Getting patients to quit smoking – why and how

This article explores the effect of smoking on the periodontal tissues, and offers advice on how to help patients quit

Public Health England figures published in 2015 indicate that one in five adults in England smoke, which equates to nearly 8 million people.1 The 2009 Adult Dental Health Survey (ADHS) reached a similar conclusion, finding that 22% of dental adults in England, Wales and Northern Ireland smoked.2

This was the first time that the decadal ADHS asked all adults, including young adults aged 16 to 18 years, questions related to smoking behaviour. These were included because of the evidence base linking smoking to reduced periodontal health.2 Indeed, over time, evidence has grown supporting the idea that poor periodontal health amongst smokers is not simply the result of below par oral hygiene regimens and the plaque biofilm that would naturally accumulate as a result.3

The ways in which smoking may have a detrimental effect on periodontal health include:3

• Smokers and non-smokers have different ‘microbial profiles and patterns of biofilm colonisation’.

• Tobacco smoke may, ‘[…] alter the protective host response and destructive inflammatory response to the plaque biofilm. […] These two effects, from exposure to tobacco smoke, tilt the balance within the periodontal tissues to a greater tendency for periodontal tissue breakdown.’

• Weakening of the healing ability of periodontium cells have been attributed to the use of tobacco products. This includes, ‘[…] fibroblasts, osteoblasts and cementoblasts, which are responsible for the formation of new cementum, connective tissue and bone, essential for a favorable response to treatment.’

As a whole, epidemiological studies indicate that, ‘[…] the use of tobacco products in general, and smoking products in particular, is the major preventable risk factor in the initiation and progression of periodontal diseases. Furthermore, tobacco use has been shown to have major adverse effects on the full range of both noninvasive and surgical periodontal procedures.’3

The EU Working Group on Tobacco and Oral Health considered the specifics of smokers having an increased susceptibility to periodontal disease. As part of that, it was suggested that the results from a variety of well-controlled studies over a period of two decades indicated smokers versus non-smokers may suffer:

• Greater marginal bone loss

• Deeper periodontal pockets

• More severe attachment loss

• More teeth with furcation involvements.4

Motivating patients to quit

In line with this, ‘Delivering better oral health: an evidence-based toolkit’ for prevention suggests that all adults and adolescents are advised not to smoke, because: ‘Smoking increases the risk of periodontal disease, reduces benefits of treatment and increases the chance of losing teeth.’5

It also states: ‘As many of the adverse effects of tobacco use on the oral tissues are reversible, this provides a useful means of motivating patients to stop.’5

Given human nature, it has been put forward that raising awareness of social and aesthetic factors may help to motivate a patient to stop smoking. Outcomes such as stained teeth, bad breath and a bad taste in the mouth may be more effective than emphasising less well-known effects on oral health such as periodontal disease.6

On this issue, Terrades and colleagues (2009) wrote: ‘The aesthetic effects of smoking should be highlighted and used as motivating factors by dentists when suggesting that their patients stop smoking. Nevertheless, dentists should be aware that the population are generally less concerned and knowledgeable about the real dangers of smoking to aspects of oral health and the profession should inform their patients about these.’6

They continued: ‘Aesthetic and social effects are the ones that people perceive more and could be used as motivating factors for smoking cessation. The effects of smoking on oral health, such as gum disease, oral cancer or impaired healing of wounds, are less well known and require further education.’6

Ask, Advise, Act

It is recommended in ‘Delivering better oral health’ that DHCPs intervene using the ‘Ask, Advise, Act’ technique with patients who smoke.5

All patients should be asked whether they are a smoker, used to smoke or have never smoked, and that status recorded. There is no need to ask them how many cigarettes they smoke a day as, irrespective of numbers, stopping is beneficial in every circumstance.5

Someone who smokes may then be advised on the best way to give up, perhaps combining medication with specialist support.5

Lastly, the DHCP can then act on each patient’s response to this discussion, helping the patient to build confidence, offering further information, providing referral details of a local stop smoking service, and/or prescribing a relevant medication to support their endeavours.5

It is acknowledged that many DHCPs are time poor, however delivering this very brief advice (VBA) to smokers can be done in just 30 seconds and, ‘[…] will increase the chance of a successful quit attempt […]’.5

Engaging in long-term benefits

Providing an overview of the issue, Stacey and colleagues (2006) wrote: ‘Smoking has […] been shown to increase the risk of periodontal destruction, even in the presence of good plaque control. Therefore the role of the dental team in promoting smoking cessation advice (SCA) is relevant to both the general and specialty based dental disciplines to encourage our patients to stop smoking.’7

They further stated: ‘The magnitude of the effect of smoking as a risk factor for periodontal disease […] suggests that a successful quit attempt is likely to have significant long-term benefit in maintaining a functioning dentition and dental health. The engagement of the entire dental team in delivering this brief intervention is, therefore, essential.’7



  1. Health matters: smoking and quitting in England. Available at: Accessed 9 November 2017
  2. Adult Dental Health Survey 2009. The Health and Social Care Information Centre 2011
  3. Chaffee BW et al. The tobacco-using periodontal patient: role of the dental practitioner in tobacco cessation and periodontal disease management. Periodontology 2000 2016; (71): 52-64
  4. Johnson NW. Bain CA. Tobacco and oral disease. BDJ 2000; (4) 189: 200-206
  5. Delivering better oral health: an evidence-based toolkit for prevention. Public Health England. Third edition, revised 2017
  6. Terrades M et al. Patients’ knowledge and views about the effects of smoking on their mouths and the involvement of their dentists in smoking cessation activities. BDJ 2009; 207: E22
  7. Stacey F et al. Smoking cessation as a dental intervention — views of the profession. BDJ 2005; 201: 109-113