Since the 1964 Surgeon General’s Report on Smoking and Health linked smoking to increased risks for cardiovascular, respiratory diseases and cancer, the overall adult smoking population declined from 42% in 1964 to 17.8% in 2012. However, smoking among the younger generation is alarmingly on the rise due to the successful promotion of alternate tobacco products. The use of electronic cigarettes (e-cig), smokeless tobacco, hookah and dissolvables has phenomenally increased. Terms like “healthier,” “mild,” and “natural” are used to market these alternatives but as described below, they all have their harmful elements.
Sellers of e-cigs advertise that their devices can be utilized in tobacco reduction and subsequent cessation in which the nicotine-addicted person can replace higher nicotine concentration cartridges with cartridges containing lower and lower levels of nicotine and, eventually, the person can switch to nicotine-free cartridges. Researchers from the Roswell Park Cancer Institute analyzed the nicotine content of 32 e-cigarette cartridges and found that one out of 4 cartridges differed by more than 20% from the labeled amount. They also found nicotine in “nicotine-free” e-cigarettes. Most devices also contain other harmful ingredients including formaldehyde, a known carcinogen.
Young people perceive some popular flavored tobacco products such as “herbal” or “natural” to be safe. Clove cigarettes (kreteks) contain 60-70% tobacco, 30-40% cloves, clove oil and other additives. These tend to be less irritating because of the clove oil, this may lead to smokers inhaling deeper into the lungs. Bidi is hand-rolled tobacco and comes in different flavors. Bidis are cheaper than a pack of cigarettes, do not have filters and they concentrate the smoke increasing the amount of tar and carcinogens inhaled by the smoker and in second hand smoke. The CDC says bidi smoke contains 3-5 times more nicotine than regular cigarettes. Both kreteks and bidis contain tobacco and deliver more nicotine, tar, and carbon monoxide than regular cigarettes and carry similar health risks. Along with the known adverse health issues of tobacco use, we also know that nicotine adversely affects the development of the adolescent brain.
Shisha is used in smoking hookahs, or waterpipes. An increasing number of hookah cafés are located near college campuses in the United States and Europe, and smoking hookah has become popular among both male and female high school and college students (ages 15 to 20). When smoking hookah, shisha tobacco is roasted, smoke passes through water, and is drawn through a rubber hose to a mouthpiece. Many users believe the water filters out the toxins contained within the shisha tobacco, and therefore, hookah smoke would be less harmful to the throat and respiratory tract than cigarette smoke. However, the water does not filter out the toxins, but rather moisturizes and cools the smoke making it less harsh. Hookah smokers may inhale the moisturized, less irritating smoke deeper into the lungs for a prolonged period of time. One session of smoking hookah usually lasts an hour with smokers inhaling 100 times more smoke than those who smoke a traditional cigarette. Lung and oral cancer, as well as periodontal disease, have been linked to hookah smoking. Hookah smoking also presents the unique risk of spreading infectious diseases such as tuberculosis and hepatitis because hookah is passed from one smoker to another without proper disinfection of mouthpieces and hoses between sessions.
Dissolvable tobacco products such as tobacco orbs, sticks, and strips were introduced in limited markets around 2009. Dissolvable products may be used in smoke-free areas and many smokers started using them in conjunction with cigarette smoking, thus maintaining the habit and increasing nicotine intake. The discreet size of the products allowed young users to bring them into schools.
Swedish snus has about 50% moisture content and can deliver the same amount of nicotine as one cigarette, which is attractive to those smokers who have difficulty quitting tobacco. Unlike American smokeless tobacco, snus is placed between the cheek and upper lip. It can be used for about 30 minutes and the nicotine is absorbed through the oral mucosa without chewing. Snus is not harmless; its use can cause dental caries, irreversible oral lesions, and gingival recession in the area of placement. However, snus contains significantly lower number of nitrosamines and other carcinogenic substances than snuff due to a different processing of tobacco used in Swedish product. Snus is still highly addictive, but it is widely held to be significantly less harmful than cigarette smoking. American tobacco manufacturers introduced a few snus products, but they do not mimic Swedish snus and, in addition, these products do not go through the same tobacco pasteurization process.
The Food and Drug Administration (FDA) regulates these tobacco products and advertising but has been slow to implement regulations. Some of the research on e-cigs is still being done. To ensure the correct labeling and quality of the products, reasonable regulations of the manufacturing and content of e-cigarettes and all tobacco products should be introduced and enforced. In the meantime, alternative forms of tobacco products should be considered a health risk and not a less harmful alternative to the old fashioned cigarette.
Dr. Robert A. Gallegos is a Fellow in the Academy of General Dentistry, he is on the faculty of Spear Education, a member the American Academy of Cosmetic Dentistry, the American Academy of Dental Sleep Medicine and the American Dental Association. Dr. Gallegos practices dentistry in Middleburg, VA. www.MiddleburgSmiles.com.