schauer G, Asman K, Jamal A. of health behavior change. Am J Health Promot.
Quitting Smoking Among Adults - United States, 2000- 1997;12(1):38-48. doi:10.4278/0890-1171-12.1.38
2015. MMWR Morb Mortal Wkly Rep. 2017;65(52):1457- 81. Dawson GM, Noller JM, Skinner JC. Models of smoking
1464. doi:10.15585/mmwr.mm6552a1 cessation brief interventions in oral health. N S W Public
69. U.S. Department of Health and Human Services. Tobacco Health Bull. 2013;24(3):131-134. doi:10.1071/NB12090
Use. Accessed October 11, 2022. [Link] 82. Holliday R, Hong B, McColl E, Livingstone-
healthypeople/objectives-and-data/browse-objectives/ Banks J, Preshaw PM. Interventions for tobacco

Tob. Induc. Dis. 2023;21(January):12

[Link]

14
 Tobacco Induced Diseases
Review Paper

cessation delivered by dental professionals. 95. Chaturvedi O, Chaturvedi P. Nicotine gum in smoking
Cochrane Database Syst Rev. 2021;2(2):CD005084. cessation. International Journal of Contemporary
doi:10.1002/14651858.CD005084.pub4 Medical Research. 2017;4(9):1964-1966. Accessed
83. Michie S, Hyder N, Walia A, West R. Development October 11, 2022. [Link]
of a taxonomy of behaviour change techniques uploads/7/7/4/6/77464738/ijcmr_1678-1_1.pdf
used in individual behavioural support for smoking 96. Centers for Disease Control and Prevention. How to Use
cessation. Addict Behav. 2011;36(4):315-319. Nicotine Lozenges. Updated May 24, 2021. Accessed
doi:10.1016/[Link].2010.11.016 October 11, 2022. [Link]
84. Moafa I, Hoving C, van den Borne B, Jafer M. Identifying campaign/tips/quit-smoking/quit-smoking-medications/
Behavior Change Techniques Used in Tobacco Cessation how-to-use-quit-smoking-medicines/how-to-use-the-
Interventions by Oral Health Professionals and Their [Link]
Relation to Intervention Effects-A Review of the 97. Tebbutt J, Khan Z, Ariyaratnam R. A case report of oral
Scientific Literature. Int J Environ Res Public Health. nicotine-associated keratosis and a review of oral mucosal
2021;18(14):7481. doi:10.3390/ijerph18147481 changes in tobacco and similar products. Br Dent J.
85. Hartmann-Boyce J, Livingstone-Banks J, Ord óñez- 2020;228(10):757-760. doi:10.1038/s41415-020-1530-x
Mena JM, et al. Behavioural interventions for smoking 98. Devi RE, Barman D, Sinha S, Hazarika SJ, Das
cessation: an overview and network meta-analysis. S. Nicotine replacement therapy: A friend or foe.
Cochrane Database Syst Rev. 2021;1:CD013229. J Family Med Prim Care. 2020;9(6):2615-2620.
doi:10.1002/14651858.CD013229.pub2 doi:10.4103/jfmpc.jfmpc_313_20
86. Epton T, Currie S, Armitage CJ. Unique effects of setting 99. Schnoll RA, Wileyto EP, Lerman C. Extended duration
goals on behavior change: Systematic review and meta- therapy with transdermal nicotine may attenuate
analysis. J Consult Clin Psychol. 2017;85(12):1182-1198. weight gain following smoking cessation. Addict Behav.
doi:10.1037/ccp0000260 2012;37(4):565-568. doi:10.1016/[Link].2011.12.009
87. Fellows JL, Bush T, McAfee T, Dickerson J. Cost [Link] ML, Benowitz NL, Auerback GM, Moscicki
effectiveness of the Oregon quitline “free patch initiative”. AB. A randomized trial of nicotine nasal spray in
Tob Control. 2007;16 Suppl 1(Suppl 1):i47-i52. adolescent smokers. Pediatrics. 2008;122(3):e595-e600.
doi:10.1136/tc.2007.019943 doi:10.1542/peds.2008-0501
88. Centers for Disease Control and Prevention. Smoking and [Link] D. Curbing the tobacco menace–An oral
Tobacco Use: 1-800-QUIT-NOW: 15 Years of Helping diagnostician’s responsibility. Journal of Advanced
People Quit. Accessed October 11, 2022. [Link] Clinical and Research Insights. 2019;6(2):32.
[Link]/tobacco/features/quitlines/ doi:10.15713/[Link].254
89. Nethan ST, Sinha DN, Chandan K, Mehrotra R. 102. Rasmina V, Uvais NA. The role of dentists in nicotine
Smokeless tobacco cessation interventions: A systematic replacement therapy. J Family Med Prim Care.
review. Indian J Med Res. 2018;148(4):396-410. 2020;9(11):5824-5825. doi:10.4103/jfmpc.jfmpc_1460_20
doi:10.4103/ijmr.IJMR_1983_17 [Link] MJ, Wahlquist AE, Dahne J, et al. Nicotine
90. Stassen LF, Hammarfjord O. Smoking cessation and replacement therapy sampling for smoking cessation
the role of the dental practitioner. J Ir Dent Assoc. within primary care: results from a pragmatic cluster
2015;61(2):90-92. randomized clinical trial. Addiction. 2020;115(7):1358-
91. US Preventive Services Task Force. Interventions 1367. doi:10.1111/add.14953
for Tobacco Smoking Cessation in Adults, Including [Link] H, Kingston R, O’Mullane D, Nilsson F.
Pregnant Persons: US Preventive Services Task Force Randomized controlled trial to evaluate tooth stain
Recommendation Statement. JAMA. 2021;325(3):265- reduction with nicotine replacement gum during
279. doi:10.1001/jama.2020.25019 a smoking cessation program. BMC Oral Health.
92. Aubin HJ, Luquiens A, Berlin I. Pharmacotherapy for 2012;12:13. doi:10.1186/1472-6831-12-13
smoking cessation: pharmacological principles and clinical [Link] S, Benowitz NL, Rigotti NA. Prevention and
practice. Br J Clin Pharmacol. 2014;77(2):324-336. Treatment of Tobacco Use: JACC Health Promotion
doi:10.1111/bcp.12116 Series. J Am Coll Cardiol. 2018;72(9):1030-1045.
93. Sumana CK, Nagaraj T, Nigam H, Gogula S, Saxena doi:10.1016/[Link].2018.06.036
S. Nicotine replacement therapy: A review. Journal of [Link] D, Saadabadi A. Varenicline. StatPearls Publishing;
Medicine, Radiology, Pathology and Surgery. 2018;5(1):6- 2022. Updated June 29, 2022. Accessed October 11, 2022.
8. doi:15713/[Link].117 [Link]
94. Hansson A, Rasmussen T, Perfekt R, Hall E, Kraiczi 107.U.S. Food and Drug Administration. FDA Updates and
H. Effect of nicotine 6 mg gum on urges to smoke, Press Announcements on Nitrosamine in Varenicline
a randomized clinical trial. BMC Pharmacol Toxicol. (Chantix). Accessed October 11, 2022. [Link]
2019;20(1):69. doi:10.1186/s40360-019-0368-9 gov/drugs/drug-safety-and-availability/fda-updates-and-

Tob. Induc. Dis. 2023;21(January):12

[Link]

15
 Tobacco Induced Diseases
Review Paper

press-announcements-nitrosamine-varenicline-chantix
[Link] MR, Smiley A, Saadabadi A. Bupropion.
StatPearls Publishing; 2022. Updated October 10, 2022.
Accessed October 11, 2022. [Link]
gov/books/NBK470212/
[Link] T, Wang X. Cytisine for smoking cessation.
CMAJ. 2018;190(19):E596. doi:10.1503/cmaj.171371
[Link] SH, Newcombe D, Sheridan J, Tingle M.
Pharmacokinetics of cytisine, an α4 β2 nicotinic
receptor partial agonist, in healthy smokers following
a single dose. Drug Test Anal. 2015;7(6):475-482.
doi:10.1002/dta.1707
[Link] P, Vinnikov D, Courtney RJ, Benowitz NL.
Cytisine for nicotine addiction treatment: a review of
pharmacology, therapeutics and an update of clinical
trial evidence for smoking cessation. Addiction.
2019;114(11):1951-1969. doi:10.1111/add.14721
[Link]ár J, Krueger AS, Avery W, et al. Synergistic drug
combinations tend to improve therapeutically relevant
selectivity. Nat Biotechnol. 2009;27(7):659-666.
doi:10.1038/nbt.1549
[Link] JO, Hays JT, Hurt RD. Combination
pharmacotherapy for stopping smoking: what
advantages does it offer? Drugs. 2010;70(6):643-650.
doi:10.2165/11536100-000000000-00000
[Link] LF, Perera R, Bullen C, Mant D, Lancaster T.
Nicotine replacement therapy for smoking cessation.
Cochrane Database Syst Rev. 2008;(1):CD000146.
doi:10.1002/14651858.CD000146.pub3
[Link] D, Chaudhary PK, Khan A, et al. Acquaintance and
Approach in the Direction of Tobacco Cessation Among
Dental Practitioners-A Systematic Review. Int J Prev Med.
2020;11:167. doi:10.4103/ijpvm.IJPVM_316_19
[Link] P, Belek MG, Grimes B, et al. Dentists’ attitudes,
behaviors, and barriers related to tobacco-use cessation in CONFLICTS OF INTEREST
the dental setting. J Public Health Dent. 2013;73(2):94- The authors have each completed and submitted an ICMJE form for
102. doi:10.1111/j.1752-7325.2012.00347.x disclosure of potential conflicts of interest. The authors declare that
[Link] D, Freeman T, Roche AM. Dentists’ and dental they have no competing interests, financial or otherwise, related to
the current work. All the authors report that since the initial planning
hygienists’ role in smoking cessation: an examination and of the work and in the past 36 months, this publication was paid with
comparison of current practice and barriers to service funds awarded to the University of Rochester (via subaward from
provision. Health Promot J Austr. 2006;17(2):145-151. the Roswell Park Cancer Institute) by the National Cancer Institute
doi:10.1071/he06145 of the National Institutes of Health (NIH) and the Food and Drug
Administration (FDA) Center for Tobacco Products under Award Number
[Link] A, Jump Z, Babb S, et al. State Medicaid U54CA228110.
Coverage for Tobacco Cessation Treatments and Barriers
to Accessing Treatments - United States, 2008-2018. FUNDING
MMWR Morb Mortal Wkly Rep. 2020;69(6):155-160. This study was supported by The National Cancer Institute (NCI), and
the FDA (TCORS Grant U54CA228110; MPIs: Goniewicz and O’Connor)
doi:10.15585/mmwr.mm6906a2
[Link] JL. Medicaid covers smoking cessation ETHICAL APPROVAL AND INFORMED CONSENT
counseling by dentists and hygienists. N Y State Dent J. Ethical approval and informed consent were not required for this study.
2014;80(4):18-19.
DATA AVAILABILITY
[Link] EM, Hayes KA, Olson LT, Battles H, Ortega-Peluso Articles used in this research are available from the authors on
C. Dentist and hygienist smoking cessation counseling reasonable request.
and awareness of Medicaid benefits. J Public Health Dent.
2019;79(3):246-252. doi:10.1111/jphd.12321 PROVENANCE AND PEER REVIEW
Not commissioned; externally peer reviewed.

Tob. Induc. Dis. 2023;21(January):12

[Link]

16