Tobacco Use and Cessation

Use of tobacco is one of the leading causes of preventable illness in the U.S.;¹ smoking accounts for approximately 20% of deaths.²  Although the prevalence of cigarette smoking among U.S. adults from the years 2005 through 2015 declined from 20.9% to 15.1%, including a 1.7% reduction during 2014–2015, this is still higher than the Healthy People 2020 smoking prevalence goal of 12% or less.³ Over 36.5 million adults in the U.S. currently smoke cigarettes and disparities in smoking prevalence persist (e.g., sex, age, race/ethnicity, socioeconomic status, etc.).³ Use of smokeless tobacco (e.g., chewing tobacco or snuff) in 2014 in adults was estimated to be 3.4%, overall; however, nearly 7 in every 100 men (6.7%) reported use compared with fewer than 1 in every 100 women (0.3%).⁴

Use of tobacco-containing products has been associated with both immediate and long-term adverse oral and systemic effects.⁵  Cigarette smoking has been conclusively linked to development of cataract and pneumonia, and accounts for approximately one-third of all cancer deaths.⁶ Cigarette smoking has been linked to about 90% of all cases of lung cancer, which is the leading cause of cancer-related death in both men and women.⁶ Smoking is also associated with oral cancer; cancer of the pharynx, larynx, esophagus, stomach, pancreas, cervix, kidney, and bladder; as well as acute myeloid leukemia.⁶ In addition to cancer, smoking causes pulmonary diseases such as chronic bronchitis and emphysema, and it has been found to worsen asthma symptoms.⁶ About 90% of all deaths from chronic obstructive pulmonary diseases are attributable to cigarette smoking.⁶ It has also been shown that smoking substantially increases the risk of cardiovascular diseases, including stroke, heart attack, vascular disease, and aneurysm.⁶ Smoking causes coronary heart disease, the leading cause of death in the U.S.; cigarette smokers are 2 to 4 times more likely to develop coronary heart disease than those who do not smoke.⁶

There are more than 7,000 chemicals found in the smoke of tobacco products, including nicotine, tar, carbon monoxide, acetaldehyde, and N-nitrosamines.^{5, 6} Nicotine is the primary addicting component.⁶ Smokeless products also contain nicotine, in addition to many other toxic chemicals.⁶ By inhaling tobacco smoke, the average smoker takes in 1 to 2 mg of nicotine per cigarette.⁶ When tobacco is smoked, nicotine rapidly reaches peak levels in the bloodstream and enters the brain. If the smoke is not directly inhaled into the lungs, as with cigar and pipe smokers, or with consumption of smokeless products, nicotine is absorbed through the mucous membranes and reaches peak blood levels and the brain more slowly.⁶ Cigarette smoking produces a rapid distribution of nicotine to the brain, with drug levels peaking within 10 seconds of inhalation.⁶ However, the acute central effects of nicotine dissipate quickly, as do the associated pleasant feelings, compelling people to continue to smoke to maintain the nicotine’s pleasurable effects and prevent withdrawal.⁶

In the central nervous system, nicotine activates neural “reward” pathways that regulate feelings of pleasure.⁶ This activation is mediated through the effects of the neurotransmitter dopamine. Nicotine increases levels of dopamine in the reward circuits, which is a reaction also seen with other drugs of abuse and is thought to be the basis for the pleasurable sensations experienced by many smokers. For many tobacco users, long-term brain changes induced by continued nicotine exposure result in addiction.⁶

Systemically, nicotine stimulates the adrenal glands to release epinephrine.⁶  This epinephrine “rush” causes an increase in blood pressure, respiration, and heart rate.⁶

More than 85% of people who try to quit smoking on their own will experience relapse, most within a week of quitting.⁶ Nicotine withdrawal symptoms include irritability, craving, depression, anxiety, cognitive and attention deficits, disturbed sleep, and increased appetite. Physical symptoms may begin as soon as a few hours after the last cigarette.⁶ Withdrawal symptoms generally peak within the first few days of quitting and usually subside within a few weeks.⁶ For some people, however, symptoms may persist for months.⁶ Although withdrawal is primarily related to the pharmacologic effects of nicotine, many behavioral factors (e.g., the feel, smell, or sight of a cigarette or the ritual involved with obtaining, handling, and lighting a cigarette) are associated with the pleasurable effects of smoking and can also affect the severity of withdrawal symptoms.⁶

Although cigarettes are the most commonly used form of tobacco, other recreational tobacco formulations include conventional smokeless tobacco; newer products like “snus” (i.e., moist, pulverized compressed smokeless tobacco in a small sack) and compressed dissolvable tobacco; cigars; tobacco pipes and water pipes (i.e., hookahs); and electronic cigarettes (e-cigarettes).⁵

Cigarettes, Cigars, and Cigarillos

Cigarettes consist of finely chopped tobacco leaves rolled in a paper wrapper.⁵ Cigarettes may also contain menthol.⁷ In April 2021, FDA announced its plans to propose tobacco product standards within the next year to ban menthol as a characterizing flavor in cigarettes and ban all characterizing flavors (including menthol) in cigars.^{7, 8}

In addition to the hazards posed by direct inhalation of the smoke (discussed above), cigarettes also affect people exposed to environmental tobacco smoke exhaled during cigarette smoking or accumulated residue on nearby surfaces (i.e., “second-hand smoke”).⁹ Second-hand smoke has been linked to cancer, periodontal disease, respiratory and cardiovascular diseases, as well as adverse health effects among children and infants (e.g., exacerbation of asthma).^{9, 10}

A cigar is a roll of tobacco wrapped in tobacco leaves or other wrapper made of tobacco.^{5, 11} They vary in size—from smaller cigars, such as little filtered cigars or “cigarillos,” to larger, premium cigars. Large cigars can deliver as much as 10 times the nicotine, twice the tar, and more than 5 times the carbon monoxide of a filtered cigarette.¹¹ Little filtered cigars and cigarillos might also contain candy or fruit flavors.¹¹

Conventional Pipes, Water Pipes, or Hookah

Pipe tobacco is generally loose-leaf tobacco smoked in a traditional pipe device with a bowl.¹² Smoking tobacco from a water pipe, or “hookah,” is a form of smoking traditionally used by men in the Middle East, North Africa, and Asia, but it is growing in popularity worldwide, among both men and women.⁵ Water pipe tobacco, also known as “shisha” or “maassel,” typically consists of shredded tobacco leaves, and often with fruit, spice, or candy flavors.⁵ Although research is limited, existing evidence suggests that the adverse health effects associated with water pipe smoking are similar to those of cigarettes.⁵

Conventional and Newer Smokeless Tobacco Products

Conventional smokeless tobacco products are oral snuff and chewing tobacco.⁵ Oral snuff is finely ground tobacco that is available either as a loose product or packaged in tea-bag–like sacks. Snuff users place a small amount, referred to as a “pinch” or “dip,” between the buccal mucosa and gingiva for approximately 30 minutes. Chewing tobacco is coarsely shredded tobacco. Users place a loose-leaf tobacco “chaw,” or compressed tobacco plug, against the buccal mucosa and chew it.⁵ Both oral snuff and chewing tobacco users usually spit out the tobacco-saliva mixture that collects in the mouth; although, more addicted users may intentionally swallow it. Both oral snuff and chewing tobacco contain cancer-causing chemicals, including N-nitrosamines, aromatic hydrocarbons, formaldehyde, and polonium 210.⁵

Snus is a newer commercially available smokeless tobacco formulation product in the U.S. modeled after Swedish snus, which is a relatively low-carcinogen, high-nicotine–content oral snuff contained in small tea-bag–like sachets.⁵ Although Swedish and U.S. snus share a name and appearance, they are manufactured differently and there are differences in the amount of carcinogens and nicotine content. Dissolvable compressed tobacco is a newer smokeless tobacco product made from finely milled tobacco and is available as orbs, lozenges, sticks, and strips.^{5, 13} Some products may resemble candy or mints, toothpicks, or breath strips, and dissolve orally.^{5, 13} Both snus and dissolvable tobacco products are marketed as spitless (“dry”) products and are available in flavors, such as menthol, spice, alcohol, fruit, and candy.⁵

A nicotine-containing pouch product (trade name “Velo” [RJR Vapor Co., LLC]), which began being marketed in 2019, is classified as a tobacco product by the FDA, as it contains nicotine extracted from tobacco; however, the product contains no tobacco leaf.¹⁴

Electronic Nicotine Delivery Systems

Different forms of electronic nicotine delivery systems include electronic cigarettes (e-cigarettes); e-pipes; vaporizers (or “mods”); slim, flash-drive-shaped cartridges (also known by the name "Juuls"); and vape or hookah pens.^{5, 15, 16} E-liquids delivered by these devices typically contain nicotine, propylene or polyethylene glycol, glycerin, and additives, and are available in a wide variety of flavors.^{5, 16} The e-liquid is heated via electric current into an aerosol that the user inhales; this is also termed “vaping.”⁵ E-cigarette use exposes the lungs to a variety of chemicals, both those in contained in the e-liquid fluids, and other chemicals produced during the heating/vaporizing process.¹⁷ A study of some e-cigarette products found the vapor contains known carcinogens and toxic chemicals, as well as potentially toxic metal nanoparticles from the device itself.¹⁸

In 2019, the FDA authorized via its premarket tobacco product application (PMTA) pathway, the marketing of IQOS™ tobacco heating system (Phillip Morris Products, SA), an electronic device that heats tobacco-filled sticks wrapped in paper to generate nicotine-containing aerosol.¹⁹ The FDA placed stringent marketing restrictions on the products in an effort to prevent youth access and exposure.¹⁹

Although it has been suggested that use of e-cigarettes may be a means to assist with quitting regular cigarettes, a population-based study²⁰ showed that after 1 year, tobacco smokers who also used e-cigarettes were at increased risk for not being able to quit smoking, compared with smokers who never used e-cigarettes.

A 2018 report from the National Academies of Health found a lack of rigorously designed studies examining the effects of e-cigarettes on oral health, as well as “no epidemiological studies examining the associations between e-cigarette use and incidence or progression of periodontal disease.”²¹ The report also found that “human studies and in vitro studies suggest that e-cigarette aerosols can cause harm to oral health by inducing gingival inflammation in the oral cavity,” but that other studies suggest “that e-cigarette use may be less harmful to oral health than continued smoking of combustible tobacco cigarettes.” There is a need to better understand the health effects of vaping, and especially the impact of vaping on the oral cavity.²²

According to the U.S. Centers for Disease Control and Prevention (CDC), during 2015, 68% of adult smokers wanted to stop smoking, 55.4% had made a past-year quit attempt, 7.4% had recently quit smoking, 57.2% had been advised by a health professional to quit, and 31.2% used cessation counseling and/or medication when trying to quit.²³ The 2008 U.S. Public Health Service clinical practice guideline for treating tobacco use and dependence²⁴ found that counseling and medication are effective when used by themselves for treating tobacco dependence; however, the combination of counseling plus medication was more effective than either method alone.

Behavioral/Nonpharmacologic
According to the 2008 U.S. Public Health Service-sponsored clinical practice guideline,²⁴ individual, group, and telephone counseling are effective strategies for tobacco cessation, and their effectiveness increases with treatment intensity. Practical counseling (i.e., problem-solving/skills training) and provision of social support during treatment were two components of counseling considered especially effective.  The guideline also found evidence for the effectiveness of broad-reach telephone “quitline” counseling for diverse populations.²⁴ In the U.S., telephone counseling is available free through a system of state-based quitlines accessible with one toll-free number (1-800-QUIT-NOW [784-8669]).⁶

Cognitive behavioral therapy has been shown to improve the success rate of smokers who are ready and willing to quit.²⁵ Programs enhance motivation, bolster social support, and teach smokers to identify and manage nicotine withdrawal symptoms, cravings, and tempting situations.²⁵ Other nonpharmacologic tobacco cessation strategies with some evidence of efficacy include hypnotherapy (i.e., hypnosis) and acupuncture.²⁶

Pharmacologic
According to the CDC,²³ use of cessation medications is appropriate for most adult smokers, with the exception of pregnant women, light smokers (i.e., persons who smoke fewer than 5 to 10 cigarettes daily), and persons with specific medical contraindications (e.g., seizure disorders²). Nicotine-replacement therapy, bupropion (an atypical antidepressant), and varenicline (a selective nicotine receptor partial agonist) are first-line pharmacologic therapies to assist with smoking cessation recommended by the U.S. Department of Health and Human Services (Table).¹

A 2014 summary of 12 Cochrane reviews²⁷ looking at efficacy and harms of pharmacologic therapies for smoking cessation used network meta-analysis to make direct and indirect comparisons of efficacy between nicotine-replacement therapy, bupropion, and varenicline for smoking cessation.  The review found higher abstinence rates with nicotine-replacement therapies (17.6%) and bupropion (19.1%), compared with placebo (10.6%). Varenicline (27.6%) and combination nicotine-replacement therapies²⁵ (e.g., longer-acting patch plus short-acting inhaler, 31.5%) were most effective for achieving smoking cessation. The analysis found that none of the therapies was associated with an increased rate of serious adverse events.

Table. Pharmacotherapy for the Treatment of Tobacco Dependence^{2, 22, 25}

Drug	Formulation(s)	Adult Dosage
Nicotinic Receptor Agonists (Nicotine-Replacement Therapy)
Transdermal nicotine patches (OTC) NicoDerm CQ®,29 generics	Patch delivering 7, 14, or 21 mg per 24 hours	>10 cigarettes/day: One 21-mg patch/day X 6 weeks One 14-mg patch/day X 2 weeks One 7-mg patch/day X 2 weeks  <10 cigarettes/day (or <45 kg) One 14-mg patch/day X 6 weeks One 7-mg patch/day X 2 weeks
Intranasal nicotine spray (Rx) Nicotrol NS®30	10-mL bottles containing 10 mg/mL solution  Each 50 microliter spray contains 0.5 mg of nicotine. One dose is 1 mg of nicotine (2 sprays, one in each nostril).	Start with 1 or 2 doses per hour, which may be increased up to a maximum recommended dose of 40 mg (i.e., 80 sprays, which is somewhat less than 1/2 bottle) per day (maximum duration of therapy 3 months)
Nicotine oral inhaler (Rx) Nicotrol® Inhaler31	10-mg cartridges	6 to 12 cartridges per day X 6–12 weeks Gradual taper (if necessary) over next 6–12 weeks
Nicotine polacrilex gum (OTC) Nicorette® Gum,29 generics	2 or 4 mg per piece of gum	Smokes within 30 minutes of waking up: 4-mg gum, one piece every 1 to 2 hours X 6 weeks 4-mg gum, one piece every 2 to 4 hours X 3 weeks 4-mg gum, one piece every 4 to 8 hours X 3 weeks Smokes after 30 minutes of waking up: 2-mg gum, one piece every 1 to 2 hours X 6 weeks 2-mg gum, one piece every 2 to 4 hours X 3 weeks 2-mg gum, one piece every 4 to 8 hours X 3 weeks
Nicotine polacrilex lozenges (OTC) Nicorette® Lozenges,29 generics Nicorette® Mini Lozenges,29 generics	2 or 4 mg per lozenge or mini lozenge	Smokes within 30 minutes of waking up: One 4-mg lozenge/mini lozenge every 1 to 2 hours X 6 weeks One 4-mg lozenge/mini lozenge every 2 to 4 hours X 3 weeks One 4-mg lozenge/mini lozenge every 4 to 8 hours X 3 weeks Smokes after 30 minutes of waking up: One 2-mg lozenge/mini lozenge every 1 to 2 hours X 6 weeks One 2-mg lozenge/mini lozenge every 2 to 4 hours X 3 weeks One 2-mg lozenge/mini lozenge every 4 to 8 hours X 3 weeks
Dopaminergic-Noradrenergic Reuptake Inhibitor
Bupropion SR (Rx) Zyban®,32 generics	150 mg tablets	Treatment should be initiated before the planned quit day, while the patient is still smoking, because it takes approximately 1 week of treatment to achieve steady-state blood levels of bupropion. The patient should set a “target quit date” within the first 2 weeks of treatment with the drug. Begin dosing with one 150-mg tablet per day for 3 days. Increase dose to 300 mg per day given as one 150-mg tablet twice each day with an interval of at least 8 hours between each dose. Do not exceed 300 mg per day
Nicotinic Receptor Partial Agonist
Varenicline tartrate (Rx) Chantix®33	0.5 or 1 mg tablets	Treatment should be initiated before the planned quit day, while the patient is still smoking. The patient should set a date to stop smoking and begin varenicline dosing one week before this date. Begin dosing with 0.5 mg once daily for 3 days.  Days 4 to 7, increase dose to 0.5 mg twice daily. From day 8 through the end of treatment, dosage is 1 mg twice daily

Abbreviations: OTC: over-the-counter; Rx: prescription; SR: sustained-release

Oral Effects of Tobacco/Nicotine Use
All of the major forms of tobacco used in the U.S. have oral health consequences.³⁴ Cigarette smoking can lead to a variety of adverse oral effects, including gingival recession, impaired healing following periodontal therapy, oral cancer, mucosal lesions (e.g., oral leukoplakia, nicotine stomatitis), periodontal disease, and tooth staining.^{5, 34} Use of smokeless tobacco is associated with increased risks of oral cancer and oral mucosal lesions (e.g., oral leukoplakia).^{5, 31}  Smokeless tobacco use also causes oral conditions such as gingival keratosis, tooth discoloration, halitosis, enamel erosion, gingival recession, alveolar bone damage, periodontal disease, coronal or root-surface dental caries due to sugars added to the product, and tooth loss.⁵

In addition to its systemic effects, described previously, nicotine, especially that contained in nicotine replacement therapies, can have various local oral effects, including local burning sensation, throat irritation, dry lips, and mouth ulcers (depending on the formulation/method of administration); however, the local effects of nicotine replacement therapy are generally mild and self-limited.³⁵ Nicotine itself is not considered a direct carcinogen, but may act as a tumor promoter.^{21, 36} A 2019 systematic review of the literature examined the specific effect of nicotine on gingival, periodontal ligament, and oral epithelial cells in in vitro models.³⁷ The review found that nicotine found at levels in tobacco smoke, nicotine replacement therapy, and e-cigarettes was unlikely to be cytotoxic to oral tissues, while saliva levels with smokeless tobacco use may be potentially cytotoxic; however, data were limited and, in some cases, contradictory.³⁷

Cessation Counseling
Because of the oral health implications of tobacco use, dental practices may provide a uniquely effective setting for tobacco use recognition, prevention, and cessation.²⁴ Health-care professionals, including dental professionals, can help smokers quit by consistently identifying patients who smoke, advising them to quit, and offering them information about cessation treatment.²³ The U.S. Department of Health and Human Services and Agency for Healthcare Research and Quality has published a 5-step algorithm for health-care professionals to use when engaging patients who are dependent on nicotine called “the 5As.”³⁸ The 5 steps are as follows:

1. Ask:  Identify and document tobacco use status for every patient at every visit.
2. Advise:  In a clear, strong, and personalized manner, urge every tobacco user to quit.
3. Assess:  Is the tobacco user willing to make a quit attempt at this time?
4. Assist: For the patient willing to make a quit attempt, use counseling and pharmacotherapy to help him or her quit. 
5. Arrange:  Schedule follow-up contact, in person or by telephone, preferably within the first week after the quit date.

While there is an ADA Seal product category for tobacco cessation products, to date, no tobacco cessation products have earned the ADA Seal of Acceptance. In evaluating products for the ADA Seal of Acceptance, the Council on Scientific Affairs determines whether the product complies with its Guidelines for Participation in the ADA’s Seal of Acceptance Program and the applicable ADA Acceptance Program Product Requirement. These requirements describe the clinical, biological, and laboratory studies necessary to evaluate safety and efficacy.

Policies and Recommendations on Tobacco Use (Trans.2016:323) and Ad interim Policy on E-cigarettes and Vaping (2019). Read the ADA policy and recommendations on tobacco use and ad interim policy on e-cigarettes and vaping here.

1. Centers for Disease Control and Prevention (CDC). The health consequences of smoking – 50 years of progress: a report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Office of the Surgeon General 2014. https://www.ncbi.nlm.nih.gov/books/NBK179276/pdf/Bookshelf_NBK179276.pdf. Accessed August 20, 2021.
2. Levy JM, Abramowicz S. Medications to Assist in Tobacco Cessation for Dental Patients. Dent Clin North Am 2016;60(2):533-40.
3. Jamal A, King BA, Neff LJ, et al. Current Cigarette Smoking Among Adults - United States, 2005-2015. MMWR Morb Mortal Wkly Rep 2016;65(44):1205-11.
4. Centers for Disease Control and Prevention. Smokeless Tobacco Use in the United States. U.S. Department of Health and Human Services. https://www.cdc.gov/tobacco/data_statistics/fact_sheets/smokeless/use_us/. Accessed August 20, 2021.
5. Couch ET, Chaffee BW, Gansky SA, Walsh MM. The changing tobacco landscape: What dental professionals need to know. J Am Dent Assoc 2016;147(7):561-9.
6. National Institute on Drug Abuse. Research Report Series: Tobacco/Nicotine (NIH Publication Number 16-4342). National Institutes of Health. https://d14rmgtrwzf5a.cloudfront.net/sites/default/files/tobaccorrs_1_2016.pdf. Accessed August 20, 2021.
7. U.S. Food & Drug Administration. Menthol and other flavors in tobacco products. https://www.fda.gov/tobaccoproducts/labeling/productsingredientscomponents/ucm2019416.htm. Accessed August 20, 2021.
8. U.S. Food and Drug Administration. News Release: FDA Commits to Evidence-Based Actions Aimed at Saving Lives and Preventing Future Generations of Smokers (April 29, 2021). https://www.fda.gov/news-events/press-announcements/fda-commits-evidence-based-actions-aimed-saving-lives-and-preventing-future-generations-smokers. Accessed August 20, 2021.
9. Centers for Disease Control and Prevention. Secondhand Smoke (SHS) Facts. U.S. Department of Health and Human Services. https://www.cdc.gov/tobacco/data_statistics/fact_sheets/secondhand_smoke/general_facts/index.htm. Accessed August 20, 2021.
10. Akinkugbe AA, Slade GD, Divaris K, Poole C. Systematic Review and Meta-analysis of the Association Between Exposure to Environmental Tobacco Smoke and Periodontitis Endpoints Among Nonsmokers. Nicotine Tob Res 2016;18(11):2047-56.
11. U.S. Food & Drug Administration. Cigars, cigarillos, little filtered cigars. https://www.fda.gov/TobaccoProducts/Labeling/ProductsIngredientsComponents/ucm482562.htm. Accessed August 20, 2021.
12. U.S. Food & Drug Administration. Pipe tobacco. https://www.fda.gov/TobaccoProducts/Labeling/ProductsIngredientsComponents/ucm482580.htm. Accessed August 20, 2021.
13. U.S. Food & Drug Administration. Dissolvable tobacco products. https://www.fda.gov/TobaccoProducts/Labeling/ProductsIngredientsComponents/ucm482569.htm. Accessed August 20, 2021.
14. Tomar SL. The Transnational Tobacco Industry and Oral Health. Community Dent Health 2019;36(2):163-68.
15. Barshad A. The Juul Is Too Cool. New York Times 2018. https://www.nytimes.com/2018/04/07/style/the-juul-is-too-cool.html. Accessed August 20, 2021.
16. U.S. Food & Drug Administration. Vaporizers, e-cigarettes, and other electronic nicotine delivery systems (ENDS). https://www.fda.gov/TobaccoProducts/Labeling/ProductsIngredientsComponents/ucm456610.htm. Accessed August 20, 2021.
17. National Institute on Drug Abuse. Drug Facts:  Electronic cigarettes (E-cigarettes). National Institutes of Health. Revised January 2020. https://www.drugabuse.gov/publications/drugfacts/electronic-cigarettes-e-cigarettes. Accessed August 20, 2021.
18. Sleiman M, Logue JM, Montesinos VN, et al. Emissions from Electronic Cigarettes: Key Parameters Affecting the Release of Harmful Chemicals. Environ Sci Technol 2016;50(17):9644-51.
19. U.S. Food and Drug Administration. News Release: FDA permits sale of IQOS Tobacco Heating System through premarket tobacco product application pathway (April 30, 2019). https://www.fda.gov/news-events/press-announcements/fda-permits-sale-iqos-tobacco-heating-system-through-premarket-tobacco-product-application-pathway. Accessed August 20, 2021.
20. Al-Delaimy WK, Myers MG, Leas EC, Strong DR, Hofstetter CR. E-cigarette use in the past and quitting behavior in the future: a population-based study. Am J Public Health 2015;105(6):1213-9.
21. National Academies of Sciences Engineering and Medicine. Public Health Consequences of E-Cigarettes. Washington (DC): National Academies Press (US) Copyright 2018 by the National Academy of Sciences. All rights reserved.; 2018.
22. Kumar P, Geisinger M, DeLong HR, Lipman RD, Araujo MWB. Living under a cloud: Electronic cigarettes and the dental patient. J Am Dent Assoc 2020;15(3):155-58.
23. Babb S, Malarcher A, Schauer G, Asman K, Jamal A. Quitting Smoking Among Adults - United States, 2000-2015. MMWR Morb Mortal Wkly Rep 2017;65(52):1457-64.
24. A clinical practice guideline for treating tobacco use and dependence: 2008 update. A U.S. Public Health Service report. Am J Prev Med 2008;35(2):158-76.
25. Rigotti NA. Strategies to help a smoker who is struggling to quit. JAMA 2012;308(15):1573-80.
26. Tahiri M, Mottillo S, Joseph L, Pilote L, Eisenberg MJ. Alternative smoking cessation aids: a meta-analysis of randomized controlled trials. Am J Med 2012;125(6):576-84.
27. Cahill K, Stevens S, Lancaster T. Pharmacological treatments for smoking cessation. JAMA 2014;311(2):193-4.
28. Alpár A, Di Marzo V, Harkany T. At the tip of an iceberg: prenatal marijuana and its possible relation to neuropsychiatric outcome in the offspring. Biological psychiatry 2016;79(7):e33-e45.
29. Glaxo SmithKline. Nicotine-Replacement Therapy (NRT). https://www.gskhealthpartner.com/en-us/respiratory-health/brands/nicotine-replacement-therapy/. Accessed August 20, 2021.
30. Pfizer Inc. Nicotrol NS® (nicotine nasal spray) 10 mg/mL (undated). http://www.pfizer.com/files/products/uspi_nicotrol.pdf. Accessed August 20, 2021.
31. Pharmacia & Upjohn Co. Nicotrol Inhaler® (nicotine inhalation system) 10 mg per cartridge (August 2019). http://labeling.pfizer.com/ShowLabeling.aspx?id=633. Accessed August 20, 2021.
32. Glaxo SmithKline. Zyban® (bupropion hydrochloride) sustained-release tablets, for oral use (Rev. 6/16). https://www.accessdata.fda.gov/drugsatfda_docs/label/2016/020711s044lbl.pdf. Accessed August 20, 2021.
33. Pfizer Laboratories. Chantix® (varenicline tartrate) tablets, for oral use (Rev. 2/19). http://labeling.pfizer.com/ShowLabeling.aspx?id=557. Accessed August 20, 2021.
34. Winn DM. Tobacco use and oral disease. J Dent Educ 2001;65(4):306-12.
35. Nicotine and health. Drug Ther Bull 2014;52(7):78-81.
36. Benowitz NL. Pharmacology of nicotine: addiction, smoking-induced disease, and therapeutics. Annu Rev Pharmacol Toxicol 2009;49:57-71.
37. Holliday RS, Campbell J, Preshaw PM. Effect of nicotine on human gingival, periodontal ligament and oral epithelial cells. A systematic review of the literature. J Dent 2019;86:81-88.
38. Agency for Healthcare Research and Quality. Five Major Steps to Intervention (The "5 A's"). U.S. Department of Health and Human Services. December 2012. https://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/tobacco/5steps.html. Accessed August 20, 2021.

Professional Resources

• ADA Tobacco Use and Vaping Resources
• Oral Health Topics: Cancer (Head and Neck)
• ADA Catalog products related to tobacco use and cessation:
  • Get the Facts about Mouth and Throat Cancer (W151)
  • Tobacco and Oral Health (W190)
• ADA Library Services
• ADA Continuing Education: E-Cigarettes: What are the Facts Behind All that Vapor? (Free: 1 hour)

Patient Resources

ADA MouthHealthy.org:

• Smoking, Smokeless Tobacco
• Smoking, 5 Steps to Quit
• Smoking and Tobacco
• Smoking, Non-Cigarette Alternatives
• Waterpipes: Why Using a Hookah is Like Smoking 100 Cigarettes

JADA “For the Patient” pages:

• A Look at E-Cigarettes (March 2019)
• Knocking Tobacco Out (December 2017)
• When the Smoke Clears: Protecting the Nonsmokers In Your Life (September 2014)

Centers for Disease Control and Prevention:

• Smoking Cessation: A Report of the Surgeon General (2020)
  
• E-Cigarette Use Among Youth and Young Adults (2016) 
• Update: Interim Guidance for Health Care Providers Evaluating and Caring for Patients with Suspected E-cigarette, or Vaping, Product Use Associated Lung Injury — United States, October 2019 (October 11, 2019)
• Characteristics of a Multistate Outbreak of Lung Injury Associated with E-cigarette Use, or Vaping — United States, 2019 (September 27, 2019)

U.S. Food and Drug Administration:

• Lung Illnesses Associated with Use of Vaping Products (current as of September 26, 2019)
• Vaping Illnesses: Consumers can Help Protect Themselves by Avoiding Tetrahydrocannabinol (THC)-Containing Vaping Products (current as of September 6, 2019)
• Problems with E-Cigarettes, Vape Products, Hookah, Cigarettes or Other Tobacco Products? Tell FDA (FDA Safety Reporting Portal)

The National Academies Press: Public Health Consequences of E-Cigarettes (2018) (downloadable as a free PDF)

For Dental Professionals—Implement in-office tobacco cessation strategies

Centers for Disease Control and Prevention:

• Patient Education and In-Office Resources: Dental Professionals: Help Your Patients Quit Smoking
• Poster: Why It Matters to Dental Professionals
• Tobacco Use: Extinguishing the Epidemic
• Infographic: CDC’s Office on Smoking and Health

University-supported continuing education and office tobacco cessation interventions for healthcare professionals who are interested in incorporating nicotine dependence treatment into their practice:

• Mayo Clinic: Nicotine Dependence Education Program
• University of California at San Francisco: Smoking Cessation Leadership Center 
• University of Michigan: Clinical Care Guidelines on Smoking Cessation

USA.gov:  The Community Guide---What Works to Boost Tobacco Cessation?

For Patients—Self-help tobacco cessation tools

National Network of Tobacco Cessation Quitlines:

• 800-QUITNOW (800.784.8669) TTY 800.332.8615
• This toll-free number is a single access point to the National Network of Tobacco Cessation Quitlines. Callers can speak with a counselor to receive help with quitting smoking, informational materials and referrals to other sources. The Quitline Map of North America provides an interactive map with information available by state regarding services offered and hours of operation.

National Institute of Dental and Craniofacial Research: Smokeless Tobacco

American Lung Association: Stop Smoking

Smokefree.gov
This Website (Smokefree.gov), developed by the National Cancer Institute, Centers for Disease Control and Prevention, National Institutes of Health and others, provides information and professional assistance to help support the immediate and long-term needs of people who want to quit smoking. The site provides:

• An online step-by-step cessation guide
• A link to the national telephone quitline
• NCI's instant messaging service
• Publications, which may be downloaded, printed, or ordered

Community-based Interventions

Guide to Community Preventive Services: Tobacco Use and Control, CDC
This guide, sponsored by the Centers for Disease Control and Prevention, provides recommendations to decision makers about the types of interventions most appropriate for reducing tobacco use and exposure for different populations. Recommendations are based upon the strength of the evidence for each intervention type according to a systematic review process and are helpful to decision makers when selecting an intervention for specific groups or individuals.

Campaign for Tobacco Free Kids

Tar Wars
Tar Wars, sponsored by the American Academy of Family Physicians is designed to educate students about being tobacco-free, provide them with the tools to make positive decisions regarding their health, and promote personal responsibility for their well-being. Information on classroom presentations is available.

The Truth Initiative^®
Known previously as the “American Legacy Foundation,” this initiative was established as part of the 1998 Master Settlement Agreement between major U.S. tobacco companies and 46 U.S. states, the District of Columbia and five territories.  Truth Initiative® is America’s largest nonprofit public health organization dedicated to making tobacco use a thing of the past.  The Truth Initiative® works to spread the truth about tobacco through education, tobacco-control research and policy studies, and community activism and engagement.

FDA's Smoking Prevention Campaigns for Teens
As a regulator of tobacco products, the Food and Drug Administration (FDA) makes a strong commitment to education the public, and especially about the dangerous health effects of tobacco use.  The FDA has three youth-oriented smoking prevention campaigns that aim to save kids’ lives by helping them rethink their use of tobacco products.  "The Real Cost" campaign targets kids ages 12 to 17 who are thinking about or already experimenting with smoking.  It also targets rural youth at risk of using smokeless tobacco.  "Fresh Empire" targets underserved, multicultural populations, including African American, Hispanic, and Asian American/Pacific Islander youth. "This Free Life” campaign, which is aimed at preventing and reducing tobacco use among lesbian, gay, bisexual and transgender (LGBT) young adults who are occasional smokers. 

Center for Disease Control and Prevention "Tips From Former Smokers"
The CDC’s “Tips from Former Smokers” builds public awareness of the immediate health damage caused by smoking and exposure to secondhand smoke though stories provided by previous smokers who have suffered negative health effects from smoking.

Literature on Tobacco Use

CDC Morbidity and Mortality Weekly Report (MMWR): Consumption of Combustible and Smokeless Tobacco — United States, 2000–2015 (December 9, 2016) and Tobacco Use Among Middle and High School Students — United States, 2011–2016 (June 16, 2017)

Mayo Clinic: Smokeless Tobacco

National Cancer Institute: Tobacco (including information on quitting smoking)

U.S. Surgeon General Reports and Publications:

• E-cigarette Use Among Youth and Young Adults: A Report of the Surgeon General (2016)
• The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General (2014)

U.S. Food and Drug Administration: Tobacco Rules, Regulations, and Guidance