Tobacco and Nicotine Products

Over the last century, up to the present, the tobacco industry has had a major impact on societal norms and health. They have convinced us that tobacco use would make us chic, calm our nerves, help us maintain a slender figure, be more attractive to the opposite sex, amongst many other things. After Surgeon General Luther Terry’s report in 1964 stated unequivocally that “Cigarette smoking is a health hazard of sufficient importance in the US to warrant remedial action” and that it was the cause of lung cancer in men, and most likely women,” the tobacco industry has tried to adapt to continue to market their products in various iterations. The purpose of this section is to review the myriad of tobacco products that are presently available to our patients and which continue to potentially compromise their oral and overall health (Table 1).

Cigarettes

The present-day cigarette has come a long way from its first ancestor; the papelote, shredded tobacco wrapped in paper, which was smoked by the poor in Spain in the 1800s. The modern-day cigarette has a filter that is made from cellulose acetate fiber, paper or activated charcoal. Below the filter is the cigarette paper and tobacco filler. The paper contains many chemicals one of which is titanium oxide, which accelerates and maintains burning. The tobacco in the cigarette is ⅓ shredded tobacco, ⅓ “reconstituted tobacco” made from a pulp of mashed tobacco stems, and other parts of the leaf which might go to waste.⁶ This mix is then impregnated with nicotine and as much as 600 chemical additives. The final third is expanded to puff tobacco, which is tobacco impregnated with Freon and/or ammonia. The ammonia increases the smoker’s ability to extract nicotine while smoking.⁶ Additionally, cigarette smoke has 7,000 chemicals with more than 70 of which can cause cancer.⁷ Despite the public’s awareness of the dangers of smoking, it is estimated that 135,720 men and women in the US will die from lung cancer in 2020, 80-90% of which will be caused by cigarette smoking. Smoking will also be the cause of one out of three of all cancer deaths, as it is known to cause cancer of the larynx, oral cavity, bladder, pancreas, cervix, kidney, stomach, blood, liver, colon, rectum and the esophagus.⁷

Thirty-two percent of all coronary heart disease deaths in the United States each year are attributable to smoking. Smoking also contributes to hypertension and stroke, with the risk of ischemic stroke nearly doubling.⁷ Smoking accounts for 11% of all stroke deaths.⁷ and will also increase the number of Americans getting diabetes, hearing loss and vision problems, chronic coughing, emphysema and bronchitis.⁷ It will exacerbate asthma in adults and also impair their immune system.⁷ The bottom line is that cigarette smoking is responsible for more than 480,000 deaths per year in the United States, including more than 41,000 deaths resulting from secondhand smoke exposure.⁷

Prevalence

Figure 1. Trends in Cigarette Smoking Rates

Figure 1. Trends in Cigarette Smoking Rates

Cigars

Higher grade cigars are made of high-quality tobacco which has been fermented and aged and used in the filler and wrapper. Low grade and machine-made cigars are composed of chopped tobacco as the filler, and the wrapper of long leaves or a paper made from tobacco pulp. Some cigars do have flavorings added. All cigar smokers, whether they inhale or not, expose their lips, tongue and throat to smoke and its toxic and cancer-causing chemicals. While many believe that cigars are not harmful because cigar smoke is not inhaled, studies have shown that some cigar smokers do inhale, thereby absorbing smoke into their lungs and bloodstream and depositing smoke particles in their lungs as well as their stomachs and digestive tract. Although cigarette use has declined in the US, the use of cigars has increased dramatically since 1993. Each year, about 9,000 Americans die prematurely from regular cigar use.^8-18

Bidis

Bidis are small, thin hand-rolled cigarettes mostly made in India and Southeast Asia. They are composed of tobacco wrapped in a tendu or temburnia leaf. Many bidis are flavored. Bidi smoking increases the risk for oral cancer, lung cancer, stomach cancer, and esophageal cancer.¹⁹

Bidis

Kreteks

Kreteks, or clove cigarettes, are imported from Indonesia and contain tobacco, cloves and other additives. Both of these products are not safe alternatives to cigarettes. Regular kretek smokers have 13 to 20 times the risk for abnormal lung function (e.g., airflow obstruction or reduced oxygen absorption) compared with nonsmokers.^19,20

Kreteks

Hookahs and Pipes

The hookah pipe (also called water pipe, shisha, goza, amongst other names) was introduced in the 1500s in the Mideast. Tobacco is heated and the smoke carrying charcoal combustion particles passes through the tobacco to water, which bubbles into a vapor that users inhale.²¹ Unfortunately, the common perception is that the water in the hookah will filter out harmful chemicals. In reality, “the smoke that passes through the water does not eliminate the hazardous, addictive chemicals released from the tobacco (Figure 2). At least 82 toxicants and carcinogens have been identified in hookah smoke, including tobacco-specific nitrosamines (TSNAs), polycyclic aromatic hydrocarbons (PAHs), and heavy metals.”^22,23 During a one-hour hookah session a person inhales as much smoke as 100 cigarettes.^22,23 According to the 2019 Youth Tobacco Survey (YTS), over 600,000 youths have used hookah in the past month, with rates of use similar in boys and girls.²⁴ The Spring 2019 National College Health Assessment found that 15.1% of undergraduates had never tried hookah and 2.1% had used it in the past month.²⁵

Hookahs and Pipes

According to the 2012-2013 Adult Tobacco Survey (ATS), 15.7% of young adults aged 18-24 who were not established cigarette smokers were hookah users, and were two times as susceptible to cigarette smoking as those who were not current hookah users.²⁶ A study of over 1,000 college students enrolled in a smoking cessation trial found that those who were dual cigarette smokers and hookah users at baseline had significantly lower odds of successfully quitting all tobacco use at 6 months.²⁷

Figure 2. Health Risks of Nicotine: Key Conclusions of the 2014 Surgeon General’s Report.

Figure 2. Health Risks of Nicotine: Key Conclusions of the 2014 Surgeon General’s Report.

Electronic Nicotine Delivery Systems (ENDS) and other Tobacco Harm Reduction Products

E-cigarettes are battery powered nicotine delivery systems that produce heated aerosol as opposed to smoke. The first non-tobacco cigarette was credited to Herbert Gilbert in 1967, with the present day e-cigarette’s credit going to Hon Lik, a Chinese pharmacist in 2004.

The intent of the e-cigarette is to create a safer and cleaner way to deliver nicotine and help cigarette smokers break their addiction to cigarettes. The liquid used in the e-cigarette is usually composed of propylene glycol and/or glycerin, nicotine ranging from 0-36 mg/ml, and up to 15,000 various flavorings and additives.²⁸ Cigarettes and most e-liquids use freebase nicotine, with freebase nicotine easily passing through the blood brain barrier. Inhaling freebase nicotine is harsh to the mouth and throat which has made it less palatable to new smokers.

In 2007 JUUL labs mixed freebase nicotine with benzoic acid creating a nicotinic salt in a biologically accepted liquid. This combination can be absorbed readily, is inhaled smoothly and delivers a 5% nicotine concentration in its pods as compared to 1-2% from its competitors. The removal of the harshness in vaping has made it easier for young people to use and become addicted to this product. In 2019 competing brands then introduced a 5% to 7% range of nicotine concentrations. The speed of the "hit" of its nicotine mimics cigarettes.²⁹

Figure 3. The speed of the “Hit” of its Nicotine Mimics Cigarettes.

Figure 3. The speed of the “Hit” of its Nicotine Mimics Cigarettes.

It is estimated that 10.8 million adults in the U.S are vaping.³⁰ According to the CDC, 2.84 million middle and high school students were current e-cigarette users in 2023.³¹ There has been great debate as to the efficacy of these products as a tobacco cessation aid as well as its safety. In addition, there is also the fear that this product may entice young people to use it, and then go on to using more dangerous tobacco products, given the sky rocketing rise in the prevalence of its use in middle and high school students. With these concerns in mind, the US Food and Drug Administration (FDA) in 2016 passed new regulations to help protect the public in this regard.

The number of electronic cigarette/e-cigarette (EC/ECs) users has been increasing rapidly, and in 2021 it was estimated that there were 82 million vapers worldwide.³² The Food and Drug Administration has not found any e-cigarette to be safe and effective in helping smokers quit. If smokers are ready to quit smoking for good, they should call 1-800 -QUITNOW or talk with their doctor about finding the best way to quit using proven methods and FDA-approved treatment and counseling .³³

E-cigarette and Vaping Associated Lung Injury (EVALI) was first noted in August 2019. Per the CDC laboratory data showed that vitamin E acetate, an additive in some THC-containing e-cigarettes, or vaping products, was strongly linked to the EVALI outbreak and was found to be related to the use of e-cigarettes. Fortunately, due to continued declines in new EVALI cases since September 2019, and the identification of vitamin E acetate as a primary cause of EVALI, the final CDC update on the number of hospitalized EVALI cases and deaths nationally was announced in February, 2020.³⁴ Hopefully, future research will help reveal the efficacy of e-cigarettes as an effective smoking cessation aid and clarify any detrimental effects on overall health as well as that on the oral cavity.

Nicotine Pouches

In 2021, 173 new nicotine pouches were released to the marketplace. Nicotine pouches are portions of nicotine in pre-packed pouches consisting of nicotine salts and are tobacco-leaf free. They range in potency between 2-8 mg of nicotine. and are placed between the upper lip and gum to release the nicotine from the pouch.

Dentists are already reporting seeing gum injuries in patients who use pouches. Nicotine pouch sales are up 700% between 2019 and 2022 especially amongst young men. Smartphones, tablets and computers are exposing vulnerable populations to influence makers marketing dangerous products to children.³⁵

Heat Not Burn Products

These systems use tobacco heated to 350 degrees Fahrenheit which is then aerosolized and inhaled into the lungs. All of these devices attempt to simulate smoking a real cigarette. Some heat specially-designed sticks, plugs, or capsules containing tobacco. Research suggests that heated tobacco products and their emissions contain many of the same harmful ingredients as regular cigarettes, as well as other harmful ingredients not present in regular cigarettes.³⁶

IQOS (HEETS)

IQOS was introduced by Phillip Morris International (PMI) in 2014 as an attempt to create a less harmful tobacco alternative to cigarettes. IQOS uses actual tobacco not combusted tobacco, with its constituents heated to 350 degrees Fahrenheit and aerosolized.³⁶ This product tries to recreate the experience of smoking just as the e-cigarette has attempted to do. It is stated that “Because the tobacco is heated and not burned, the level of harmful chemicals is significantly reduced compared to cigarette smoke”³⁶ Per the FDA, “It is important to note that these products are not safe, so people, especially young people, who do not currently use tobacco products should not start using them or any other tobacco product.”³⁷ According to the Chief Executive of PMI, it will try to launch its IQOS ILUMA in late 2024 or 2025 if it receives approval from the FDA. This product directly heats the tobacco in its TEREA tobacco sticks.

Smokeless Tobacco

It is speculated the first use of tobacco by humans was by inhaling it in powdered form through the nose thousands of years ago. ““Public health authorities including the Surgeon General and the National Cancer Institute have found that smokeless tobacco use is hazardous to one’s health and can lead to nicotine addiction.”² Smokeless tobacco contains 3,000 chemicals and at least 28 carcinogens causing oral, pancreatic and esophageal cancer. The use of smokeless tobacco is also associated with other health problems including lesions in the mouth and tooth decay.”² Unfortunately, young people are still using these products to the detriment of their health.³⁸

Snuff

Snuff is a finely ground, moist, fire-cured tobacco that is placed between the lower lip and the gums, or SNUS, the Swedish name for snuff which may have less nitrosamines and is similarly used. Nicotine is absorbed through the oral mucosa.

Snuff

Chewing Tobacco

This product comes as a loose leaf, twist or plug. Chewing tobacco is chewed or placed between the cheek and gum and left there for several hours. Nicotine is absorbed through the oral mucosa.

Chewing Tobacco

Compressed Tobacco

This form of smokeless tobacco is finely processed tobacco that can be dissolved in the mouth. This product comes in the form of sticks, strips, orbs and lozenges (not the same as those used for quitting smoking), and as they linger in the mouth can create pathologies as well. Nicotine is absorbed through the oral mucosa.