Smoking and oral health

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 verifiable CPD. To provide feedback on this article, please contact

Aims and Objectives

The aim of this article is to consider the oral health risks of smoking cigarettes and how to communicate them to patients to best effect, as well as a plan to help patients quit. On completing this CPD session, the reader will:

•Understand that smoking increases the risk of periodontal disease and oral cancer, as well as myriad other conditions within the oral cavity.

•Understand how dental professionals are in an ideal position to help patients quit smoking.

•Understand how to broach the subject with patients in a positive and effective manner.

•Understand the role of the ‘ask, act, advise’ smoking cessation model within dental practice.

•Understand the issues from an evidence-based perspective.

Smoking and oral health

This article considers the oral health risks of cigarette smoking and how to communicate them to patients to best effect, as well as a plan to help patients quit.

According to the Adult Dental Health Survey (ADHS) 2009, 22% of adults smoke.1 Detrimental to oral health, smoking increases the risk of periodontal disease and oral cancer, as well as carcinoma of the larynx, halitosis, tooth loss, implant failure, loss of taste, delayed wound healing, stained teeth and mouth sores, and increased nicotine stomatitits, candidiasis, leukoplakia, caries and calculus.2

Putting the effect of smoking on the gums into perspective, Singleton and colleagues (2014) wrote that smokers are between two and 14 times more likely to develop periodontal disease than non-smokers.2 In addition, ‘Tobacco smoking has been identified as the most important risk factor for oral cancer’, as stated by Stacey and colleagues (2006).3

Smoking cessation

Dawson and colleagues (2013) wrote: ‘The United Kingdom’s (UK) National Institute for Health and Clinical Excellence deems that brief interventions for smoking cessation are cost effective and recommends that all health professionals should refer people who smoke to an intensive support service.’4

Building on this idea, Singleton and colleagues (2014) considered that dental professionals are in an ideal position to help people quit smoking, stating: ‘Brief and simple advice from health care professionals can make a difference in tobacco quit rates. Tobacco cessation treatment has been shown to be a cost-effective intervention to increase the number of patients who quit tobacco use. Dental professionals are in a unique position to raise their patients’ awareness of the harmful effects of tobacco use, educate them about the signs and symptoms of tobacco-related oral disease, and assist them in quit¬ting at regular dental visits. Dentists and dental hygienists can show patients the visible signs of oral disease during routine dental exams.’2

Sood and her team (2014) took this idea one step further, ascertaining patients’ perceptions of the dentist’s role in smoking cessation actitivies.5 They found that: ‘Patients perceive that dentists can play an important part in smoking cessation activities. Hence, dentists should not hesitate to give smoking cessation advice to their patients and grasp this opportunity to improve the general and oral health of the community.’5

Terrades and colleagues (2009) further cemented the position of the dental professional in effectively helping patients to quit by stating: ‘…dentists are one of the health professions more frequently in contact with the general population, and there is evidence that they are as effective in providing smoking cessation counselling as any other healthcare group.’6

Planning for success

Having suggested that dental professionals are ideally placed to offer advice, there is a caveat, according to Sood and colleagues (2014): ‘Many patients feel that decision about quitting smoking is one’s personal choice. Dentist should advice once or twice and should not ask again and again if a patient quitted smoking or not. Furthermore, many feel that asking about smoking status and quitting status may be embarrassing.’5

Exploring this issue objectively, ‘Delivering better oral health: an evidence-based toolkit for prevention’ suggests the following professional intervention: ‘Ask, Advise, Act: take a history of tobacco use, give brief advice to users and signpost to local stop smoking service’.7 This has been graded as ‘I’, meaning that the concept is supported by strong evidence from at least one systematic review of multiple well-designed randomised control trial/s.7

When it comes to asking patients about their smoking, it may be prudent to enquire the following:

• Are you a smoker?

• How many cigarettes do you smoke each day?

•How soon after waking up in the morning do you have your first cigarette?

•Have you ever tried to stop smoking?

•Are you interested in stopping now?8

As for advising patients, Watt and colleagues (2003) indicated that patients who smoke should be told about the value of smoking cessation.8 They suggested that while many people know of the link to, for example, lung cancer, fewer people realise the risk to their oral health.8 The authors further propose that tailoring the information to individual patient’s needs might be effective. They wrote: ‘For example, stained teeth, halitosis and soft tissue changes in the mouth may be especially pertinent to young people. The early effects of tobacco use on the mouth are visible and reversible and may be a useful means of motivating smokers on the benefits of stopping. All smokers however will have their own good reasons for stopping.’8

Moving on to the final step – to act – guidance directs the dental team to react to the patient’s response by, for instance, building confidence, giving information and referring. The final step with this model is to refer the patient to their local smoking cessation service.9

The ‘Delivering better oral health’ toolkit has also weighed up what might be a beneficial course of action if a patient is not amenable to giving up smoking. It is considered that such patients, ‘…may wish to consider reducing how much they smoke using a licensed nicotine-containing product to help reduce smoking. The health benefits to reducing are unclear but those who use these will be more likely to stop smoking in the future.’7

Great expectations

As the World Health Organization (WHO) tells us: ‘…urgent and concerted action is required in order to reduce the disease, suffering and premature death which directly results from tobacco use.’10

The document ‘Tobacco or oral health. An advocacy guide for oral health professionals’ proposes that: ‘The dental team has a major role to play in smoking prevention. Evidence suggests that smoking cessation interventions are both effective and cost-effective. A brief intervention will often result in significant health gain and, in the long term, reduce smoking-related health-care costs to countries.’10

In line with these expectations, Terrades and colleagues (2009) wrote: ‘All patients, including smokers, have very positive attitudes and high expectations towards their dentists’ involvement in smoking cessation activities. Smokers are willing to follow their dentists’ suggestions and advice. Dentists should not hesitate to counsel their patients to stop smoking and to show them the visible effects of smoking as soon as they appear.’6



  1. Adult Dental Health Survey 2009. The Health and Social Care Information Centre 2011

  2. Singleton JA et al. Tobacco cessation treatment education for dental students using standardized patients. Journal of Dental Education 2014; 78(6): 895-905

  3. Stacey F et al. Smoking cessation as a dental intervention — views of the profession. BDJ 2009; 201(2): 109-113

  4. Dawson G et al. Models of smoking cessation brief interventions in oral health. NSW Public Health Bulletin 2013; 24(3): 131-134

  5. Sood P et al. Dental patient’s knowledge and perceptions about the effects of smoking and role of dentists in smoking cessation activities. European Journal of Dentistry 2013; 8(2): 216-223

  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(11): E22

  7. Delivering better oral health: an evidence-based toolkit for prevention. Public Health England 2014

  8. Watt RG et al. Prevention. Part 1: Smoking cessation advice within the general dental practice. BDJ 2003; 194(12): 665-668

  9. Smokefree and smiling. Helping dental patients to quit tobacco. Public Health England 2014

  10. Tobacco or oral health. An advocacy guide for oral health professionals. WHO/FDI 2005