Johnson & Johnson is delighted to bring you this article, with the aim of supporting the ongoing CPD needs of dental healthcare professionals in improving and maintaining the oral health of their patients.
This article is equivalent to one hour of Enhanced CPD. To provide feedback on this article, please contact [email protected]
Learning outcomes
Aims and objectives
The aim of this article is to consider the effects of tobacco and e-cigarette use on oral health, as well as offering some insight into how the dental team may be able to help amenable patients quit.
On completing this CPD session, the reader will:
• Understand the prevalence of smoking and e-cigarette use in the UK, as well as the cost to the NHS
• Understand the kinds of health challenges tobacco smokers face
• Understand the current evidence base relating to e-cigarettes
• Understand how dental professionals can help smokers to quit
• Understand the role of e-cigarettes.
Smoking cessation and the dental team 
 This article considers the effects of tobacco and e-cigarette use on oral health, as well as offering some insight into how the dental team may be able to help amenable patients quit.
According to the Office for National Statistics, in 2018 14.7% of adults over the age of 18 in the UK smoked cigarettes, equating to 7.2 million people. The data also indicates that 6.3% of the adult population in Great Britain in 2018 were using an e-cigarette, which is about 3.2 million people.1  
Adding to the known facts and figures, a position paper issued by the Royal College of General Practitioners states that smoking tobacco exposes the smoker to over 5,000 chemicals. Of those 5,000, many are poisonous and over 70 may cause cancer.2
Other data sources indicate that one in four adult deaths in Scotland and one in six in England are attributable to smoking, with smoking-related health issues costing the NHS around £400 million in Scotland and £2 billion in England per year.3
Smoking signals health problems
Offering an overview of some of the health issues associated with tobacco smoke, Tatullo and colleagues (2016) wrote: ‘Although it is well known that cigarette smoking is a risk factor for cardiovascular diseases, pulmonary diseases, cancer, and other systemic pathologies, the area of human body directly exposed to tobacco smoke effects is the oral cavity. Neoplastic and preneoplastic conditions take a particular attention among oral diseases induced by tobacco smoking, because of the importance that early diagnosis can have with such clinical pictures.’ 4
They added: ‘Cigarettes smoking is also one of the most important known cofactor in the development of oral leukoplakia, palatal leukokeratosis and melanosis, and of the modifications of the oral microenvironment which can lead to several opportunistic pathologies, such as oral candidiasis and hairy tongue.  Furthermore, tobacco smoking represents a high risk factor for periodontal diseases, enhancing the loss of gingival attachment, and the increase of gingival regression, with the final result of a severe progression of periodontal inflammation.’4
They additionally stated: ‘As reported in literature, wound healing after periodontal scaling was significantly altered in smokers, with an increased risk of dental implant failure.’4
Given the known risks of smoking cigarettes, it has been suggested that e-cigarettes may offers smokers an alternative to smoking.4
E-cigarettes – the story so far
E-cigarettes are rechargeable electric gadgets that vaporise propylene or polyethylene glycol-based liquids into an aerosol containing varying levels of nicotine.5
They are relatively new, having first been introduced in the 2000s. Their newness, however, means that whilst the effects of conventional cigarettes are well-known, the role of e-cigarettes in relation to carcinogenesis is yet to be proven one way or another.6
Current evidence does nonetheless suggest that e-cigarettes have fewer ‘key toxicants’ than cigarettes.2
Expanding on this, The National Centre for Smoking Cessation and Training’s guidance states, ‘Whilst use of e-cigarettes is not without health risk, it is much less hazardous than smoking cigarettes. Current estimates put vaping somewhere in the vicinity of 95% less harmful than smoking tobacco, based on comparisons of the composition of carcinogens and toxicants in tobacco smoke and e-cigarette vapour.’7
Looking beyond such carcinogens and toxicants, Kim and colleagues (2018) investigated the cariogenic potential of sweet flavours in e-cigarette liquids.8
They found that: ‘E-cigarette aerosols produced four-fold increase in microbial adhesion to enamel. Exposure to flavored [sic] aerosols led to two-fold increase in biofilm formation and up to a 27% decrease in enamel hardness compared to unflavoured [sic] controls. Esters (ethyl butyrate, hexyl acetate, and triacetin) in e-liquids were associated with consistent bacteria-initiated enamel demineralization, whereas sugar alcohol (ethyl maltol) inhibited S. mutans growth and adhesion. The viscosity of the e-liquid allowed S. mutans to adhere to pits and fissures.’8
Kim and colleagues (2018) concluded: ‘This study systematically evaluated e-cigarette aerosols and found that the aerosols have similar physio-chemical properties as high-sucrose, gelatinous candies and acidic drinks. Our data suggest that the combination of the viscosity of e-liquids and some classes of chemicals in sweet flavors [sic] may increase the risk of cariogenic potential. Clinical investigation is warranted to confirm the data shown here.’8
In addition, e-cigarette use has been linked to xerostomia, nicotine stomatitis, hairy tongue and angular cheilitis. It has also been suggested that e-cigarettes contribute to the pathogenesis of periodontitis. The evidence linking e-cigarettes to these conditions does have some limitations. As with the possibility of a link with cancer, more research is needed.6
As Sultan and colleagues (2018) pointed out: ‘As has been the case for conventional cigarettes, it is likely that ENDS [electronic nicotine delivery systems] will be consumed for many years before their true carcinogenic potential is realized, and therefore, prospective longitudinal studies on the role of ENDS on oral cancer risk are highly desirable. ‘6
Intervention in practice 
General dental practitioners are in a good position to help people in the UK who smoke, as they see a large number of the population on a regular basis.3 For instance, over half of the adult population in England saw a dentist over a two-year period, as recorded by the Health and Social Care Information Centre.9  
Broadening this idea to include all dental professionals, Gillam and Yusuf (2019) wrote: ‘Dental teams are ideally positioned to provide both preventive advice and brief interventions to benefit patients, beyond the remit of solely improving their oral health, but also tackling chronic disease conditions including obesity, Type II diabetes, cardiovascular diseases, and cancers.’10
It is recommended in ‘Delivering better oral health: an evidence-based toolkit for prevention’ (2017) that dental professionals intervene using the ‘Ask, Advise, Act’ technique with patients who smoke.11
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 always beneficial.11
Someone who smokes may then be advised on the best way to give up, perhaps combining medication with specialist support.11
Lastly, the dental professionals 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 efforts. 11
It has been acknowledged that many dental professionals are time poor but 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 […]’. 11
Seeking successful outcomes
Summarising the current station, Rosseel and colleagues (2009) wrote: ‘Dentists and other members of the dental team are well placed to provide smoking cessation advice and the link between smoking and oral health problems certainly makes advising patients to quit a legitimate part of the dentist’s work.’12
As for e-cigarettes, Tatullo and colleagues (2016) offered the following advice: ‘… [the] e-cigarette represents [an] … alternative to traditional cigarettes…; however, many respectable studies suggested that the main components of e-cigarette liquids could be potentially harmful, because of the still poorly known effects of such substances on the human organism.’4
Most recently, Tomar (2019) stated: ‘In the current era of “tobacco harm reduction”, we are witnessing an increasing partnership between the transnational tobacco corporations and the research community, including some oral health researchers. Sales of electronic nicotine delivery devices are exploding although, as happened with earlier generations of novel tobacco products, the market is heavily driven by teenage consumers.’13
He concluded: ‘Oral health receives little or no attention in the discussions of tobacco product development or regulation. We urgently need research on the health effects of these new products [e-cigarettes] to catch up with their sales, while remembering that their manufacturing and marketing are increasingly controlled by the same vectors of disease as other tobacco products: the transnational tobacco corporations.’13
Gillam DG, Yusuf H. Brief motivational interviewing in dental practice. Dentistry Journal 2019; 7(51): doi: 10.3390/dj702005
11. Delivering better oral health: an evidence-based toolkit for prevention. Public Health England. Third edition, revised 2017
12. Rosseel JP et al. Summary of: What determines the provision of smoking cessation advice and counselling by dental care teams? BDJ 2009; 206(7): 376-377
13. Tomar SL. The transnational tobacco industry and oral health. Community Dental Health 2019; 36: 163-168



  1. Adult smoking habits in the UK: 2018. Office for National Statistics, July 2019

  2. RCGP Position Statement on the use of electronic nicotine vapour products (e-cigarettes), updated September 2017.

  3. Tatullo M et al. Crosstalk between oral and general health status in e-smokers. Medicine 2016; 95: 49-55

  4. Sultan AS et al. Electronic nicotine delivery systems: oral health implications and oral cancer risk. J Oral Pathol Med. 2018; 1-7

  5. Electronic cigarettes: A briefing for stop smoking services. National Centre for Smoking Cessation and Training (NCSCT) 2016. Accessed 22 July 2019

  6. Kim SA et al. Cariogenic potential of sweet flavors in electronic-cigarette liquids. PLoS One 2018; 13(9): e0203717

  7. NHS Dental Statistics. England, 2018-19 – quarter 2. NHS Digital, February 2019