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While tobacco use continues to decline in adults, its prevalence is growing among young people, emphasizing the need for effective prevention and intervention strategies.
By Linda D. Boyd, RDH, RD, EdD
After reading this course, the participant should be able to:
1. Explain the various alternative tobacco products and prevalence
2. Describe the health effects of tobacco use.
3. Discuss the "5 A's" of tobacco cessation and the approach to
addressing these with patients.
4. Summarize resources available to assist with tobacco intervention.
The United States Surgeon General refers to tobacco use as a pediatric
disease because 90% of adult tobacco users start the habit before they turn 18.1
This is a concern because the current prevalence of tobacco use among young
people suggests it is on the rise. Part of this increase may be due to the
advent of alternative tobacco products (ATPs)—from water pipes to electronic
cigarettes (e-cigarettes). Amrock and Wietzman2 have deemed the use
of ATPs as presenting the "second front in the war on tobacco."
Cigarettes are the most commonly used form of tobacco use in adults.3
The prevalence of tobacco use among adults and youth in the US is
measured by national surveys, which revealed 17% of adults, 9% of high school
students, and 2% of middle school students were current cigarette smokers,
defined as smoking >1 cigarette per day in the past 30 days.3,4
This is misleading, however, because young people tend to favor ATPs.3.4
The overall prevalence for tobacco use in general was approximately 7% of
middle school students, 25% of high school students, and 21% of adults.5
ATPs include smoked and smokeless items, such as cigars, snus,
dissolvables, e-cigarettes, water pipes/hookahs, chewing tobacco, to name a
few.6,7 Electronic nicotine delivery systems (ENDS) heat liquid
containing nicotine to an aerosol that is inhaled.8 ENDS include
vaporizers, vape pens, hookah pens, e-pipes, and e-cigarettes. According to the
General, these delivery systems can also be used for cannabinoids and other
The increase in the use of ENDS by youth is more rapid than in adults,
with national surveys showing 1% to 5% of adults using ENDS compared to 14% to
16% of high school students.4,5,11 From 2011 to 2015, the use of
ENDS among high school students increased from 1.5% to 16%. In middle school
students, the reported use increased from < 1% to more than 5% between 2011
and 2015.5 Even more alarming is that approximately 10% of high
school and 8% of middle school students reported daily use of ENDS.4 Of those
using e-cigarettes, 63% reported using flavored ENDS products, suggesting this
enhances their appeal to adolescents.4,9 ENDS usage is also
associated with the utilization of other tobacco products among youth and young
The Tobacco Products and Risk Perceptions Survey found that 1% of adults
who had never smoked reported using ENDS in the past 30 days, with almost 5% of
those who had never smoked using these products at some point.12 It
is concerning that people who identify as nonsmokers are using ENDS, suggesting
a widespread belief they are less harmful than other tobacco products.9 The
survey also found nearly 21% of current smokers reported using ENDS.12 Systematic
reviews of ENDS to reduce the harmful health effects of cigarette smoking and
aid in decreasing smoking frequency suggest ENDS may be helpful in tobacco
cessation.13,14 However, the long-term safety and health effects of
ENDS use are unknown. Additionally, the evidence about the ability of ENDS to
reduce smoking is of low quality.13,14 Oral health professionals
need to monitor emerging information on this topic and beware of e-cigarette
vendors wanting to advertise their products in the dental office.
Hookah tobacco is known by a number of names, including water pipe
tobacco, maassel, shisha, narghile, and argileh. A water pipe (hookah) is used
to smoke it.15 The water pipe is made of a head, body, bowl, and a
hose containing a mouthpiece. The hookah tends to be used socially at parties,
cafes, and lounges.16 Flavor enhancers may also be added, and almost
79% of youth who used a hookah reported choosing it because of the flavors
available.17 Hookah use has been a part of Middle Eastern culture
for centuries, but has only recently become popular among young adults and
youth in the US.16 Many users believe water pipe smoking is less
harmful than cigarettes, but evidence suggests the health outcomes and
addiction issues are similar.18 Water pipe smoking sessions tend to
last 30 minutes to 90 minutes. A systematic review and meta-analysis found one
session of water pipe smoking resulted in 74.1 liters of smoke inhalation vs
0.6 liters for smoking a single cigarette.19 Higher levels of carbon
monoxide, nicotine, and tar are also released during a session of water pipe
The prevalence of water pipe use among adults is approximately 4%.3 Conversely,
the use of hookahs in youth is higher—about 7% of high school students,
increasing from 4% in 2011.5 In middle school students, hookah use
prevalence increased from 1% in 2011 to 2% in 2015.5
Smokeless tobacco products include chewing tobacco (also known as spit
tobacco), dry snuff, and moist snuff or snus. The tobacco in these products may
be loose leaf, powdered, or in pouches. These products contain high-intensity
sweeteners, such as sucralose, in higher concentrations than is found in candy
and soda.20 Sweeteners mask the unpleasant taste of tobacco and make
it more appealing, especially to youth.20 In 2014, 59% of youth who
used smokeless tobacco reported choosing a flavored variety.21
About 2.5% of adults reported using smokeless tobacco products.3
However, 6% of high school students and almost 2% of middle school students
reported using smokeless tobacco.5 The percentage of youth using
smokeless tobacco decreased about 1% from 2011 to 2015.5 Despite
this decrease, frequent use (> 20 days in the last 30 days) of smokeless
tobacco was most prevalent among high school students (42%) and middle school
Dissolvable tobacco products come in strips (placed on the tongue to
dissolve), sticks (similar to large toothpicks), and lozenges or orbs (like a
breath mint or candy).22 The nicotine content varies, but they can
contain as much or more than a typical cigarette. Data on the prevalence of
dissolvable tobacco use are not available because it is typically combined with
smokeless tobacco in national surveys.
Cigars, little cigars, and cigarillos, as well as tobacco wrapped in a
tobacco leaf are additional forms of tobacco use.23 One cigar
contains as much tobacco as a pack of cigarettes.23 The little
cigars and cigarillos may be flavored to enhance appeal, especially to youth
and young adults. Adolescents reported using cigars because they liked the
flavors (73.8%) and were more affordable (58.2%).17 Approximately 9%
of high school students and 5% of adults reported using cigars in the past 30
In addition to
the well-known negative health effects of tobacco use, nicotine exposure
significantly harms the developing adolescent brain.9 The fact that
the use of ATPs among youth is increasing emphasizes the need for effective prevention
and cessation programs.
Like traditional cigarette smoking, water pipe smoking harms
cardiovascular and respiratory health by increasing blood pressure, decreasing
immunity, and raising the risk for chronic obstructive pulmonary disease.18,24
A systematic literature review found five studies that evaluated the
association between periodontal diseases and water pipe smoking.24
Of these studies, four were with the same participants, limiting the sample
size. This led Waziry et al24 to suggest that it is unclear whether
an association exists between water pipe smoking and periodontal diseases. The
health effects of heated and aerosolized components of e-cigarette liquids (eg,
nicotine, solvents, flavoring, toxicants, etc) are unknown at this time.9
Another emerging tobacco trend is polytobacco use, or the use of more
than one type of tobacco product. This is a growing trend among those who use
ATPs and is associated with increased risk of nicotine addiction.25,26
This addiction leads to more problems with tobacco dependence and can hinder
the success of tobacco cessation.25,26 The long-term health effects
of polytobacco use warrant further research.
Prevention and Cessation
prevention and cessation programs have been focused on smoking, leaving few
resources to address ATPs. According to the US Preventive Services Task Force's
(USPSTF) guidelines for children and adolescents, efforts should focus on
assessing risk, interventions to prevent tobacco use, and tobacco cessation.27
Risk assessment should include exposure to parental smoking, access to tobacco
products, peers who use tobacco, and exposure to tobacco advertising.27
Oral health professionals can provide preventive messages related to both
oral and general health. Messages need to be meaningful for youth in order to
make a difference. Highlighting the short-term effects of tobacco use, such as
staining of teeth and breath malodor or shortness of breath, which may impact
endurance during athletic events, may be more effective for young tobacco
users. According to the USPSTF, there is limited evidence related to the most
effective approach to tobacco cessation in youth, and there are no
pharmaceutical agents approved for this age group.27
The most current USPSTF guidelines for adults continue to recommend the "5
A's" framework for tobacco intervention: asking about tobacco use; advising
tobacco users to quit; assessing readiness to quit; assisting with quit
attempt; and arranging follow-up.28 A modified version focused on
ask, advise, and refer has also been proposed for oral health professionals,
but research suggests patients are more successful in quit attempts when using
the "5 A's" approach.29
Screening patients for tobacco use, including ATPs, may be more
challenging than for more traditional cigarette or smokeless tobacco use,
because these products are not normally included on the medical history. As
individuals who report never using tobacco may in fact use ENDS, there is a
need to approach gathering this information more comprehensively.
Ask. The health history
should list the actual types of ATPs to prompt questions by the oral health
professional about the various types of tobacco products and frequency of use.
Table 1 provides a sample of the information needed for tobacco use assessment.
Advise. Oral health professionals must advise patients to quit tobacco use to
support oral and overall health. Patients should be educated on quitting in
clear language that is personalized for each individual's need at every
appointment.30 Expect ambivalence (conflicted feelings about
tobacco use) and listen nonjudgmentally to the patient's concerns about
Assess. Oral health professionals need to assess patients' readiness to quit
tobacco use. This readiness to change behavior is a component of the
Transtheoretical Model of Behavior Change, which is foundational for
motivational interviewing and is widely used to help people quit smoking.31
In motivational interviewing, oral health professionals act as guides to assist
patients in choosing to change behavior and support self-efficacy. An in-depth
discussion of motivational interviewing is beyond the scope of this article,
but many credible resources related to the topic are available.
Patients may be in various stages of quitting, including precontemplation
(not interested in quitting), contemplation (thinking about quitting),
preparation (planning to quit in next 30 days), action (quitting successfully
for up to 6 months), and maintenance (quitting successfully for more than 6
months). The stage of readiness to quit should also be recorded in the patient
Assist. Table 2 provides a sampling of tobacco resources available to clinicians
and patients. The resources for clinicians provide information on behavioral
and pharmacologic approaches to assist patients in tobacco cessation. If the
office or clinic has a website, links can be provided for tobacco cessation
resources. An electronic record template may include a prompt to record the
resources provided to patients so monitoring may occur over time. Ideally,
collaboration by an interprofessional team to assist patients in successfully
quitting tobacco is the preferred approach given the time constraints and
expertise of the dental team. The interprofessional team may include the
patient's physician, nurse practitioner, physician assistant, pharmacist,
and/or substance abuse counselor, as well as others. Oral health professionals
need to remember that even individuals who smoke only one cigarette per day
still have a 64% higher risk of early death, primarily from lung cancer, than
Arrange. Oral health
professionals need to follow up with patients 1 week after a planned quit date
and at each recare appointment to re-assess or provide support for another quit
attempt or relapse prevention.30 In 2006, approximately 44% of
adults reported a quit attempt in the past year, yet 95% to 98% resumed tobacco
use without formal treatment. This underscores the need for oral health
professionals to be actively involved in relapse prevention.33
Relapse prevention involves
patients learning strategies to avoid or recover from lapses or relapses.
Avoiding blame and guilt for a relapse is essential because negative emotions
reduce the chances of success.33 Patients should be encouraged to
examine the relapse to identify the trigger(s) and find approaches to avoid or
overcome those trigger(s).33
- US Department of Health & Human Services. The Health Consequences
of Smoking: 50 Years of Progress. A Report of the Surgeon General. Available
at: surgeongeneral.gov/library/reports/50-years-of-progress. Accessed January
- Amrock SM, Weitzman M. Alternative tobacco products as a second front
in the war on tobacco. JAMA. 2015;314:1507–1508.
- Hu SS, Neff L, Agaku IT, et al. Tobacco product use among
adults—United States, 2013-2014. MMWR Morb Mortal Wkly Rep.
- Neff LJ, Arrazola RA, Caraballo RS, et al. Frequency of tobacco use among
middle and high school students--United States, 2014. MMWR Morb Mortal Wkly
- Singh T, Arrazola RA, Corey CG, et al. Tobacco use among middle and
high school students--United States, 2011-2015. MMWR Morb Mortal Wkly Rep.
- Lauterstein D, Hoshino R, Gordon T, Watkins BX, Weitzman M, Zelikoff
J. The changing face of tobacco use among United States youth. Curr Drug
Abuse Rev. 2014;7:29–43.
- McMillen R, Maduka J, Winickoff J. Use of emerging tobacco products in
the United States. J Environ Public Health. 2012;2012:989474.
- Food & Drug Administration. Vaporizers, E-Cigarettes, and other
Electronic Nicotine Delivery Systems (ENDS). 2016. Available at: fda.gov/
Accessed January 24, 2017.
- US Department of Health & Human Services. E-cigarette Use Among
Youth and Young Adults: A Report of the Surgeon General—Executive Summary.
- Morean ME, Kong G, Camenga DR, Cavallo DA, Krishnan-Sarin S. High
school students' use of electronic cigarettes to vaporize cannabis. Pediatrics.
- Gilreath TD, Leventhal A, Barrington-Trimis JL, et al. Patterns of
alternative tobacco product use: Emergence of hookah and e-cigarettes as
preferred products amongst youth. J Adolesc Health. 2016;58:181–185.
- Weaver SR, Majeed BA, Pechacek TF, Nyman AL, Gregory KR, Eriksen MP.
Use of electronic nicotine delivery systems and other tobacco products among
USA adults, 2014: Results from a national survey. Int J Public Health.
- Hartmann-Boyce J, McRobbie H, Bullen C, Begh R, Stead LF, Hajek P.
Electronic cigarettes for smoking cessation. Cochrane Database Syst Rev. 2016;9:CD010216.
- Glasser AM, Collins L, Pearson JL, et al. Overview of electronic
nicotine delivery systems: A systematic review. Am J Prev Med.
- United States Food and Drug Administration. Hookah tobacco (Shisha or
Waterpipe Tobacco). Available at: fda.gov/TobaccoProducts/Labeling/
ProductsIngredientsComponents/ucm482575.htm. Accessed January 24, 2017.
- Maziak W, Taleb ZB, Bahelah R, et al. The global epidemiology of
waterpipe smoking. Tob Control. 2015;24(Suppl 1):i3-i12.
- Ambrose BK, Day HR, Rostron B, et al. Flavored tobacco product use
among US youth aged 12-17 Years, 2013-2014. JAMA. 2015;314:1871–1873.
- Haddad L, Kelly DL, Weglicki LS, Barnett TE, Ferrell AV, Ghadban R. A
systematic review of effects of waterpipe smoking on cardiovascular and
respiratory health outcomes. Tob Use Insights. 2016;9:13–28.
- Primack BA, Carroll MV, Weiss PM, et al. Systematic review and
meta-analysis of inhaled toxicants from waterpipe and cigarette smoking. Public
Health Rep. 2016;131:76–85.
- Miao S, Beach ES, Sommer TJ, Zimmerman JB, Jordt SE. High-intensity
sweeteners in alternative tobacco products. Nicotine Tob Res.
- Corey CG, Ambrose BK, Apelberg BJ, King BA. Flavored tobacco product
use among middle and high school students—United States, 2014. MMWR Morb
Mortal Wkly Rep. 2015;64:1066–1070.
- United States Food and Drug Administration. Tobacco Products:
Dissolvable tobacco products. Available at: fda.gov/TobaccoProducts/Labeling/
ProductsIngredientsComponents/ucm482569.htm. Accessed January 24, 2017.
- United States Food and Drug Administration. Tobacco Products: Cigars,
cigarillos, little filtered cigars. Available at: fda.gov/TobaccoProducts/
Labeling/ProductsIngredientsComponents/ucm482562.htm Accessed January 24, 2017.
- Waziry R, Jawad M, Ballout RA, Al Akel M, Akl EA. The effects of
waterpipe tobacco smoking on health outcomes: an updated systematic review and
meta-analysis. Int J Epidemiol. 2016. Epub ahead of print.
- Sung HY, Wang Y, Yao T, Lightwood J, Max W. Polytobacco use of
cigarettes, cigars, chewing tobacco, and snuff among US adults. Nicotine Tob
- Butler KM, Ickes MJ, Rayens MK, Wiggins AT, Hahn EJ. Polytobacco use
among college students. Nicotine Tob Res. 2016;18:163–169.
- Moyer VA, US Preventive Services Task Force. Primary care
interventions to prevent tobacco use in children and adolescents: US Preventive
Services Task Force recommendation statement. Ann Intern Med.
- Siu AL, US Preventive Services Task Force. Behavioral and
pharmacotherapy interventions for tobacco smoking cessation in adults,
including pregnant women: US Preventive Services Task Force Recommendation
Statement. Ann Intern Med. 2015;163:622–634.
- Gordon JS, Andrews JA, Crews KM, Payne TJ, Severson HH. The 5A's vs
3A's plus proactive quitline referral in private practice dental offices:
preliminary results. Tob Control. 2007;16:285–288.
- Black JH 3rd. Evidence base and strategies for successful smoking
cessation. J Vasc Surg. 2010;51:1529–1537.
- Lindson-Hawley N, Thompson TP, Begh R. Motivational interviewing for
smoking cessation. Cochrane Database Syst Rev. 2015:Cd006936.
- Inoue-Choi M, Liao LM, Reyes-Guzman C, Hartge P, Caporaso N, Freedman
ND. Association of long-term, low-intensity smoking with all-cause and
cause-specific mortality in the National Institutes of Health-AARP Diet and
Health Study. JAMA Intern Med. 2017;177:87–95.
- Collins SE, Witkiewitz K, Kirouac M, Marlatt
GA. Preventing relapse following smoking cessation. Curr Cardiovasc Risk Rep. 2010;4:421–428.
From Dimensions of Dental Hygiene. February 2017;15(2):50-53.