Use of Tobacco and Nicotine Products Position Statement
O. Uti, L. Ayo-Yusuf, R. Holliday, F. Cieplik, A. Hbibi, H. Priya, M. Charles-Ayinde, and C. Fox
Tobacco and nicotine use remains a significant public health concern worldwide. Despite extensive efforts to reduce its prevalence, tobacco use continues to be a leading cause of preventable diseases and deaths (1). Tobacco is widely used, with currently more than one billion smokers globally (2). Tobacco and nicotine products encompass varieties of combustible products such as factory-manufactured cigarettes, roll-your-own cigarettes, water pipes/shisha/hookah/nargile, cigars, cigarillos and pipe tobacco. There are also some non-combustible tobacco products such as smokeless tobacco or snuff and emerging nicotine products including electronic cigarettes (e-cigarettes), vaping devices, heated tobacco products, oral nicotine pouches, nicotine gels, and dissolvables.
The major harms related to tobacco and nicotine product use, which are well documented, are linked to a multitude of compounds present in tobacco and tobacco smoke (such as carcinogens, particulate matter and carbon monoxide) (3 -5). Tobacco smoke consists of more than 7000 chemical compounds and approximately 70 known carcinogens. Half of these compounds occur naturally in the green tobacco leaf, whereas the remainder is generated when the tobacco is burned (6). Some of the chemicals found in tobacco smoke include nicotine (the addictive drug in tobacco), hydrogen cyanide, formaldehyde, lead, arsenic, ammonia, radioactive elements, such as polonium-210, benzene, carbon monoxide, tobacco-specific nitrosamines (TSNAs), and polycyclic aromatic hydrocarbons (PAHs) (7).
Tobacco and nicotine product use is a leading cause of preventable disease, disability, and death worldwide (8). The harms associated with smoking are extensive, affecting nearly every organ in the body. Its use can lead to both acute and chronic oral diseases making users experience a higher incidence of potentially malignant oral lesions, head and neck cancers, periodontal disease, impaired wound healing, reduced ability to smell and taste, melanoses, smoker’s palate, teeth staining, and peri-implant diseases, as compared to the general population (8 - 11). Smoking is an independent risk factor for tooth loss and implant failure (12).
Exposure to secondhand smoke (SHS) results in the death of 1.3 million nonsmokers each year (13,14). SHS causes a 20 to 30 percent increased risk for lung cancer for those living with a smoker, and a 25 to 30 percent increased risk for coronary heart disease for non-smokers exposed to SHS (15). Infants and children who are exposed to smoke are at risk for sudden infant death syndrome (SIDS) (16, 17), acute respiratory infection, bronchitis, pneumonia, middle ear infections, and asthma during infancy and the causal relationship with early childhood caries has also been suggested (18, 19). Thirdhand smoke (THS), the contaminant that persists after SHS, also poses significant health risks, especially to infants, children, and non-smoking adults (20). Over time, these harmful residues react with indoor air pollutants to form carcinogenic compounds, which can be absorbed through the skin, inhaled, or ingested via hand-to-mouth contact (20). Studies have shown that thirdhand smoke exposure can lead to respiratory issues, skin irritation, and DNA damage, with potential long-term effects such as an increased risk of cancer and developmental problems in children (20 - 22).
In most populations, smoking prevalence is much higher among groups with lower levels of education or income (23) and among those with mental health disorders and other co-addictions (24, 25). Smoking is also more prevalent among males than females in many populations globally (26, 27), with the smoking prevalence among men being four times higher than that among women (28). Most smokers start smoking during adolescence, with almost 90% of smokers beginning between 15 and 25 years of age (29). However, girls who smoke tend to start at an earlier age than boys (26).
Tobacco dependence is a condition driven by nicotine addiction which often requires multiple attempts to quit successfully. Quitting smoking is challenging due to nicotine addiction and psychological dependence. The World Health Organization (WHO) has reported that over 60% of the world's 1.25 billion tobacco users – more than 750 million people – wish to quit, yet 70% lack access to effective cessation services (30). Smoking cessation has great benefits for oral and general health. Former smokers have a comparable risk of tooth loss compared with never smokers (31). Smoking cessation success varies widely depending on several factors, including the methods used, the level of support available, and the individual’s motivation to quit. Fewer than four in ten adults who smoke cigarettes used evidence-based proven treatments when trying to quit smoking (32). Smoking cessation interventions delivered by dental teams have been shown to be effective (33).
Electronic Nicotine Delivery Systems (ENDS), commonly referred to as e-cigarettes, vapes, or electronic cigarettes, have become increasingly popular in some regions over the past decade. ENDS delivers the user with an aerosol that typically contains propylene glycol, vegetable glycerin, nicotine and flavoring chemicals (34). The inhalation of chemicals in the aerosol, including flavorings and other additives, presents largely unknown health risks, including possible short-term respiratory and cardiovascular effects (35). ENDS are often marketed with appealing flavors and sleek designs that attract youth, leading to increased experimentation and concerns over the potential progression to smoking combustible tobacco products (34). It is important to note that while the exclusive use of ENDS may pose fewer health risks than combustible tobacco smoking, there is emerging evidence on the adverse effects of ENDs on oral health (36,37). Furthermore, the long-term health effects of using ENDS are not yet fully understood and additional research is required (38, 39).
There is evidence from randomized trials that nicotine-containing ENDS contribute to increased quit rates as compared to conventional nicotine replacement therapy (NRT) (40). There are insufficient randomized trials directly comparing ENDS to other stop-smoking medications. Indirect trial evidence suggests nicotine-containing ENDS achieve comparable quit rates to the medications varenicline and cytisine, and improved quit rates compared to the medication bupropion (41). However, as consumer products, in observational studies, e-cigarettes were not consistently associated with increased smoking cessation in the adult population (42). The same has been observed in observational studies of other stop-smoking treatments, despite proven efficacy in randomized trials (43). A recent large cohort study in the US suggests that vaping maybe associated with significantly reduced smoking cessation especially when used nondaily. (44).
Based on scientific evidence, IADR supports the following recommendations:
1. IADR opposes the use of all forms of tobacco and nicotine.
IADR supports tobacco end game measures to prevent the sale of tobacco products to achieve a smoke-free generation through minimum age regulations (43). Subsequently, the public should be educated on the health and financial costs of tobacco and nicotine product use. Patients should be aware of the risk of tooth loss and implant failure associated with smoking and the benefits of cessation on oral health and tooth longevity. Increased attention and resources should be devoted to the prevention of tobacco and nicotine product use among children and adolescents and the implementation of Article 14 guidelines to the WHO Framework Convention on Tobacco Control (WHO FCTC) (45), including routine screenings for tobacco and nicotine product use and offering treatment of tobacco and nicotine dependence to all tobacco and nicotine product users.
2. IADR supports research to improve prevention, treatment, and deepen our understanding of tobacco- and nicotine- related general and oral health risks.
IADR also welcomes continued research to elucidate further the health effects of using both established and newly emerging tobacco and nicotine products and exposure to their emissions or aerosols; identify the biological mechanisms, behavioral patterns, and relative risks involved in producing those health effects; and develop and evaluate effective methods for prevention and cessation of all tobacco and nicotine products.
3. IADR supports and recommends a personalized oral health care approach for the tobacco – and nicotine product – using patient that can also be applied to the patient who presents other associated risk factors to oral and periodontal diseases.
4. IADR supports and encourages governments to strengthen tobacco and nicotine product control policies.
Governments should implement and enforce strong tobacco and nicotine product control policies, including comprehensive bans on tobacco and nicotine product advertising, promotion, and sponsorship, as outlined in the WHO FCTC. Policies should also include plain packaging requirements, graphic health warnings on tobacco and nicotine products, and restrictions on sales to minors.
5. IADR supports increases in tobacco and nicotine product taxes.
Raising taxes on tobacco and nicotine products is an effective way to reduce tobacco and nicotine product use, particularly among price-sensitive populations such as youth and low-income individuals. The revenue generated from these taxes should be reinvested in public health initiatives, including smoking cessation programs and healthcare services.
6. IADR supports tobacco and nicotine product use cessation programs.
Accessible and affordable tobacco and nicotine product use cessation services should be available to all tobacco and nicotine product users. This includes providing, in each country, a specific quit line and in-person counseling, nicotine replacement therapies, and other evidence-based treatments as recommended in the WHO global clinical guideline for smoking cessation (26, 46) or as may be provided for in national tobacco and nicotine cessation clinical guidelines. Public health campaigns should raise awareness of the resources available and encourage tobacco and nicotine users to seek help in quitting. Training and involving dental professionals in the management of smoking cessation may be of special interest to control and drive clinical cessation strategies. Regular accompaniment and long-term monitoring of former smokers within clinical settings may reduce the risk of relapses of tobacco and nicotine product use.
7. IADR supports the protection of non-smokers from secondhand and thirdhand smoke. Governments should enforce smoke-free laws in all indoor public places, workplaces, and public transportation to protect non-smokers from the harm of secondhand smoke. Public awareness campaigns should also educate the public about the dangers of secondhand smoke and the importance of smoke-free environments. It is recommended that in choosing meeting sites, IADR gives preference to cities that have enacted comprehensive clean indoor air policies that include restaurants, hotels, conference centers, and other public spaces.
8. IADR supports the regulation of emerging tobacco and nicotine products.
The rise of new non-combustible tobacco and nicotine products, such as electronic cigarettes and heated tobacco products, presents new challenges for tobacco and nicotine product control in balancing the risk of uptake by nicotine-naive individuals, especially young people, against the potential benefits for cigarette smokers.
9. IADR supports preventing tobacco and nicotine industry interference in scientific processes and policymaking.
Given the tobacco and nicotine industry's long history of manipulating research and obstructing public health efforts, IADR supports policies that ensure scientific integrity and prevent industry influence in regulatory and legislative processes and are in alignment with the WHO Framework Convention on Tobacco Control (WHO FCTC).
Further Research Areas
1. Long-Term Oral Health Effects – Investigate the lasting impact of new and emerging tobacco and nicotine products on oral health.
2. Use Among Vulnerable Populations – Examine tobacco and nicotine consumption patterns in vulnerable groups, including youth, adolescents, pregnant women, and low-income and minority communities.
3. Tobacco and Nicotine Cessation Strategies – Evaluate personalized cessation approaches, the effectiveness of digital cessation tools, and the long-term success of cessation programs, including relapse prevention strategies.
4. Economic Impact of Smoking Cessation – Assess the projected economic effects of smoking cessation on the burden of tobacco- and nicotine product- related diseases, including a focus on oral health outcomes and overall quality of life.
5. Effectiveness of Tobacco and Nicotine Product Control Policies – Analyze the impact of existing tobacco and nicotine product control measures such as taxation, advertising restrictions, and plain packaging, including the role of graphic health warnings in promoting cessation across different populations.
6. Mechanisms of Tobacco and Nicotine Product Induced Oral Diseases – Explore the interactions between tobacco and nicotine product use and oral diseases, including its relationship with Human Papillomavirus (HPV).
7. Carcinogenic Effects of Smokeless Tobacco – Investigate the cancer-causing potential of smokeless tobacco and its impact on oral tissues and the oral microbiome.
8. Commercial Determinants of Health: Investigate how profit-driven tobacco and nicotine industry actions impact population health outcomes and mechanisms to increase the transparency of industry strategies.
Conclusion
Tobacco use is one of the most significant public health challenges globally, contributing to millions of deaths each year and imposing a heavy burden on healthcare systems. Despite extensive knowledge of the harms associated with tobacco and nicotine products, its use remains widespread, driven by addiction, social factors, and aggressive marketing by the tobacco and nicotine product industry. This calls for strong international partnerships to implement evidence-based tobacco and nicotine product control measures contained in the WHO FCTC, including making tobacco and nicotine cessation widely accessible to those who use tobacco and nicotine products and conducting research on the long-term oral health effects of both conventional tobacco products and the new emerging tobacco and nicotine products.
