Science Policy

Tobacco

R.C. Moffat, K.M. Byrd, X. Li, Y-H. Yu, C.H. Fox, M.K.S. Charles-Ayinde


The American Association for Dental, Oral, and Craniofacial Research (AADOCR) recognizes that tobacco use is one of the largest public health threats in the world1,2. Tobacco products come in many forms. Some are smoked, and others are not, but none is safe for human consumption3. Despite this common knowledge, reports show that most people who use cigarettes began smoking as an adolescent4; and nearly nine out of 10 smokers started smoking by age 184. In 2021, of the 2.55 million high- and middle- students that reported current (past 30-day) use of a tobacco product, e-cigarettes were the most commonly used tobacco-derived product*, cited by 2.06 million5. Among adolescent and adult users, smokeless tobacco (spit tobacco), snus, and electronic nicotine delivery systems (ENDS) are considered harm reduction alternatives to smoked tobacco; however, they contain their own risks for oral and overall health. After years of rigorous and extensive research, chronic tobacco use has been shown as a primary risk factor for six of the eight leading causes of death worldwide, and tobacco use is estimated to contribute to the death of eight million people each year6.


Tobacco use can result in acute and chronic oral diseases. Head and neck cancers1,2,7 and periodontitis2,8,9, compromised wound healing10,11, a reduction in the ability to smell and taste12, melanoses (dark pigmentation of the oral tissues)13, smoker’s palate (harder white thickened mucosal tissues)13, staining of teeth14 and restorations14,15, and peri-implant diseases16 are all seen at higher rates in tobacco users than in nonusers. Smokeless tobacco use is a risk factor for oral cancer, erythroplakia, leukoplakia, periodontal disease, and staining of teeth and restorations17. Caries risk in the primary dentition is increased due to secondhand smoke exposure18. Poorly developed enamel in the primary and permanent dentition may be related to secondhand cigarette smoke exposure during childhood19. Smoking increases the risk for stroke by about three-fold coronary heart disease by 2–4 times, lung cancer by twenty-five-fold, and head and neck cancer by 10-fold7,20. Smoking also causes reproductive problems, cardiovascular disease, leukemia, cataracts, pulmonary disease, and cancers of the liver, blood, cervix, kidney, pancreas, stomach, lung, larynx, bladder, oropharynx, and esophagus7.


Furthermore, each day in the United States, about 1600 youth smoke their first cigarette, and nearly 200 become daily cigarette smokers4. Adolescents report various factors leading to the initiation of smoking, including peer pressure, parents that are smokers, rebelliousness, clever marketing tactics from the tobacco industry, and nicotine as a “feel-good” drug without intoxication21. If smoking persists at the current rate among youth in this country, 5.6 million of today’s population younger than 18 years of age are projected to die prematurely from a smoking-related illness2. This represents about one in every 13 American youth. If youth can be discouraged from starting smoking, it is less likely that they will start smoking as adults.

Since 2014, ENDS, specifically e-cigarettes, have been the most commonly used tobacco-derived product* among U.S. youth5. Between 2011 and 2019, the proportion of high school students who were current e-cigarette users increased from 1.5% to 27.5%22. Ninety-nine percent of e-cigarettes contain nicotine23. Therefore, the use of e-cigarettes with this addictive component can result in short- and long-term health effects in adolescents. These effects include damage to regions of the developing brain that control attention, learning, mood, and impulse control24, increased risk for future addiction to other drugs24, increased mental health impacts25, respiratory function impairment, and structural changes in lung tissue26 as well as increased risk of coronary heart disease and heart attack27. Furthermore, health claims that e-cigarettes are effective smoking cessation aids are inconclusive based on current scientific evidence28. According to the 2020 Surgeon General’s report, the current evidence is suggestive but not sufficient to infer that the use of e-cigarettes containing nicotine is associated with increased smoking cessation compared with the use of e-cigarettes not containing nicotine, and the evidence is suggestive but not sufficient to infer that more frequent use of e-cigarettes is associated with increased smoking cessation compared with less frequent use of e-cigarettes28,29,30,31 indicating that much more research is needed.


Secondhand smoke (SHS) imposes significant risks as well. Tobacco smoke contains at least 7,000 chemicals, 70 of which can cause cancer and many more that are toxic or teratogenic32. Secondhand exposure results in the death of 41,000 nonsmoking adults and 400 infants each year32. 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 SHS33. Infants and children who are exposed to smoke are at risk for sudden infant death syndrome (SIDS)1,7,34,35, acute respiratory infection, bronchitis, pneumonia, middle ear infections, and asthma during infancy35. Prenatal exposure to secondhand smoke has been associated with thirdhand smoke, which refers to the residual toxins that are found on surfaces in the home due to smoking36. These volatile compounds become airborne particulate matter easily dispersed throughout the home over time37. Because children generally are found in areas close to the ground that is more highly contaminated and because infants ingest dust at a rate that is more than twice that of an adult, they are even more susceptible to thirdhand smoke37. Studies have shown that children exposed to thirdhand smoke have increased cognitive deficits in addition to the other associated risks of secondhand smoke exposure36,37.
Based on the scientific evidence, AADOCR supports the following recommendations: 

 

  1.  AADOCR opposes the use of all forms of tobacco. Subsequently, the public should be educated on the health and financial costs of tobacco use. Increased attention and resources should be devoted to prevention of tobacco use among children and adolescents, routine screening for tobacco use, treatment of tobacco dependence, and further quality research on this topic. It is incumbent on the health care community to reduce the burden of tobacco-related morbidity and mortality by supporting preventive measures, educating the public about the risks of tobacco, screening for tobacco use and nicotine dependence, and incorporating evidence-based approaches to tobacco use intervention into clinical practice.
  2.  AADOCR welcomes continued research to elucidate further the health effects of using established tobacco products and newly emerging tobacco-derived products and exposure to their emissions; 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. 
  3.  AADOCR supports collaboration with other organizations, healthcare providers, and institutions to inform the public of tobacco-related research findings and to advocate for appropriate public policy. 
  4.   AADOCR supports national, state, and local legislation that eliminates tobacco advertising, promotions, and sales that appeal to or influence children and adolescents. Additionally, AADOCR also supports the continued enactment and enforcement of state and local clean indoor air policies or ordinances prohibiting smoking in public places. In choosing meeting sites, AADOCR gives preference to cities that have enacted comprehensive clean indoor air policies that include restaurants, hotels, conference centers, and other public spaces.


*Electronic nicotine delivery systems (ENDS) in this context refers to products comprised of an “e-liquid” containing nicotine derived from tobacco, as well as flavorings, propylene glycol, vegetable glycerin, and other ingredients38. 


Author Contributions
R.C.M. and K.M.B. contributed to the design, interpretation, and drafting, of the position statement. X. Li, C.H.F., M.K.S.C.A, and all members of the IADR Science Information Subcommittee critically revised the statement. All authors gave final approval and agree to be accountable for all aspects of the work.


Acknowledgments 
The members of the 2022 AADOCR Science Information Subcommittee were K.M. Byrd, X. Li, R.C. Moffat, and Y-H. Yu. The AADOCR Science Information Committee thanks all members of the Subcommittee for providing subject matter expertise during the drafting of the policy statement.
The authors received no financial support and declare no potential conflicts of interest concerning the authorship of this article.

References

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(Adopted 2023)