SMOKING AND PERIODONTAL DISEASE Dr Pradeep Dr Anna Hughes Dr Tina Choo Ass Prof Leticia A. Miranda _figures/img_e16614fe651edeb1.webp) - Dr Pradeep - Dr Anna Hughes - Dr Tina Choo - Ass Prof Leticia A. Miranda Close-up photograph of a lit cigarette with smoke rising from the burning tip. The cigarette rests on dark soil or ash, set against a reflective surface showing its shadow. This image serves as a visual representation of smoking in the context of periodontal disease. SMOKING STATS & FACTS * America – 12.5 % of adults (31 M) * America – 400K or 1/5 deaths * Europe–26.4% of adults * Australia – 23% of adults (3.5M) smokers (NHS survey 2004-2005) * Now 13.6% in Australia, cost now $25+ * More Men vs women * Contributes to 1/3 of cancer deaths * in 2015, nearly 21,000 deaths in Australia were attributable directly to tobacco smoking _figures/img_b45c1c473bb26970.webp) - America – 12.5% of adults (31 M) - America – 400K or 1/5 deaths - Europe – 26.4% of adults - Australia – 23% of adults (3.5M) smokers (NHS survey 2004-2005) - Now 13.6% in Australia, cost now $25+ - More Men vs women - Contributes to 1/3 of cancer deaths - In 2015, nearly 21,000 deaths in Australia were attributable directly to tobacco smoking A photograph of retail cigarette shelves stocked with various brands including Marlboro, Camel, and Newport, displaying price tags such as '$13.00' and '$14.50'. ## **A Global Perspective** - As many as 6.25 trillion cigarettes are smoked annually across the globe.⁹⁵ - Tobacco kills 6 million people each year.¹⁴² - Only 30% of the world’s population have access to smoking cessation services.¹⁴⁴ - Only 22% of the world’s population are protected by smoke-free laws.¹⁴⁴ - As many as 6.25 trillion cigarettes are smoked annually across the globe. - Tobacco kills 6 million people each year. - Only 30% of the world's population have access to smoking cessation services. - Only 22% of the world's population are protected by smoke-free laws. **WHAT IS IN A CIGARETTE?** **Over 4000 chemicals** **Over 60 potentially toxic carcinogens:** CO, hydrogen cyanide, reactive oxidizing radicals, **nicotine**, Tar- a chemical substance that occurs when tobacco is burnt **Nicotine** is the addictive part– physical effects similar to caffeine. Stimulant, increase BP & vasoconstriction **Dangerous combination** _figures/img_8401a2c16f176d5f.webp) **Over 4000 chemicals** **Over 60 potentially toxic carcinogens:** CO, hydrogen cyanide, reactive oxidizing radicals, **nicotine**, Tar – a chemical substance that occurs when tobacco is burnt. **Nicotine** is the addictive part – physical effects similar to caffeine. Stimulant, increases BP & vasoconstriction. **Dangerous combination** Labelled diagram illustrating the contents of a cigarette. The visual shows a central vertical image of a lit cigarette with lines connecting it to various chemical names and icons on both sides. Left side labels include Hexamine (Barbecue lighter), Butane (Lighter fluid), Benzene (Petrol fumes), Nicotine (Insecticide), Carbon Monoxide, Acetic acid (Vinegar), and Methanol (Rocket fuel). Right side labels include Stearic acid (Candle wax), Amonia (Toilet cleaner), Toluene (Industrial solvent), Arsenic (Poison), Cadmium (Batteries), and Acetone (Paint stripper / Nail varnish). - Nicotine, which is an alkaloid, is found within the tobacco leaf and evaporates when the cigarette is lighted. - **It is quickly absorbed in the lungs, and it reaches the brain within 10 to 19 seconds.** - Nicotine is highly addictive. It causes a rise in blood pressure, increased heart and respiratory rates, and peripheral vasoconstriction. - Nicotine, which is an alkaloid, is found within the tobacco leaf and evaporates when the cigarette is lighted. - **It is quickly absorbed in the lungs, and it reaches the brain within 10 to 19 seconds.** - Nicotine is highly addictive. It causes a rise in blood pressure, increased heart and respiratory rates, and peripheral vasoconstriction. • Biochemical tests can also be used to assess smoking status, including exhaled carbon **monoxide** and the measurement of **cotinine** (**the major metabolite of nicotine**) in serum, saliva, or urine. • Cotinine is measured in preference to nicotine because the half-life of nicotine is short (≈1 to 2 hours), **whereas that of cotinine is approximately 20 hours**. • Plasma and **saliva cotinine** concentrations in smokers are approximately **100 ng/mL** and the **urine concentration is approximately 1200 ng/ mL**. • Nonsmokers usually have plasma and saliva cotinine concentrations of **less than 2 ng/mL**, unless they are passive smokers. - Biochemical tests can also be used to assess smoking status, including exhaled carbon **monoxide** and the measurement of **cotinine** (**the major metabolite of nicotine**) in serum, saliva, or urine. - Cotinine is measured in preference to nicotine because the half-life of nicotine is short (≈1 to 2 hours), **whereas that of cotinine is approximately 20 hours**. - Plasma and **saliva cotinine** concentrations in smokers are approximately **100 ng/mL** and the **urine concentration is approximately 1200 ng/mL**. - Nonsmokers usually have plasma and saliva cotinine concentrations of **less than 2 ng/mL**, unless they are passive smokers. <b>**TYPES OF TOBACCO**</b> - Cigarettes - Pipe smokers - Cigar smokers - Pouches - Betel nut chewing - Shisha - Snus– smokeless, available in Scan, banned in Europe; Sweden has lowest rate of tobacco-related mortality, incl lung cancer. _figures/img_82e124d313f1e522.webp) - Cigarettes - Pipe smokers - Cigar smokers - Pouches - Betel nut chewing - Shisha - Snus – smokeless, available in Scan, banned in Europe; Sweden has lowest rate of tobacco-related mortality, incl lung cancer. Photograph illustrating various tobacco products and paraphernalia. The image displays a wooden cigar humidor filled with cigars, a bundle of cigarettes (some white filters, some orange), a brown smoking pipe resting on loose shredded tobacco leaves, and a pile of loose tobacco leaf. # TYPES OF TOBACCO There is no safe way to use tobacco. Whether inhaled, sniffed, sucked, chewed, mixed with other ingredients or harmful chemicals added, tobacco is harmful in all its forms. ### SMOKELESS TOBACCO Consumed orally or nasally, without combustion (burning). There are two main types, snuff and chewing tobacco. **DRY SNUFF** Powdered tobacco inhaled through the nose or taken orally. Widespread use of dry snuff has declined. MOST USED: EUROPE **MOIST SNUFF** Ground tobacco held in the mouth between the cheek and gum. Some moist snuff is wrapped into small paper or cloth packets. Other moist snuff products are known as khaini, nawa, shamman. MOST USED: WORLDWIDE **CHEWING TOBACCO** Oral smokeless tobacco or tobacco pastes are placed in the mouth, chew or inner lip and sucked (dipped) or chewed. Also known as spit tobacco because users spit out saliva and tobacco juices. Other versions of smokeless tobacco include: plug, loose leaf, khaini, maras, gutka, and twist. **Paan masala** or betel quid consists of tobacco, areca nuts, catechu, slaked lime (calcium hydroxide), sweeteners and flavouring wrapped in a betel leaf. Paan masala includes: kadhipudi, hogeryale, gundi, kaddipudi, zarda, gutkha, krawm and mawa. MOST USED: ASIA, EUROPE ### SMOKING TOBACCO Tobacco smoking involves burning dried or cured leaves of tobacco plants and inhaling the smoke. Combustion releases active compounds in tobacco such as nicotine and nitrosamines which are absorbed through the lungs. **MANUFACTURED CIGARETTES** The most commonly used tobacco product. They consist of shredded or reconstituted tobacco, processed with hundreds of chemicals and additives and rolled into paper covered tipping and with a cellulose acetate filter, that is lit at one end and the smoke is inhaled. MOST USED: WORLDWIDE **ROLL YOUR OWN** Roll-your-own (RYO) cigarettes are hand-filled from fine-cut, loose tobacco rolled in a cigarette paper. RYO smokers inhale high concentrations of tar, nicotine and nitrosamines and are at increased risk of cancers of the mouth, throat and lung. MOST USED: EUROPE, AND NEW ZEALAND **BIDIS** Sun-dried, flaked tobacco, hand-wrapped in dried tendu (or temburni) leaf and tied with string. More tar and carbon monoxide is delivered by bidi smokers as they puff harder to keep bidis lit. The most used smoked tobacco product in India. MOST USED: SOUTH ASIA **CIGARS** Made of air-cured and fermented tobacco in a tobacco leaf wrapper. The aging and fermentation produces higher levels of cancer-causers. Cigars come in many sizes, including cigarillos, blunts, cheroots, and stumpen. Cheroots and shunnas are cigars where both ends are clipped. MOST USED: WORLDWIDE **PIPES** Made of briar, clay, or other substances. Tobacco is placed in the bowl, lit and the smoke is inhaled through the stem. In Southeast Asia, clay pipes known as sullpa, chillum, and hookis are widely used. MOST USED: WORLDWIDE **WATER PIPES** Also known as shisha, hookah, narghile, or hubble-bubble. Flavoured tobacco is burned in a smoking bowl covered with foil and coal. The smoke is cooled by filtration through a basin of water and consumed through a hose and mouthpiece. MOST USED: NORTH AFRICA, ASIA, RUSSIA, EUROPE *** **Fig. 2.1.2.** Examples of smokeless tobacco products, by country or region: South-East Asia: kiwam, zarda, gutka; USA: moist snuff, dry snuff, moist snuff (caffeinated), plug, twist tobaccos, dissolvables (orbs, strips, sticks, tobacco-coated toothpicks); Sweden: snus (pouch); Venezuela: chimó; Uzbekistan: nasway; Sudan: toombak; India: red toothpowder, mawa; Saudi Arabia: shammah; Brazil: rapé. _figures/img_860dc90a2b3c4af8.webp) _figures/img_87863fe68ddd781c.webp) There is no safe way to use tobacco. Whether inhaled, sniffed, sucked, chewed, mixed with other ingredients or harmful chemicals added, tobacco is harmful in all its forms. #### Smokeless Tobacco Consumed orally or nasally, without combustion (burning). There are two main types, snuff and chewing tobacco. **Dry Snuff** Powdered tobacco inhaled through the nose or taken orally. Widespread use of dry snuff has declined. MOST USED: EUROPE **Moist Snuff** Ground tobacco held in the mouth between the cheek and gum. Some moist snuff is wrapped into small paper or cloth packets. Other moist snuff products are known as khaini, nawa, shamman. MOST USED: WORLDWIDE **Chewing Tobacco** Oral smokeless tobacco or tobacco pastes are placed in the mouth, chew or inner lip and sucked (dipped) or chewed. Also known as spit tobacco because users spit out saliva and tobacco juices. Other versions of smokeless tobacco include: plug, loose leaf, khaini, maras, gutka, and twist. **Paan masala** or betel quid consists of tobacco, areca nuts, catechu, slaked lime (calcium hydroxide), sweeteners and flavouring wrapped in a betel leaf. Paan masala includes: kadhipudi, hogeryale, gundi, kaddipudi, zarda, gutkha, krawm and mawa. MOST USED: ASIA, EUROPE #### Smoking Tobacco Tobacco smoking involves burning dried or cured leaves of tobacco plants and inhaling the smoke. Combustion releases active compounds in tobacco such as nicotine and nitrosamines which are absorbed through the lungs. **Manufactured Cigarettes** The most commonly used tobacco product. They consist of shredded or reconstituted tobacco, processed with hundreds of chemicals and additives and rolled into paper covered tipping and with a cellulose acetate filter, that is lit at one end and the smoke is inhaled. MOST USED: WORLDWIDE **Roll Your Own** Roll-your-own (RYO) cigarettes are hand-filled from fine-cut, loose tobacco rolled in a cigarette paper. RYO smokers inhale high concentrations of tar, nicotine and nitrosamines and are at increased risk of cancers of the mouth, throat and lung. MOST USED: EUROPE, AND NEW ZEALAND **Bidis** Sun-dried, flaked tobacco, hand-wrapped in dried tendu (or temburni) leaf and tied with string. More tar and carbon monoxide is delivered by bidi smokers as they puff harder to keep bidis lit. The most used smoked tobacco product in India. MOST USED: SOUTH ASIA **Cigars** Made of air-cured and fermented tobacco in a tobacco leaf wrapper. The aging and fermentation produces higher levels of cancer-causers. Cigars come in many sizes, including cigarillos, blunts, cheroots, and stumpen. Cheroots and shunnas are cigars where both ends are clipped. MOST USED: WORLDWIDE **Pipes** Made of briar, clay, or other substances. Tobacco is placed in the bowl, lit and the smoke is inhaled through the stem. In Southeast Asia, clay pipes known as sullpa, chillum, and hookis are widely used. MOST USED: WORLDWIDE **Water Pipes** Also known as shisha, hookah, narghile, or hubble-bubble. Flavoured tobacco is burned in a smoking bowl covered with foil and coal. The smoke is cooled by filtration through a basin of water and consumed through a hose and mouthpiece. MOST USED: NORTH AFRICA, ASIA, RUSSIA, EUROPE *** **Fig. 2.1.2.** Examples of smokeless tobacco products, by country or region: South-East Asia: kiwam, zarda, gutka; USA: moist snuff, dry snuff, moist snuff (caffeinated), plug, twist tobaccos, dissolvables (orbs, strips, sticks, tobacco-coated toothpicks); Sweden: snus (pouch); Venezuela: chimó; Uzbekistan: nasway; Sudan: toombak; India: red toothpowder, mawa; Saudi Arabia: shammah; Brazil: rapé. Informational diagram titled 'TYPES OF TOBACCO' divided into two main sections: 'SMOKELESS TOBACCO' and 'SMOKING TOBACCO'. The Smokeless section details Dry Snuff, Moist Snuff, and Chewing Tobacco with corresponding images. The Smoking section details Manufactured Cigarettes, Roll Your Own, Bidis, Cigars, Pipes, and Water Pipes with corresponding images. Figure displaying examples of smokeless tobacco products from various countries and regions. Images include Kiwam, Zarda, Gutka, Moist snuff, Dry snuff, Snus, Chimó, Moist snuff (caffeinated), Plug, Nasway, Toombak, Twist, Red toothpowder, Shammah, Orbs, Strips, Sticks, Tobacco-coated toothpicks, Mawa, and Rapé. The use of tobacco is associated with a range of different diseases, contributing to the burden of nine disease groups. Below are the estimated percentages of the burden attributable to tobacco use for different disease groups, in 201516: - 41% of respiratory diseases - 22% of cancers - 12% of cardiovascular diseases - 7% of infections - 4% of endocrine disorders The use of tobacco is associated with a range of different diseases, contributing to the burden of nine disease groups. Below are the estimated percentages of the burden attributable to tobacco use for different disease groups, in 2015-16: - 41% of respiratory diseases - 22% of cancers - 12% of cardiovascular diseases - 7% of infections - 4% of endocrine disorders **Biological plausibility** THE UNIVERSITY OF WESTERN AUSTRALIA **Effect on host** LOCAL and SYSTEMIC * Temperature and gases effect * Vasoconstriction * Microvasculature * Fibroblast function * Neutrophils * Cytokines * IgG reduced * Adhesion molecules _figures/img_49405a1026fdc9f6.webp) #### Biological Plausibility **Effect on host** **Local and Systemic** - Temperature and gases effect - Vasoconstriction - Microvasculature - Fibroblast function - Neutrophils - Cytokines - IgG reduced - Adhesion molecules Microscopic image showing fibroblast cells or tissue structure relevant to 'Fibroblast function' listed in the bullet points. The image displays elongated cellular structures typical of connective tissue cells under magnification. # DOES SMOKING INCREASE THE RISK FOR GUM DISEASE? * **Previous epidemiological studies – smoking is a significant risk factor for the development of periodontal diseases** * Smokers have deeper PD, more deep pockets, more gingival recession, bone loss, more teeth with furcation involvement, more tooth loss, less gingivitis & less BOP * **Smokers & Former smokers have more periodontitis than NS** * **40% of Chronic Periodontitis cases may be due to smoking** * Link between passive smoking and periodontitis _figures/img_7512cd5e20208778.webp) - Previous epidemiological studies – smoking is a significant risk factor for the development of periodontal diseases - Smokers have deeper PD, more deep pockets, more gingival recession, bone loss, more teeth with furcation involvement, more tooth loss, less gingivitis & less BOP - Smokers & Former smokers have more periodontitis than NS - 40% of Chronic Periodontitis cases may be due to smoking - Link between passive smoking and periodontitis Clinical intraoral photograph showing severe periodontal disease. The image displays significant gingival recession exposing the roots of the teeth. There is visible calculus (tartar) accumulation and generalized tooth discoloration. The gums appear inflamed and there are multiple missing teeth with gaps in the dental arch. # DOES SMOKING INCREASE THE RISK FOR GUM DISEASE? - Effect is dose dependent: daily use, quantity & duration - Require a certain level of tobacco use - **OR for severe attachment loss:** - **OR 2 light smokers vs NS** - **OR 4.75 in heavy smokers vs NS** \* **Light (<10cigs/day)** \* **Heavy (>30 cigs/day)** _figures/img_03c1ab6a5b297635.webp) - Effect is dose dependent: daily use, quantity & duration - Require a certain level of tobacco use - **OR for severe attachment loss:** - OR 2 light smokers vs NS - OR 4.75 in heavy smokers vs NS - Light (<10 cigs/day) - Heavy (>30 cigs/day) Photo showing two men in an outdoor setting. The man on the left is wearing a black visor with white fur trim and a black shirt; he has a large cluster of lit cigarettes or incense sticks inserted into his mouth. The man on the right is wearing glasses and a blue t-shirt with the text 'SABIAN' visible. He is holding a black torch-like device pointing towards the cigarettes in the other man's mouth, which are emitting smoke. A watermark at the bottom reads '©THEWIZARDOFODDTV.COM'. This image serves as a humorous visual metaphor for the concept of smoking discussed in the slide. HOW DOES SMOKING INCREASE THE RISK FOR GUM DISEASE? - Previously believed it was due to more plaque formation --> more severe periodontitis - Current data suggest not _figures/img_fff4a30f5e5afde2.webp) _figures/img_0ab5de1c2ecd5e36.webp) - Previously believed it was due to more plaque formation → more severe periodontitis - Current data suggest not Clinical photo showing a close-up of a man's mouth while smoking. The image demonstrates significant dental pathology consistent with the topic 'gum disease,' including severe staining and what appears to be periodontal damage on the visible teeth. Clinical photo displaying an anterior view of upper teeth exhibiting heavy yellow-brown extrinsic staining (likely tobacco-related) and inflamed gingival tissue. This visual supports the context of how smoking affects oral health despite not necessarily increasing plaque formation. SMOKERS vs NON SMOKERS In general, smokers present: - Increased amounts of plaque and calculus (Bergstrom et al 1986 e 2005) - **LESS** gingivitis and **LESS** BOP (**Haffajee et al 2001**) - Deeper probing depths and increased number of sites with deeper probing depths (**Bergstrom et al 2000**) - More attachment loss & recession (**Haffajee et al 2001**) - More alveolar bone loss (Grossi et al 1995) - More tooth loss **Krall et al 1997**) - More furcation involved teeth (**Mullaly et al 1996**) #### Smokers vs Non-Smokers In general, smokers present: - Increased amounts of plaque and calculus (Bergstrom et al 1986 e 2005) - **LESS** gingivitis and **LESS** BOP (**Haffajee et al 2001**) - Deeper probing depths and increased number of sites with deeper probing depths (**Bergstrom et al 2000**) - More attachment loss & recession (**Haffajee et al 2001**) - More alveolar bone loss (Grossi et al 1995) - More tooth loss (**Krall et al 1997**) - More furcation involved teeth (**Mullaly et al 1996**) The logo for University of Western Australia is visible in the top right corner. HOW DOES SMOKING INCREASE THE RISK FOR GUM DISEASE? **Effect on Oral Flora Bacteria** * Tobacco smoke contains carbon monoxide (CO) * CO lowers O2 – **favour growth of anaerobic bacteria**, even in shallower pockets <5mm * **Favorable habitat for periopathogens (Aa, Pg)** * Maxillary teeth, upper & lower incisors. Palatal areas * Some studies show no difference -inconsistent data on how smoking affects periodontal microbiome _figures/img_ecf39597c672361d.webp) #### Effect on Oral Flora Bacteria - Tobacco smoke contains carbon monoxide (CO) - CO lowers O₂ – **favour growth of anaerobic bacteria**, even in shallower pockets <5mm - **Favorable habitat for periopathogens (Aa, Pg)** - Maxillary teeth, upper & lower incisors. Palatal areas - Some studies show no difference – inconsistent data on how smoking affects periodontal microbiome Clinical photo: A close-up of a person smoking a cigarette. The image visually supports the slide's context regarding tobacco smoke and its effects on oral health. • On average, **smokers** were **four times** as likely to have periodontitis as compared with never smokers after adjusting for age, gender, race/ethnicity, education, and income/poverty ratio. • **Former smokers** were **1.7 times** more likely to have periodontitis than persons who had never smoked. • This study also demonstrated a dose-response relationship between cigarettes smoked per day and the odds of having periodontitis. • In subjects **smoking 9 or fewer cigarettes** per day, the odds of having periodontitis were **2.8**, whereas subjects who **smoked 31 or more cigarettes per day** were **almost six times** more likely to have periodontitis. • In **former smokers**, the odds of having periodontitis **declined** with the number of years since quitting - On average, **smokers** were **four times** as likely to have periodontitis as compared with never smokers after adjusting for age, gender, race/ethnicity, education, and income/poverty ratio. - **Former smokers** were **1.7 times** more likely to have periodontitis than persons who had never smoked. - This study also demonstrated a dose-response relationship between cigarettes smoked per day and the odds of having periodontitis. - In subjects **smoking 9 or fewer cigarettes** per day, the odds of having periodontitis were **2.8**, whereas subjects who **smoked 31 or more cigarettes** per day were **almost six times** more likely to have periodontitis. - In **former smokers**, the odds of having periodontitis **declined** with the number of years since quitting WHY DOES SMOKING INCREASE THE RISK FOR GUM DISEASE? **Effect on gingival blood vessels** • Less redness & BOP • Dose dependent • Nicotine – Vasoconstrictive • Fewer blood vessels _figures/img_1cd0f8858314794e.webp) #### Effect on gingival blood vessels - Less redness & BOP - Dose dependent - Nicotine – Vasoconstrictive - Fewer blood vessels Clinical photo of a human mouth showing severe periodontal disease. The image displays the upper and lower anterior teeth with significant brown calculus (tartar) deposits along the gumline. The gingival tissue appears inflamed and swollen, consistent with the context of smoking-related gum disease described in the slide text. **THE UNIVERSITY OF WESTERN A** (a) Clinical appearance in smoker * Fibrotic 'tight' gingiva, rolled margins * Less gingival redness and bleeding * More severe, widespread disease than same age non-smoking control * Anterior, maxilla, palate are worst areas affected * Anterior recession, open embrasures * Nicotine staining * Calculus (b) Clinical characteristics of smoker * Relatively earlier onset * Rapid disease progression * Greater severity and extent of disease (pockets, clinical attachment loss, bone loss) * More tooth loss * Poorer response to non-surgical therapy * Recurrence within 1 year of surgery - ?avoid surgery * Increased % are refractory to treatment **Less gingivitis and BOP** - Bleeding index non-compatible with amounts of plaque and calculus - Reduced bleeding due to vasoconstriction and reduced number of vessels in the gingiva of smokers - Fibrotic gingiva with less edema _figures/img_92c671038c97365b.webp) _figures/img_70ab10ab80213ab3.webp) #### Clinical appearance in smoker - Fibrotic 'tight' gingiva, rolled margins - Less gingival redness and bleeding - More severe, widespread disease than same age non-smoking control - Anterior, maxilla, palate are worst areas affected - Anterior recession, open embrasures - Nicotine staining - Calculus #### Clinical characteristics of smoker - Relatively earlier onset - Rapid disease progression - Greater severity and extent of disease (pockets, clinical attachment loss, bone loss) - More tooth loss - Poorer response to non-surgical therapy - Recurrence within 1 year of surgery – ?avoid surgery - Increased % are refractory to treatment #### Less gingivitis and BOP - Bleeding index non-compatible with amounts of plaque and calculus - Reduced bleeding due to vasoconstriction and reduced number of vessels in the gingiva of smokers - Fibrotic gingiva with less edema Two-column text box labeled as Figure 36.2 summarizing details for smokers. Left column (a) lists 'Clinical appearance in smoker' including fibrotic gingiva, less redness/bleeding, severe disease, anterior recession, nicotine staining, and calculus. Right column (b) lists 'Clinical characteristics of smoker' including earlier onset, rapid progression, greater severity/tooth loss, poor response to therapy, recurrence, and refractory treatment. Split-view clinical photograph showing the effects of smoking on periodontal health. Left panel (a) shows anterior teeth with heavy plaque/calculus accumulation and dark discoloration. Right panel (b) shows a view of the posterior dentition revealing significant brownish-black tobacco staining on the tooth surfaces and adjacent gingival tissue. **Fig. 11-8**. Clinical appearance of a 53-year-old male patient who reports smoking one pack a day for 35 years. (a) Anterior view; (b) palatal view of the maxillary anterior teeth, and (c) lingual view of the mandibular anterior teeth. Note the heavy staining. Periodontal examination revealed probing depths of up to 9 mm, gingival recessions, and furcation involvements at all molars. (Source: Courtesy of Dr. Matthew Hickin.) **Fig. 11-9**. Same patient as in Fig. 11-8. (a, b) Maxillary left buccal and palatal views and (c) corresponding radiograph; (d, e) mandibular left buccal and lingual views and (f) corresponding radiograph. Heavy staining and advanced bone loss are apparent. (Source: Courtesy of Dr. Matthew Hickin.) (a) (b) (c) (a) (b) (c) (d) (e) (f) H1 20 _figures/img_b5bd09e3416797ab.webp) _figures/img_05e1a294a732432e.webp) **Fig. 11-8.** Clinical appearance of a 53-year-old male patient who reports smoking one pack a day for 35 years. (a) Anterior view; (b) palatal view of the maxillary anterior teeth, and (c) lingual view of the mandibular anterior teeth. Note the heavy staining. Periodontal examination revealed probing depths of up to 9 mm, gingival recessions, and furcation involvements at all molars. (Source: Courtesy of Dr. Matthew Hickin.) **Fig. 11-9.** Same patient as in Fig. 11-8. (a, b) Maxillary left buccal and palatal views and (c) corresponding radiograph; (d, e) mandibular left buccal and lingual views and (f) corresponding radiograph. Heavy staining and advanced bone loss are apparent. (Source: Courtesy of Dr. Matthew Hickin.) Clinical photograph showing three views of a patient's dentition: (a) anterior view revealing heavy extrinsic staining on upper and lower front teeth; (b) palatal view of maxillary anterior teeth with dark brown/black calculus deposits; (c) lingual view of mandibular anterior teeth also exhibiting severe staining. These images demonstrate advanced periodontal disease indicators such as heavy plaque/calculus accumulation. Composite figure combining clinical photos and radiographs of the same patient: (a) maxillary left buccal view showing stained molars; (b) maxillary left palatal view with heavy calculus; (c) periapical radiograph of maxillary left posterior teeth showing reduced alveolar bone height; (d) mandibular left buccal view with stained molars; (e) mandibular left lingual view with heavy calculus; (f) periapical radiograph of mandibular left posterior teeth showing significant horizontal bone loss around roots. The combination of clinical and radiographic views demonstrates both surface staining and underlying periodontal destruction. **WHY DOES SMOKING INCREASE THE RISK FOR GUM DISEASE?** **Effect on host response - both innate and immune response affected** * Effect depend on duration & dose * Impaired healing response & enhanced destruction * Less neutrophils (PMNs) migrate into GCF& pocket * Nicotine - PMNs produce more MMPs, impaired phagocytosis & chemotaxis * PMNs - more inflammatory mediators released in response to bacteria * Reduced fibroblast proliferation, migration, matrix production & attachment to root surface * B cell function impaired - reduced levels of antibodies produced #### Effect on host response – both innate and immune response affected - Effect depends on duration & dose - Impaired healing response & enhanced destruction - Less neutrophils (PMNs) migrate into GCF & pocket - Nicotine – PMNs produce more MMPs, impaired phagocytosis & chemotaxis - PMNs – more inflammatory mediators released in response to bacteria - Reduced fibroblast proliferation, migration, matrix production & attachment to root surface - B cell function impaired – reduced levels of antibodies produced <table> <thead> <tr> <th colspan="2"> <!-- --> </th> </tr> </thead> <tbody> <tr> <td colspan="2"><strong>TABLE 23.1</strong> Effects of Smoking on Gingivitis and Periodontitis</td> </tr> <tr> <th colspan="2"> <!-- --> </th> </tr> <tr> <td>Gingivitis</td> <td><span style="text-indent:-2.75em">↓</span>Gingival inflammation and bleeding on probing</td> </tr> <tr> <td>Periodontitis</td> <td><span style="text-indent:-2.75em">↑</span>Prevalence and severity of periodontal destruction</td> </tr> <tr> <td rowspan="8"></td> <td><span style="text-indent:-2.75em">↑</span>Pocket depth, attachment loss, and bone loss</td> </tr> <tr> <td rowspan="2"><span style="text-indent:-2.75em">↑</span>Rate of periodontal destruction</td> </tr> <tr> <td><span style="text-indent:-2.75em">↑</span>Prevalence of severe periodontitis</td> </tr> <tr> <td><span style="text-indent:-2.75em">↑</span>Tooth loss</td> </tr> <tr> <td rowspan="2"><span style="text-indent:-2.75em">↑</span>Prevalence with increased number of cigarettes smoked per day</td> </tr> <tr> <td><span style="text-indent:-2.75em">↓</span>Prevalence and severity with smoking cessation</td> </tr> </tbody> </table> <tiny-object> Directed.decreased: ↑increased </tiny-object> _figures/img_1bdef08b1bc1a1ab.webp) | | Effects of Smoking on Gingivitis and Periodontitis | |:--------------------------------|:---------------------------------------------------| | **Gingivitis** | ↓ Gingival inflammation and bleeding on probing | | **Periodontitis** | ↑ Prevalence and severity of periodontal destruction | | | ↑ Pocket depth, attachment loss, and bone loss | | | ↑ Rate of periodontal destruction | | | ↑ Prevalence of severe periodontitis | | | ↑ Tooth loss | | | ↑ Prevalence with increased number of cigarettes smoked per day | | | ↓ Prevalence and severity with smoking cessation | *Note: ↓ decreased; ↑ increased* Table titled 'Effects of Smoking on Gingivitis and Periodontitis' with columns for 'Periodontal Disease' and 'Effects of Smoking'. It lists two main diseases: Gingivitis and Periodontitis. For Gingivitis, it shows decreased gingival inflammation and bleeding on probing. For Periodontitis, it details increased prevalence and severity of periodontal destruction, pocket depth, attachment loss, bone loss, rate of periodontal destruction, prevalence of severe periodontitis, tooth loss, and prevalence with increased smoking. It also notes decreased prevalence and severity with smoking cessation. A legend at the bottom explains that ↓ means decreased and ↑ means increased. <table> <thead> <tr> <th colspan="2"> <b> TABLE 23.3 </b> Effects of Smoking on the Etiology and Pathogenesis of Periodontal Disease </th> </tr> <tr> <th> Etiologic Factor </th> <th> Effects of Smoking </th> </tr> </thead> <tbody> <tr> <td> Microbiology </td> <td> Increased complexity of the microbiome and colonization of periodontal pockets by periodontal pathogens </td> </tr> <tr> <td rowspan="4"> Immune— inflammatory response </td> <td> Altered neutrophil chemotaxis, phagocytosis, and oxidative burst </td> </tr> <tr> <td> ↑ Tumor necrosis factor-α and prostaglandin <sub> 2 </sub> enin gingival crevicular fluid </td> </tr> <tr> <td> ↑ Neutrophil collagenaseand elastase in gingival crevicular fluid </td> </tr> <tr> <td> ↑ Production of prostaglandin <sub> 2 </sub> by monocytes in response to lipopolysaccharide </td> </tr> <tr> <td rowspan="4"> Physiology </td> <td> ↓ Gingival blood vessels with ↑ inflammation </td> </tr> <tr> <td> ↓ Gingival crevicular fluid flowand bleeding on probing with ↑ inflammation </td> </tr> <tr> <td> ↓ Subgingival temperature </td> </tr> <tr> <td> ↑ Time needed to recover from local anesthesia </td> </tr> <tr> <td colspan="2"> ↓, Decreased; ↑, increased. </td> </tr> </tbody> </table> _figures/img_5b0b7c3b5e6656dc.webp) | Etiologic Factor | Effects of Smoking | |:-------------------------------|:-------------------------------------------------------------------------| | **Microbiology** | Increased complexity of the microbiome and colonization of periodontal pockets by periodontal pathogens | | **Immune-inflammatory response** | Altered neutrophil chemotaxis, phagocytosis, and oxidative burst | | | ↑ Tumor necrosis factor-α and prostaglandin E₂ in gingival crevicular fluid | | | ↑ Neutrophil collagenase and elastase in gingival crevicular fluid | | | ↑ Production of prostaglandin E₂ by monocytes in response to lipopolysaccharide | | **Physiology** | ↓ Gingival blood vessels with ↑ inflammation | | | ↓ Gingival crevicular fluid flow and bleeding on probing with ↑ inflammation | | | ↓ Subgingival temperature | | | ↑ Time needed to recover from local anesthesia | *Note: ↓ decreased; ↑ increased* A structured table summarizing the effects of smoking on periodontal disease across three categories: Microbiology (increased complexity of microbiome), Immune-inflammatory response (altered neutrophil function and increased inflammatory markers like TNF-α and prostaglandin E₂), and Physiology (reduced gingival blood vessels and fluid flow but increased inflammation). The table includes a legend at the bottom indicating '↓' for decreased and '↑' for increased values. <form> <table border="1" rules="rows"> <tr> <td rowspan="4"></td> <td>SMOKING</td> <td rowspan="4"></td> </tr> <tr> <td>Local</td> <td>Systemic</td> </tr> <tr> <td>Peripheral vasoconstriction</td> <td>Decreased immunity</td> </tr> <tr> <td>local ischemia</td> <td>↓PMN chemotaxis/</td> </tr> <tr> <td rowspan="2"></td> <td>Phagocytosis</td> <td>↓IgG, IgA</td> </tr> <tr> <th rowspan="2">↑Pathogenic organisms</th> <th rowspan="2">↑Oxidant stress</th> </tr> <tr> <td>P. gingivalis</td> <td></td> </tr> <tr> <td>T. forsythia</td> <td></td> </tr> <tr> <td colspan="2"></td> <td>Activation of</td> </tr> <tr> <td colspan="2"></td> <td>inflammatory cascade</td> </tr> <tr> <td colspan="2"></td> <td>TNF-α, IL-6, IL-1β</td> </tr> <tr> <td colspan="3">PERIODONTAL</td> </tr> <tr> <td colspan="3">DISEASES</td> </tr> </table> </form> _figures/img_bd26a3d1c6365758.webp) #### Smoking | | Local | Systemic | |:--------|:-----------------------------|:-----------------------------| | | Peripheral vasoconstriction | Decreased immunity | | | Local ischemia | ↓ PMN chemotaxis / phagocytosis / ↓ IgG, IgA | | | ↑ Pathogenic organisms | ↑ Oxidant stress | | | *P. gingivalis* | | | | *T. forsythia* | | | | | Activation of inflammatory cascade | | | | TNF-α, IL-6, IL-1β | | | **PERIODONTAL DISEASES** | | *Note: ↓ decreased; ↑ increased* Flowchart diagram illustrating the pathogenesis of periodontal diseases associated with smoking. The flow starts at 'SMOKING' and branches into 'Local' and 'Systemic' pathways. Local pathway leads to 'Peripheral vasoconstriction local ischemia', which increases 'Pathogenic organisms (P. gingivalis, T. forsythia)'. Systemic pathway leads to 'Decreased immunity', affecting 'PMN chemotaxis/phagocytosis' and 'IgG, IgA', resulting in 'Oxidant stress'. Both pathways converge on 'Activation of inflammatory cascade (TNF-α, IL-6, IL-1β)', ultimately leading to 'PERIODONTAL DISEASES'. Arrows indicate causal relationships between factors. **HOW DOES SMOKING AFFECT PERIODONTAL TREATMENT** * **Bold Less favorable response** to any kind of periodontal treatment * Pre-Tx clinical assessment: underestimate PD as gum is less swollen & more fibrosis - more resistant to probing (tight) vs NS * **Bold Post-Tx SRP/SRD:** less PD reduction & less attachment gain (avg 0.5mm) * Root surface contaminated by smoking products – may affect attachment of cells * >10 cigs/day = heavy smoking * Tooth loss? – Lack long-term studies - **Less favorable response** to any kind of periodontal treatment - Pre-Tx clinical assessment: underestimate PD as gum is less swollen & more fibrosis – more resistant to probing (tight) vs NS - **Post-Tx SRP/SRD:** less PD reduction & less attachment gain (avg 0.5 mm) - Root surface contaminated by smoking products – may affect attachment of cells - >10 cigs/day = heavy smoking - Tooth loss? – Lack long-term studies <table> <thead> <tr> <th colspan="2"><b>TABLE 23.4</b> Effects of Smoking on the Response to Periododontal Therapy</th> </tr> </thead> <tbody> <tr> <td colspan="2"><b>Therapy</b> <b>Effects of Smoking</b></td> </tr> <tr> <td rowspan="4">Nonsurgical</td> <td>╳ Clinical response to root surface debridement<br> ╳ Reduction in probing depth<br> ╳ Gain in clinical attachment levels<br> ╳ Negative impact of smoking with ╳ level of plaque control</td> </tr> <tr> <td>╳ Probing depth reduction and ╳ gain in clinical attachment levels after access flap surgery<br> ╳ Deterioration of furcations after surgery<br> ╳ Gain in clinical attachment levels, ╳ bone fill, ╳ recession, and ╳ membrane exposure after guided tissue regeneration<br> ╳ Root coverage after grafting procedures for localized gingival recession<br> ╳ Probing depth reduction after bone graft procedures<br> ▐ Risk for implant failure and periimplantitis</td> </tr> <tr> <td>╳ Probing depth and attachment loss during maintenance therapy<br> ▐ Disease recurrence in smokers<br> ▐ Need for retreatment in smokers<br> ▐ Tooth loss in smokers after surgical therapy</td> </tr> <tr> <td>╳ Decreased; ▐ increased.</td> </tr> </tbody> </table> _figures/img_17d1bb2f70a28d1f.webp) | Therapy | Effects of Smoking | |:---------------|:------------------------------------------------------------------------------------------------------------| | **Nonsurgical** | ↓ Clinical response to root surface debridement<br>↓ Reduction in probing depth<br>↓ Gain in clinical attachment levels<br>↓ Negative impact of smoking with ↓ level of plaque control | | **Surgical** | ↓ Probing depth reduction and ↓ gain in clinical attachment levels after access flap surgery<br>↓ Deterioration of furcations after surgery<br>↓ Gain in clinical attachment levels, ↓ bone fill, ↓ recession, and ↓ membrane exposure after guided tissue regeneration<br>↓ Root coverage after grafting procedures for localized gingival recession<br>↓ Probing depth reduction after bone graft procedures<br>↑ Risk for implant failure and periimplantitis | | **Maintenance** | ↓ Probing depth and attachment loss during maintenance therapy<br>↑ Disease recurrence in smokers<br>↑ Need for retreatment in smokers<br>↑ Tooth loss in smokers after surgical therapy | *Note: ↓ decreased; ↑ increased* A structured table titled 'Effects of Smoking on the Response to Periodontal Therapy'. It is divided into three main categories: 'Nonsurgical', 'Surgery and implants', and 'Maintenance care'. The table details the negative effects of smoking on each therapy type using arrows (downward for decreased, upward for increased) to indicate trends in clinical parameters like probing depth, attachment levels, and disease recurrence. A legend at the bottom clarifies that '↓' means Decreased and '↑' means Increased. **PERIODONTAL TREATMENT ON SMOKERS** * **Surgery:** smoking decrease tissue oxygenation * **Tissues** – prone to infection * **Increase risk** of post-surgical wound infection * **Poorer results** with all periodontal surgery & dental implants _figures/img_a38dc1e6fca9a71e.webp) #### Periodontal Treatment on Smokers - **Surgery:** smoking decreases tissue oxygenation - **Tissues** – prone to infection - **Increased risk** of post-surgical wound infection - **Poorer results** with all periodontal surgery & dental implants Clinical photograph showing a periodontal surgical site on the maxillary anterior teeth. The image displays exposed bone and gingival tissue with visible bleeding, consistent with the context of 'periodontal treatment' and 'tissues prone to infection' mentioned in the slide text. **IMPLANT THERAPY** Smoking. There is strong evidence that smoking is a risk factor for adverse implant outcomes. The evidence shows that smokers have an increased risk of peri-implantitis (reported odds ratios ranged from 3.6 to 4.6) and radiographic marginal bone loss (reported odds ratios ranged from 2.2 to 10) compared to non-smokers. There is some evidence for a dose effect of cigarette smoking. * **Smoking.** Smoking is not a contraindication for implant placement. However, patients should be informed that the survival and success rates are lower in smokers. Heavy smokers should be informed that they are at greater risk of implant failure and loss of marginal bone. Patients who smoke should be informed that there is an increased risk of implant failure when sinus augmentation procedures are used. The University of Western Australia #### Implant Therapy **Smoking.** There is strong evidence that smoking is a risk factor for adverse implant outcomes. The evidence shows that smokers have an increased risk of peri-implantitis (reported odds ratios ranged from 3.6 to 4.6) and radiographic marginal bone loss (reported odds ratios ranged from 2.2 to 10) compared to non-smokers. There is some evidence for a dose effect of cigarette smoking. - **Smoking.** Smoking is not a contraindication for implant placement. However, patients should be informed that the survival and success rates are lower in smokers. Heavy smokers should be informed that they are at greater risk of implant failure and loss of marginal bone. Patients who smoke should be informed that there is an increased risk of implant failure when sinus augmentation procedures are used. The official logo of The University of Western Australia, featuring the university's crest and name. - Better for gum health & tooth retention - Increased gingival bleeding – improved vasculature - Improved healing response: greater PD reductions - Less risk for moderate or severe periodontitis (**OR 3.3** current smokers, 2 for FS vs NS) - **Reduce smoking** also reduces risk for developing periodontitis (30 cig/day to 10 cig/day) - **Passive smoking**, foetal health, risk of offspring smoking, cost - Time to revert to non-smoker (NS) status unknown but may take decades --- *Note: “NS” = Non-Smoker; “FS” = Former Smoker; “PD” = Periodontal Depth* - Better for gum health & tooth retention - Increased gingival bleeding – improved vasculature - Improved healing response: greater PD reductions - Less risk for moderate or severe periodontitis (**OR 3.3** current smokers, 2 for FS vs NS) - **Reduce smoking** also reduces risk for developing periodontitis (30 cig/day to 10 cig/day) - **Passive smoking**, foetal health, risk of offspring smoking, cost - Time to revert to non-smoker (NS) status unknown but may take decades --- *Note: “NS” = Non-Smoker; “FS” = Former Smoker; “PD” = Periodontal Depth* | Time after cessation | Direct benefits | | --- | --- | | 2 days | Sense of taste and smell improved | | 1 month | Skin clearer, more hydrated | | 3 months | Improved breathing, no cough or wheeze | | | Improved lung function (up to 10%) | | | Risk of mouth and throat cancer reduced | | 6 months | Most smoking-related oral white patches will have disappeared | | 1 year | Gingival circulation improved | | 10 years | Risk of heart attack reduced to half that of a smoker | | 15 years | Risk of lung cancer reduced by half | | | Risk of heart attack same as never smoker | _figures/img_0c67ca5acbebf925.webp) | Time after cessation | Direct benefits | |:--------------------|:--------------------------------------------------------------------------------| | 2 days | Sense of taste and smell improved | | 1 month | Skin clearer, more hydrated | | 3 months | Improved breathing, no cough or wheeze<br>Improved lung function (up to 10%)<br>Risk of mouth and throat cancer reduced | | 6 months | Most smoking-related oral white patches will have disappeared | | 1 year | Gingival circulation improved | | 10 years | Risk of heart attack reduced to half that of a smoker | | 15 years | Risk of lung cancer reduced by half<br>Risk of heart attack same as never smoker | A table listing the direct benefits of stopping smoking over time. The table has two columns: 'Time after cessation' and 'Direct benefits'. Rows include time points from 2 days to 15 years, with corresponding health improvements such as improved taste and smell, clearer skin, reduced risk of cancer, and decreased heart attack risk. REPRODUCED WITH PERMISSION FROM DROPE J, SCHLUGER NW, EDITORS, THE TOBACCO ATLAS, 6TH EDN, ATLANTA, GA, AMERICAN CANCER SOCIETY AND VITAL STRATEGIES, 2018, P. 37. COPYRIGHT 2018 THE AMERICAN CANCER SOCIETY, INC. REPRINTED WITH PERMISSION FROM WWW.CANCER.ORG1 ```mermaid graph LR A("WITHIN 20 MINUTES: Your heart rate and blood pressure drop.") --> B("WITHIN 12 HOURS: Your carbon monoxide level in the blood drops to normal.") B --> C("WITHIN 2-12 WEEKS: Your circulation improves and your lung function increases.") C --> D("WITHIN 1-9 MONTHS: Your coughing and shortness of breath decrease.") D --> E("WITHIN 1 YEAR: Your risk of coronary heart disease is about half that of a smoker's.") E --> F("WITHIN 5 YEARS: Your risk of stroke is reduced to that of a nonsmoker's.") F --> G("WITHIN 10 YEARS: Your risk of lung cancer falls to about half that of a smoker's, and your risk of cancer of the mouth, throat, esophagus, bladder, cervix, or pancreas decreases.") G --> H("WITHIN 15 YEARS: Your risk of coronary heart disease is that of a nonsmoker's.") ``` _figures/img_99bfddf796ee510e.webp) REPRODUCED WITH PERMISSION FROM DROPE J, SCHLUGER NW, EDITORS, THE TOBACCO ATLAS, 6TH EDN, ATLANTA, GA, AMERICAN CANCER SOCIETY AND VITAL STRATEGIES, 2018, P. 37. COPYRIGHT 2018 THE AMERICAN CANCER SOCIETY, INC. REPRINTED WITH PERMISSION FROM WWW.CANCER.ORG1 ```mermaid graph LR A("WITHIN 20 MINUTES: Your heart rate and blood pressure drop.") --> B("WITHIN 12 HOURS: Your carbon monoxide level in the blood drops to normal.") B --> C("WITHIN 2-12 WEEKS: Your circulation improves and your lung function increases.") C --> D("WITHIN 1-9 MONTHS: Your coughing and shortness of breath decrease.") D --> E("WITHIN 1 YEAR: Your risk of coronary heart disease is about half that of a smoker's.") E --> F("WITHIN 5 YEARS: Your risk of stroke is reduced to that of a nonsmoker's.") F --> G("WITHIN 10 YEARS: Your risk of lung cancer falls to about half that of a smoker's, and your risk of cancer of the mouth, throat, esophagus, bladder, cervix, or pancreas decreases.") G --> H("WITHIN 15 YEARS: Your risk of coronary heart disease is that of a nonsmoker's.") ``` Timeline diagram illustrating health improvements after quitting smoking. The timeline progresses from 'WITHIN 20 MINUTES' to 'WITHIN 15 YEARS'. Each stage is marked with an icon (clock, lungs, head, heart) and a caption describing the physiological benefit, such as blood pressure dropping or risk of lung cancer decreasing. **QUITTING SMOKING- OUR ROLE** * About 70% of smokers would like to quit * Most patients see dentists/hygienists more than their GP – opportunity for dentist to help.. * ?? Refer to medical GP _figures/img_f9d262149ba94c49.webp) #### Quitting Smoking – Our Role - About 70% of smokers would like to quit - Most patients see dentists/hygienists more than their GP – opportunity for dentist to help.. - ?? Refer to medical GP Photo showing the word 'QUIT' formed by broken cigarettes. # VAPING/E CIGARETTES – DEFINITIONS * Battery powered devices which heat a liquid containing chemicals and flavouring into an aerosol which is inhaled through a mouthpiece , and then exhaled by the user as a fine particulate smoke- **NOT A TOBACCO PRODUCT** * Liquid- **called e-liquid, e-juice ,vape juice** * Water * Carrier solution- propylene glycol , glycerine * Nicotine- but only on prescription in Australia ( and present in black market vapes) * Flavouring – many types Reusable or disposable - Battery powered devices which heat a liquid containing chemicals and flavouring into an aerosol which is inhaled through a mouthpiece, and then exhaled by the user as a fine particulate smoke - **NOT A TOBACCO PRODUCT** - Liquid - called e-liquid, e-juice, vape juice - Water - Carrier solution - propylene glycol, glycerine - Nicotine - but only on prescription in Australia (and present in black market vapes) - Flavouring - many types - Reusable or disposable # HISTORY OF VAPING * “Vaping” like device first patented in 1965. * Vaping word coined in 1979. * In 2003, a Chinese pharmacist and smoker Hon Lik, in an attempt to give up smoking, is credited with inventing the modern device his company patents were bought by Imperial tobacco in 2013. * Vaping introduced into the EU in 2005/2006. * Data collection started @ 2011- then 2% of ex and current smokers in England. * Now 4.2 million ( 8.3% ) users in the UK, 7% are 11-17 year olds. * In Australia in 2019, @ 400, 000 users, dual use is 45% (of vapers who smoke cigs). * Only 22% of 15-24 year olds have never vaped. - "Vaping" like device first patented in 1965. - Vaping word coined in 1979. - In 2003, a Chinese pharmacist and smoker Hon Lik, in an attempt to give up smoking, is credited with inventing the modern device; his company patents were bought by Imperial tobacco in 2013. - Vaping introduced into the EU in 2005/2006. - Data collection started @ 2011 - then 2% of ex and current smokers in England. - Now 4.2 million (8.3%) users in the UK, 7% are 11-17 year olds. - In Australia in 2019, @ 400,000 users, dual use is 45% (of vapers who smoke cigs). - Only 22% of 15-24 year olds have never vaped. MARKETING AND THE USE OF VAPES **2015- Juul brand launched in the USA by a silicon valley group. High nicotine.** **HUGE marketing- modern devices, targeted to millennials specifically.** **Adverts in teen magazines , cartoons , school sites- huge increase in sales as not FDA regulated for years** FDA NEWS RELEASE **FDA Denies Authorization to Market JUUL Products** Currently Marketed JUUL Products Must Be Removed from the US Market _figures/img_0f6930084aba42ab.webp) **2015 - Juul brand launched in the USA by a silicon valley group. High nicotine.** **HUGE marketing - modern devices, targeted to millennials specifically.** **Adverts in teen magazines, cartoons, school sites - huge increase in sales as not FDA regulated for years** **FDA NEWS RELEASE** **FDA Denies Authorization to Market JUUL Products** Currently Marketed JUUL Products Must Be Removed from the US Market A collage of four Juul brand advertisements featuring young people in modern, colorful settings. Each panel shows a different demographic (female teen, couple, female teen sitting, male teen jumping) with the Juul device and branding visible. **Understanding The Different Ty...** jointhevapelife.ie **Vaping – Liberation Programs** liberationprograms.org **The Different Types Of Vape De...** buyv2cigs.co.uk **BIDI Vape – Types of Vaping D...** bidivape.tumblr.com alleroepediatrics.com **What Are The Different Types o...** ruthlessvapor.com **EVOLUTION OF VAPING** **What are vaping devices in 202...** mrfog.com _figures/img_47b29880b84f11a0.webp) _figures/img_50e0d0a1b4e4369d.webp) _figures/img_fc9ba4574e8c95bd.webp) _figures/img_60fa914f9add4609.webp) _figures/img_e826b0d737a9cf24.webp) _figures/img_774ce4c143d9e034.webp) _figures/img_3bb4bd893addaac4.webp) **Understanding The Different Ty...** jointhevapelife.ie **Vaping – Liberation Programs** liberationprograms.org **The Different Types Of Vape De...** buyv2cigs.co.uk **BIDI Vape – Types of Vaping D...** bidivape.tumblr.com alleroepediatrics.com **What Are The Different Types o...** ruthlessvapor.com **EVOLUTION OF VAPING** **What are vaping devices in 202...** mrfog.com Labelled diagram showing 'TYPES OF E-CIGARETTES'. It displays seven distinct device categories from left to right: Cigalike E-cigs (resembling a cigarette), Vape Pods (a small black rectangular device), Vape Pen (a red and white pen-style device), Box or Vape Mods (a blue box-shaped device), Squonk Mods (a dark grey device with a tank), Other Vapes (an orange hookah-like device), and an unlabeled teal circular object. Labelled diagram titled 'The Different Types Of Vape De...'. It shows five vaping devices on a blue background: a traditional cigarette, a black vape stick, a black vape pen, a silver and black vape mod, and a black disposable pod. Labelled diagram titled 'What are vaping devices in 202...'. It features six illustrations of different vaping products including colorful pods, a large box mod, a red vape pen, a white vape pen, and a slim disposable device. Labelled diagram titled 'Evolution of the e-cigarette'. It depicts four stages of development from left to right: Cigalike (orange tip), Vape pen (blue body), Box mod (magenta body), and Vape pod (grey body). Labelled diagram titled 'Types of Vaping Devices'. It illustrates three main types against purple circles: Cig-a-like (cigarette shape), Vape Pen (pen shape), and Mod (large rectangular battery shape). Diagram titled 'EVOLUTION OF VAPING'. It displays a timeline of four generations of devices: Cigalike (2000), Vape Pen (Mid 2000's), Mods (Early 2010's), and Pod Mods (Mid 2010's). Labelled diagram comparing various vaping forms. From left to right it shows: A pipe, a cigar, a large size vape battery, a medium size vape starter, disposable e-cigarettes, and disposable e-cigars. <div> </div> _figures/img_2f02501a854e4116.webp) Photo showing seven different types of vaping and tobacco products arranged horizontally. From left to right: a white disposable-style e-cigarette with a rose gold button; a rectangular grey tank device; a silver cylindrical e-cigarette with ventilation holes; a black e-cigarette with a heart-shaped button; a clear tank device with visible internal components; a traditional tobacco cigarette labeled 'CE'; and a white heated tobacco product resembling a slim pen. # INGREDIENTS OF VAPES * Propylene glycol-humectant-used in food, chemical and pharmaceutical industries, generally recognised as safe to consume(toxic in high doses)- when vapourised- lactic acid, acetic acid, pyruvic acid. Present in theatrical fog- National Academy of Science 2018 Toxicity of E- cigarette Constituents * Glycerine- also a humectant and preservative - not cariogenic – but with some fruit flavours may increase microbial adhesion and biofilm formation. * Fruit flavours- some PH below 5.5 * Diacetyl – butter food flavouring, if inhaled can cause permanent lung damage * Sweeteners- various * Other chemicals found in the aerosol vapour not listed in the ingredients –VOC, nanoparticles, heavy metals, formaldehyde… - Propylene glycol - humectant - used in food, chemical and pharmaceutical industries, generally recognised as safe to consume (toxic in high doses) - when vapourised - lactic acid, acetic acid, pyruvic acid. Present in theatrical fog - National Academy of Science 2018 Toxicity of E-cigarette Constituents - Glycerine - also a humectant and preservative - not cariogenic - but with some fruit flavours may increase microbial adhesion and biofilm formation. - Fruit flavours - some pH below 5.5 - Diacetyl - butter food flavouring, if inhaled can cause permanent lung damage - Sweeteners - various - Other chemicals found in the aerosol vapour not listed in the ingredients - VOC, nanoparticles, heavy metals, formaldehyde... The provided text is a table showing ingredient listings as they appeared on product packaging/website. Since it is a structured table with defined headers and content, it should be formatted in HTML. ```html <table> <tr> <th colspan="2">Table 1 Ingredients listing as it appeared on product packaging/website (including spelling errors)</th> </tr> <tr> <th>Country of manufacture</th> <th>Ingredients as listed</th> </tr> <tr> <td>China</td> <td> <ul> <li>Propylone glycol, vegetable glycerin, natural and artificial flavourings</li> <li>Propylone glycol, vegetable glycerin, natural and artificial flavourings</li> <li>Propolyne glycol, glycerol, nicotine, ethyl maltol, phenyl carbinol, flavours</li> </ul> </td> </tr> <tr> <td>Germany</td> <td> <ul> <li>Propylene glycol (E1520), glycerin (VG E422), distilled water, natural flavours</li> </ul> </td> </tr> <tr> <td>UK</td> <td> <ul> <li>Vegetable glycerin, propylene glycol, Heizenburg flavourings (UK)</li> <li>Vegetable glycerin, propylene glycol, natural and artificial flavourings</li> <li>Vegetable glycerin, propylene glycol, flavourings</li> <li>Propylene glycol, vegetable glycerin, water, berry flavouring, nicotine.</li> <li>Contains linalool may produce an allergic reaction</li> </ul> </td> </tr> <tr> <td>Netherlands</td> <td> <ul> <li>Propylene glycol, vegetable glycerin, nicotine, flavourings</li> </ul> </td> </tr> </table> ``` _figures/img_9587111f1703078b.webp) <table> <tr> <th colspan="2">Table 1 Ingredients listing as it appeared on product packaging/website (including spelling errors)</th> </tr> <tr> <th>Country of manufacture</th> <th>Ingredients as listed</th> </tr> <tr> <td>China</td> <td> <ul> <li>Propylone glycol, vegetable glycerin, natural and artificial flavourings</li> <li>Propylone glycol, vegetable glycerin, natural and artificial flavourings</li> <li>Propolyne glycol, glycerol, nicotine, ethyl maltol, phenyl carbinol, flavours</li> </ul> </td> </tr> <tr> <td>Germany</td> <td> <ul> <li>Propylene glycol (E1520), glycerin (VG E422), distilled water, natural flavours</li> </ul> </td> </tr> <tr> <td>UK</td> <td> <ul> <li>Vegetable glycerin, propylene glycol, Heizenburg flavourings (UK)</li> <li>Vegetable glycerin, propylene glycol, natural and artificial flavourings</li> <li>Vegetable glycerin, propylene glycol, flavourings</li> <li>Propylene glycol, vegetable glycerin, water, berry flavouring, nicotine.</li> <li>Contains linalool may produce an allergic reaction</li> </ul> </td> </tr> <tr> <td>Netherlands</td> <td> <ul> <li>Propylene glycol, vegetable glycerin, nicotine, flavourings</li> </ul> </td> </tr> </table> A structured table comparing ingredient listings across four countries of manufacture: China, Germany, UK, and Netherlands. The table includes specific ingredients listed for each country, highlighting variations in terminology (e.g., 'Propylone glycol' vs. 'Propylene glycol') and additional details such as allergen warnings for the UK entry. # Research focus on smoking vs vaping **The role of e-cigs in** **modifying smoking rates** * Divided opinions and data * Beard et al suggested vaping better than NRT 2020 * Main worry is non-smoking vaping youths x 3 risk of taking up smoking- some evidence that tobacco smoking has increased in the US recently * Several studies have shown improved periodontal health with smoking cessation and uptake of vaping and increased bleeding **The health risks of e- cigs** **alone( +/- Nicotine)** * Consumption vs inhalation * Lung damage associated with Vitamin E acetate/ THC- cannibas derivatives in vaping * Addiction to Nicotine and youth brain development * Case reports of oral ulcerations, xerostomia, dry throat, cough * Longterm data lacking #### The role of e-cigs in modifying smoking rates - Divided opinions and data - Beard et al suggested vaping better than NRT 2020 - Main worry is non-smoking vaping youths x 3 risk of taking up smoking - some evidence that tobacco smoking has increased in the US recently - Several studies have shown improved periodontal health with smoking cessation and uptake of vaping and increased bleeding #### The health risks of e-cigs alone (+/- Nicotine) - Consumption vs inhalation - Lung damage associated with Vitamin E acetate/THC - cannabis derivatives in vaping - Addiction to Nicotine and youth brain development - Case reports of oral ulcerations, xerostomia, dry throat, cough - Longterm data lacking # CURRENT EVIDENCE ON VAPING ALONE AND DENTAL HEALTH | **Periodontitis** | **Xerostomia** | **Erosion and caries** | | :--- | :--- | :--- | | **Microbiological changes** | Dry mouth and throat reported | Ph of some vaping liquids low | | E- cigs influence periodontal microbiome and cytokine profile, 6 month long study, Thomas et al 2022-distinct subgingival microbiome changes in vapers | Nicotine + humectants | Propylene glycol and glycerine-may have an effect on biofilm ( Ganesen et al 2020) | | Clinical changes- In their SR, less BOP noted in several studies ( Figueredo et al 2021 The impact of vaping on periodontitis ) | | PG-acidic byproducts | | | | Flavours | | Higher than average case and self reported gingival diseases in vapers ( US and South Korea) | | Nicotine – increase PH of vapes | | | | No long term data | | Periodontitis | Xerostomia | Erosion and caries | | :--- | :--- | :--- | | **Microbiological changes** | Dry mouth and throat reported | pH of some vaping liquids low | | E-cigs influence periodontal microbiome and cytokine profile, 6 month long study, Thomas et al 2022 - distinct subgingival microbiome changes in vapers | Nicotine + humectants | Propylene glycol and glycerine - may have an effect on biofilm (Ganesen et al 2020) | | Clinical changes - In their SR, less BOP noted in several studies (Figueredo et al 2021 The impact of vaping on periodontitis) | | PG - acidic byproducts | | Higher than average case and self reported gingival diseases in vapers (US and South Korea) | | Flavours | | | | Nicotine - increase pH of vapes | | | | No long term data | <!-- TABLE 1 --> <table> <tr> <th colspan="2">Fig. 1 Mean and standard deviation ph of 45 purposefully selected e-cigarette vapes, undiluted and freshly opened. Red line indicates cut <br>off point of erosive potential pH (5.5)</th> </tr> <tr> <th>Product</th> <th>Mean pH</th> </tr> <tr> <td>UK manufacturer 6 cherry bomb</td> <td>7.55</td> </tr> <tr> <td>Multiple manufacturers 1 blueberry bomb</td> <td>7.49</td> </tr> <tr> <td>German manufacturer 2 cherry</td> <td>6.87</td> </tr> <tr> <td>German manufacturer 2 peach</td> <td>6.55</td> </tr> <tr> <td>German manufacturer 2 orange</td> <td>5.95</td> </tr> <tr> <td>Chinese manufacturer 2 cola</td> <td>5.83</td> </tr> <tr> <td>German manufacturer 2 vanilla</td> <td>5.63</td> </tr> <tr> <td>German manufacturer 2 melon</td> <td>5.37</td> </tr> <tr> <td>Chinese manufacturer 2 orange</td> <td>5.21</td> </tr> <tr> <td>Chinese manufacturer 2 pineapple</td> <td>5.12</td> </tr> <tr> <td>Chinese manufacturer 3 salt fruit</td> <td>5.11</td> </tr> <tr> <td>Chinese manufacturer 5 snooter</td> <td>5.10</td> </tr> <tr> <td>German manufacturer 2 lemon</td> <td>5.10</td> </tr> <tr> <td>Chinese manufacturer 1 Heisenberg</td> <td>5.05</td> </tr> <tr> <td>Chinese manufacturer 1 cola</td> <td>5.04</td> </tr> <tr> <td>German manufacturer 3 banana</td> <td>4.85</td> </tr> <tr> <td>German manufacturer 2 blueberry</td> <td>4.74</td> </tr> <tr> <td>German manufacturer 2 apple</td> <td>4.63</td> </tr> <tr> <td>Chinese manufacturer 1 lime mist</td> <td>4.60</td> </tr> <tr> <td>Chinese manufacturer 2 mango</td> <td>4.56</td> </tr> <tr> <td>Chinese manufacturer 1 strawberry cream</td> <td>4.52</td> </tr> <tr> <td>Chinese manufacturer 1 grapefruit juice</td> <td>4.71</td> </tr> <tr> <td>Chinese manufacturer 1 vanilla coffee</td> <td>4.50</td> </tr> <tr> <td>German manufacturer 2 mixed fruit</td> <td>4.50</td> </tr> <tr> <td>Chinese manufacturer 2 grape mist</td> <td>4.47</td> </tr> <tr> <td>Chinese manufacturer 1 mango smoothie</td> <td>4.57</td> </tr> <tr> <td>Chinese manufacturer 2 banana</td> <td>4.55</td> </tr> <tr> <td>Chinese manufacturer 2 cherry</td> <td>4.41</td> </tr> <tr> <td>Chinese manufacturer 2 blueberry blasting</td> <td>4.40</td> </tr> <tr> <td>Chinese manufacturer 2 watermelon</td> <td>4.30</td> </tr> <tr> <td>Chinese manufacturer 2 apple</td> <td>4.20</td> </tr> <tr> <td>Chinese manufacturer 1 orange</td> <td>4.13</td> </tr> <tr> <td>Chinese manufacturer 2 dessert vanilla</td> <td>4.10</td> </tr> <tr> <td>Chinese manufacturer 2 blackcurrant smoothie</td> <td>4.11</td> </tr> <tr> <td>Chinese manufacturer 3 pink lemon</td> <td>4.01</td> </tr> <tr> <td>German manufacturer 1 mango</td> <td>4.00</td> </tr> <tr> <td>UK manufacturer 3 Heisenberg</td> <td>4.00</td> </tr> <tr> <td>Chinese manufacturer 1 strawberry cheesecake</td> <td>3.92</td> </tr> <tr> <td>Chinese manufacturer 1 maidens prayer</td> <td>3.60</td> </tr> <tr> <td>UK manufacturer 3 sionites</td> <td>3.50</td> </tr> <tr> <td>Chinese manufacturer 1 bay lime rain</td> <td>3.52</td> </tr> <tr> <td>Chinese manufacturer 2 blood orange cantaloupe</td> <td>3.50</td> </tr> <tr> <td>Chinese manufacturer 1 pineapple pie</td> <td>3.42</td> </tr> <tr> <td>UK manufacturer 1 red bull</td> <td>3.15</td> </tr> </table> _figures/img_473fea8adb254b46.webp) <table> <tr> <th colspan="2">Fig. 1 Mean and standard deviation pH of 45 purposefully selected e-cigarette vapes, undiluted and freshly opened. Red line indicates cut off point of erosive potential pH (5.5)</th> </tr> <tr> <th>Product</th> <th>Mean pH</th> </tr> <tr> <td>UK manufacturer 6 cherry bomb</td> <td>7.55</td> </tr> <tr> <td>Multiple manufacturers 1 blueberry bomb</td> <td>7.49</td> </tr> <tr> <td>German manufacturer 2 cherry</td> <td>6.87</td> </tr> <tr> <td>German manufacturer 2 peach</td> <td>6.55</td> </tr> <tr> <td>German manufacturer 2 orange</td> <td>5.95</td> </tr> <tr> <td>Chinese manufacturer 2 cola</td> <td>5.83</td> </tr> <tr> <td>German manufacturer 2 vanilla</td> <td>5.63</td> </tr> <tr> <td>German manufacturer 2 melon</td> <td>5.37</td> </tr> <tr> <td>Chinese manufacturer 2 orange</td> <td>5.21</td> </tr> <tr> <td>Chinese manufacturer 2 pineapple</td> <td>5.12</td> </tr> <tr> <td>Chinese manufacturer 3 salt fruit</td> <td>5.11</td> </tr> <tr> <td>Chinese manufacturer 5 snooter</td> <td>5.10</td> </tr> <tr> <td>German manufacturer 2 lemon</td> <td>5.10</td> </tr> <tr> <td>Chinese manufacturer 1 Heisenberg</td> <td>5.05</td> </tr> <tr> <td>Chinese manufacturer 1 cola</td> <td>5.04</td> </tr> <tr> <td>German manufacturer 3 banana</td> <td>4.85</td> </tr> <tr> <td>German manufacturer 2 blueberry</td> <td>4.74</td> </tr> <tr> <td>German manufacturer 2 apple</td> <td>4.63</td> </tr> <tr> <td>Chinese manufacturer 1 lime mist</td> <td>4.60</td> </tr> <tr> <td>Chinese manufacturer 2 mango</td> <td>4.56</td> </tr> <tr> <td>Chinese manufacturer 1 strawberry cream</td> <td>4.52</td> </tr> <tr> <td>Chinese manufacturer 1 grapefruit juice</td> <td>4.71</td> </tr> <tr> <td>Chinese manufacturer 1 vanilla coffee</td> <td>4.50</td> </tr> <tr> <td>German manufacturer 2 mixed fruit</td> <td>4.50</td> </tr> <tr> <td>Chinese manufacturer 2 grape mist</td> <td>4.47</td> </tr> <tr> <td>Chinese manufacturer 1 mango smoothie</td> <td>4.57</td> </tr> <tr> <td>Chinese manufacturer 2 banana</td> <td>4.55</td> </tr> <tr> <td>Chinese manufacturer 2 cherry</td> <td>4.41</td> </tr> <tr> <td>Chinese manufacturer 2 blueberry blasting</td> <td>4.40</td> </tr> <tr> <td>Chinese manufacturer 2 watermelon</td> <td>4.30</td> </tr> <tr> <td>Chinese manufacturer 2 apple</td> <td>4.20</td> </tr> <tr> <td>Chinese manufacturer 1 orange</td> <td>4.13</td> </tr> <tr> <td>Chinese manufacturer 2 dessert vanilla</td> <td>4.10</td> </tr> <tr> <td>Chinese manufacturer 2 blackcurrant smoothie</td> <td>4.11</td> </tr> <tr> <td>Chinese manufacturer 3 pink lemon</td> <td>4.01</td> </tr> <tr> <td>German manufacturer 1 mango</td> <td>4.00</td> </tr> <tr> <td>UK manufacturer 3 Heisenberg</td> <td>4.00</td> </tr> <tr> <td>Chinese manufacturer 1 strawberry cheesecake</td> <td>3.92</td> </tr> <tr> <td>Chinese manufacturer 1 maidens prayer</td> <td>3.60</td> </tr> <tr> <td>UK manufacturer 3 sionites</td> <td>3.50</td> </tr> <tr> <td>Chinese manufacturer 1 bay lime rain</td> <td>3.52</td> </tr> <tr> <td>Chinese manufacturer 2 blood orange cantaloupe</td> <td>3.50</td> </tr> <tr> <td>Chinese manufacturer 1 pineapple pie</td> <td>3.42</td> </tr> <tr> <td>UK manufacturer 1 red bull</td> <td>3.15</td> </tr> </table> Bar chart comparing the mean pH values of 45 different e-cigarette vape products. The y-axis lists specific product names (e.g., 'UK manufacturer 6 cherry bomb', 'German manufacturer 2 peach'). The x-axis represents pH scale from 0 to 9. Each bar shows the average pH (blue) and standard deviation (orange). A vertical red line at pH 5.5 marks the threshold for erosive potential. # WHY IS THE DATA SO INCONSISTENT? * Vaping has only begun being studied in the last few years. * Hundreds of different e-cigarette devices, thousands of e-liquid formulations, nicotine concentrations and flavours, constantly changing market, in many countries unregulated . * Different users- current smokers with existing disease, * Healthy non-smokers with no disease, * Recent ex-smokers +/- disease * Quiting smokers who smoke and vape +/- nicotene - Vaping has only begun being studied in the last few years. - Hundreds of different e-cigarette devices, thousands of e-liquid formulations, nicotine concentrations and flavours, constantly changing market, in many countries unregulated. - Different users: - Current smokers with existing disease - Healthy non-smokers with no disease - Recent ex-smokers +/- disease - Quitting smokers who smoke and vape +/- nicotine **Vaping in Australia** | Age Group | Percentage | |---|---| | 18-24 years | 21.7% | | 15-17 years | 7.6% | According to the Australian Bureau of Statistics, more than 1 in 5 (21.7%) young Australians aged 18-24 and 7.6% of 15-17 year olds have used an e-cigarette or vaping device at least once. It’s likely that these figures are under-reported because responses were provided by an adult living in the same household. With the exception of Western Australia, each state and territory permits the sale of vapes and e-cigarettes, but not the sale or purchase of liquid flavours that contain nicotine. For this reason, most users purchase their products and liquids online. Doctors in Australia can prescribe nicotine vaping products as a means of weaning off tobacco use, though there is little evidence that vaping is successful in achieving this outcome. <i>Lung Foundation Australia</i> <i>nib foundation</i> Vaping and young people For educators Supporters _figures/img_6e2c172b2ede970f.webp) **Vaping in Australia** | Age Group | Percentage | |---|---| | 18-24 years | 21.7% | | 15-17 years | 7.6% | According to the Australian Bureau of Statistics, more than 1 in 5 (21.7%) young Australians aged 18-24 and 7.6% of 15-17 year olds have used an e-cigarette or vaping device at least once. It's likely that these figures are under-reported because responses were provided by an adult living in the same household. With the exception of Western Australia, each state and territory permits the sale of vapes and e-cigarettes, but not the sale or purchase of liquid flavours that contain nicotine. For this reason, most users purchase their products and liquids online. Doctors in Australia can prescribe nicotine vaping products as a means of weaning off tobacco use, though there is little evidence that vaping is successful in achieving this outcome. *Lung Foundation Australia* *nib foundation* Vaping and young people For educators Supporters Horizontal bar chart titled 'Vaping in Australia' showing usage statistics for two age groups. The top bar represents '18-24 years' at 21.7% (light purple), and the bottom bar represents '15-17 years' at 7.6% (dark purple). The x-axis ranges from 0% to 22%. # Where E-Cigarettes Are Banned Laws banning or restricting the sale, use or marketing of e-cigarettes and vapes (2021) * **Full ban**: 29 COUNTRIES * **Nicotine-containing varieties banned**: 6 COUNTRIES * **Restricted**: 45 COUNTRIES Israel: liquids of >20mg nicotine/mL banned. Indonesia: 57% tax on liquids' retail price. Source: Global Tobacco Control | statista ### Global Regulations * **UK**: Now regulated as a tobacco product. * **USA**: From 2016, FDA is regulating e-cigs as a tobacco product. In 2019, the US CDC changed the age from 18 to 21. * **Australia**: * Nicotine restrictions apply. * Non-nicotine vapes classified as legal consumer products. * Nicotine classed as a poison and needs a script. * Hence e-cigs in Australia not currently properly assessed. _figures/img_ccd157b0fd0a433d.webp) #### Where E-Cigarettes Are Banned Laws banning or restricting the sale, use or marketing of e-cigarettes and vapes (2021) - **Full ban**: 29 COUNTRIES - **Nicotine-containing varieties banned**: 6 COUNTRIES - **Restricted**: 45 COUNTRIES Israel: liquids of >20mg nicotine/mL banned. Indonesia: 57% tax on liquids' retail price. Source: Global Tobacco Control | statista #### Global Regulations - **UK**: Now regulated as a tobacco product. - **USA**: From 2016, FDA is regulating e-cigs as a tobacco product. In 2019, the US CDC changed the age from 18 to 21. - **Australia**: - Nicotine restrictions apply. - Non-nicotine vapes classified as legal consumer products. - Nicotine classed as a poison and needs a script. - Hence e-cigs in Australia not currently properly assessed. A world map chart titled 'Where E-Cigarettes Are Banned'. The map visualizes laws regarding e-cigarettes and vapes in 2021 using a color-coded legend. Red areas indicate a full ban, orange indicates that nicotine-containing varieties are banned, and yellow indicates restricted status. Grey areas show no specific data for this category. Notable regions include South America (mostly red), parts of Africa and Asia (red and orange), and North America/Europe (yellow). A small line-art illustration of an e-cigarette is visible in the bottom left corner. **Are e-cigarettes dangerous?** Electronic cigarettes (or e-cigarettes) are the most common form of electronic nicotine delivery systems (ENDS) and electronic non-nicotine delivery systems (ENNDS) but there are others, such as e-cigs and e-pipes. ENDS contain varying amounts of nicotine and harmful emissions. E-cigarette emissions typically contain nicotine and other toxic substances that are harmful to both users, and non-users who are exposed to the aerosols second-hand. Some products claiming to be nicotine-free (ENNDS) have been found to contain nicotine. The consumption of nicotine in children and adolescents has deleterious impacts on brain development, leading to long-term consequences for brain development and potentially leading to learning and anxiety disorders. Nicotine is highly addictive and some evidence suggest that never-smoker minors who use ENDS can double their chance of starting to smoke tobacco cigarettes later in life. Evidence reveals that these products are harmful to health and are not safe. However, it is too early to provide a clear answer on the long-term impact of using them or being exposed to them. Some recent studies suggest that ENDS use can increase the risk of heart disease and lung disorders. Nicotine exposure in pregnant women can have similar consequences for the brain development of the fetus. www.who.int/news-room/questions-and-answers/item/tobacco-e-cigarettes# nicotine and other harmful chemicals. **Are e-cigarettes dangerous?** Electronic cigarettes (or e-cigarettes) are the most common form of electronic nicotine delivery systems (ENDS) and electronic non-nicotine delivery systems (ENNDS) but there are others, such as e-cigs and e-pipes. ENDS contain varying amounts of nicotine and harmful emissions. E-cigarette emissions typically contain nicotine and other toxic substances that are harmful to both users, and non-users who are exposed to the aerosols second-hand. Some products claiming to be nicotine-free (ENNDS) have been found to contain nicotine. The consumption of nicotine in children and adolescents has deleterious impacts on brain development, leading to long-term consequences for brain development and potentially leading to learning and anxiety disorders. Nicotine is highly addictive and some evidence suggest that never-smoker minors who use ENDS can double their chance of starting to smoke tobacco cigarettes later in life. Evidence reveals that these products are harmful to health and are not safe. However, it is too early to provide a clear answer on the long-term impact of using them or being exposed to them. Some recent studies suggest that ENDS use can increase the risk of heart disease and lung disorders. Nicotine exposure in pregnant women can have similar consequences for the brain development of the fetus. www.who.int/news-room/questions-and-answers/item/tobacco-e-cigarettes# nicotine and other harmful chemicals. Department of Health Western Australian Government HealthyWA Health information for Western Australians Search this site Go to whole of WA Government Search Home | Health conditions | **Healthy living** | Safety and first aid | Treatments and tests | News | WA Health system | Service finder Home > Healthy living > Electronic cigarettes (e-cigarettes) # Electronic cigarettes (e-cigarettes) - Electronic cigarettes (e-cigarettes) are battery-operated devices that heat a liquid that emits an aerosol which is inhaled through a mouthpiece, and then exhaled by the user as a fine-particulate smoke. - The liquid is often called ‘e-liquid’, ‘e-juice’, or ‘vape juice’ and is intended to deliver chemicals directly to the lungs. - Using an e-cigarette is often called ‘vaping’. - The device often comes in many shapes and sizes and may look like a cigarette. Others may look like everyday items such as pens, highlighters or USB memory sticks. E-cigarettes can contain water, flavours, solvents and nicotine. Chemicals found in e-cigarettes, e-liquids, and the aerosol smoke or “vapour” that they generate include: very fine particles; heavy metals such as nickel, tin and lead; volatile organic compounds such as benzene, which is found in car exhaust; and poly-cyclic aromatic hydrocarbons such as naphthalene, found in mothballs. All of these are known to be toxic, including chemicals that can cause cancer. Many e-cigarettes contain nicotine, which is the highly addictive and poisonous chemical also found in tobacco. Even though an e-cigarette’s packaging might say it is nicotine-free, testing has shown that many e-cigarettes in Australia are labelled incorrectly and in fact do contain nicotine. E-liquids can come in thousands of different flavours, such as tobacco, confectionery, fruit and other flavours. PDF: Electronic cigarettes - Electronic cigarettes (e-cigarettes) are battery-operated devices that heat a liquid that emits an aerosol which is inhaled through a mouthpiece, and then exhaled by the user as a fine-particulate smoke. - The liquid is often called ‘e-liquid’, ‘e-juice’, or ‘vape juice’ and is intended to deliver chemicals directly to the lungs. - Using an e-cigarette is often called ‘vaping’. - The device often comes in many shapes and sizes and may look like a cigarette. Others may look like everyday items such as pens, highlighters or USB memory sticks. E-cigarettes can contain water, flavours, solvents and nicotine. Chemicals found in e-cigarettes, e-liquids, and the aerosol smoke or “vapour” that they generate include: very fine particles; heavy metals such as nickel, tin and lead; volatile organic compounds such as benzene, which is found in car exhaust; and poly-cyclic aromatic hydrocarbons such as naphthalene, found in mothballs. All of these are known to be toxic, including chemicals that can cause cancer. Many e-cigarettes contain nicotine, which is the highly addictive and poisonous chemical also found in tobacco. Even though an e-cigarette’s packaging might say it is nicotine-free, testing has shown that many e-cigarettes in Australia are labelled incorrectly and in fact do contain nicotine. E-liquids can come in thousands of different flavours, such as tobacco, confectionery, fruit and other flavours. Electronic cigarettes (e-cigarettes) Department of Health Western Australian Government HealthyWA Health information for Western Australians Home > Healthy living > Electronic cigarettes (e-cigarettes) Electronic cigarettes (e-cigarettes) - Electronic cigarettes (e-cigarettes) are battery-operated devices that heat a liquid that emits an aerosol which is inhaled through a mouthpiece, and then exhaled by the user as a fine-particulate smoke. - The liquid is often called 'e-liquid', 'e-juice', or 'vape juice' and is intended to deliver chemicals directly to the lungs. - Using an e-cigarette is often called 'vaping'. - The device often comes in many shapes and sizes and may look like a cigarette. Others may look like everyday items such as pens, highlighters or USB memory sticks. E-cigarettes can contain water, flavours, solvents and nicotine. Chemicals found in e-cigarettes, e-liquids, and the aerosol smoke or "vapour" that they generate include: very fine particles; heavy metals such as nickel, tin and lead; volatile organic compounds such as benzene, which is found in car exhaust; and poly-cyclic aromatic hydrocarbons such as naphthalene, found in mothballs. All of these are known to be toxic, including chemicals that can cause cancer. Many e-cigarettes contain nicotine, which is the highly addictive and poisonous chemical also found in tobacco. Even though an e-cigarette's packaging might say it is nicotine-free, testing has shown that many e-cigarettes in Australia are labelled incorrectly and in fact do contain nicotine. E-liquids can come in thousands of different flavours, such as tobacco, confectionery, fruit and other flavours. PDF: Electronic cigarettes - Electronic cigarettes (e-cigarettes) are battery-operated devices that heat a liquid that emits an aerosol which is inhaled through a mouthpiece, and then exhaled by the user as a fine-particulate smoke. - The liquid is often called 'e-liquid', 'e-juice', or 'vape juice' and is intended to deliver chemicals directly to the lungs. - Using an e-cigarette is often called 'vaping'. - The device often comes in many shapes and sizes and may look like a cigarette. Others may look like everyday items such as pens, highlighters or USB memory sticks. E-cigarettes can contain water, flavours, solvents and nicotine. Chemicals found in e-cigarettes, e-liquids, and the aerosol smoke or "vapour" that they generate include: very fine particles; heavy metals such as nickel, tin and lead; volatile organic compounds such as benzene, which is found in car exhaust; and poly-cyclic aromatic hydrocarbons such as naphthalene, found in mothballs. All of these are known to be toxic, including chemicals that can cause cancer. Many e-cigarettes contain nicotine, which is the highly addictive and poisonous chemical also found in tobacco. Even though an e-cigarette's packaging might say it is nicotine-free, testing has shown that many e-cigarettes in Australia are labelled incorrectly and in fact do contain nicotine. E-liquids can come in thousands of different flavours, such as tobacco, confectionery, fruit and other flavours. Electronic cigarettes (e-cigarettes) Logo for the Government of Western Australia Department of Health. Logo for HealthyWA (Health information for Western Australians). The preliminary findings from the review of health outcomes and findings from the review of smoking behaviour in relation to e-cigarettes are that there is: - Conclusive evidence that intentional or accidental exposure to e-liquids related to e-cigarettes can lead to poisoning, and that poisonings can be severe and can result in death. - Conclusive evidence that a significant number of poisonings occur in children under the age of six (8,296 between 2012 and 2017 in the United States alone). - Conclusive evidence that the use of e-cigarettes is related to burns and injuries, and that burns and injuries can be severe and can result in death. There is evidence that that the incidence of e-cigarette-associated burns and injuries has increased over time as use has increased (national The preliminary findings from the review of health outcomes and findings from the review of smoking behaviour in relation to e-cigarettes are that there is: - Conclusive evidence that intentional or accidental exposure to e-liquids related to e-cigarettes can lead to poisoning, and that poisonings can be severe and can result in death. - Conclusive evidence that a significant number of poisonings occur in children under the age of six (8,296 between 2012 and 2017 in the United States alone). - Conclusive evidence that the use of e-cigarettes is related to burns and injuries, and that burns and injuries can be severe and can result in death. There is evidence that the incidence of e-cigarette-associated burns and injuries has increased over time as use has increased (national TIME MAGAZINE - THE TEENAGER WHO NEEDED A DOUBLE LUNG TRANSPLANT BECAUSE HE VAPED-MEDIA HYPE OR TIP OF THE ICEBERG? _figures/img_7eff7e6c4c550dd5.webp) _figures/img_160859fc9d2aadb7.webp) TIME MAGAZINE - THE TEENAGER WHO NEEDED A DOUBLE LUNG TRANSPLANT BECAUSE HE VAPED - MEDIA HYPE OR TIP OF THE ICEBERG? Clinical photo showing a young male athlete in a green running jersey with bib number 256, appearing healthy outdoors near a chain-link fence. This image represents the 'before' state referenced in the OCR context. Clinical photo showing the same young male lying in a hospital bed covered by a blue blanket, wearing an oxygen mask. This image represents the 'during his illness' state mentioned in the OCR context. **Case Scenario 23.1** **Patient:** 62-year-old male **Chief Complaint:** “I have tenderness around dental implants that were placed 1 year ago, and I notice bleeding when I’m brushing them.” **Background Information** The patient had a history of hypertension and hypothyroidism. He currently smokes 10–15 hand-rolled cigarettes per day, and he has smoked on and off for over 40 years. He managed to quit for a period around the time of implant placement, but he resumed smoking recently. The patient sees his dentist regularly, has been edentulous for 10 years and struggled to wear a complete maxillary denture. He uses a powered toothbrush twice per day to brush around the implants. **Current Findings:** (1 year after implant placement): Generalized probing depths of 5–6 mm around all the implants. Bleeding on probing score, 80%. Evidence of radiographic bone loss of 2–4 mm from baseline records. Generally poor oral hygiene. _figures/img_2357a611238e0863.webp) _figures/img_8d37334efdb5a2cc.webp) **Case Scenario 23.1** **Patient:** 62-year-old male **Chief Complaint:** "I have tenderness around dental implants that were placed 1 year ago, and I notice bleeding when I'm brushing them." **Background Information** The patient had a history of hypertension and hypothyroidism. He currently smokes 10–15 hand-rolled cigarettes per day, and he has smoked on and off for over 40 years. He managed to quit for a period around the time of implant placement, but he resumed smoking recently. The patient sees his dentist regularly, has been edentulous for 10 years and struggled to wear a complete maxillary denture. He uses a powered toothbrush twice per day to brush around the implants. **Current Findings:** (1 year after implant placement): Generalized probing depths of 5–6 mm around all the implants. Bleeding on probing score, 80%. Evidence of radiographic bone loss of 2–4 mm from baseline records. Generally poor oral hygiene. Clinical photograph showing a close-up view of inflamed gingival tissue surrounding two dental implants with gold-colored healing abutments. The tissue appears erythematous (red) and edematous, indicating significant inflammation consistent with peri-implant mucositis or early peri-implantitis. Clinical photograph displaying the maxillary arch from an occlusal perspective. Four dental implants are visible in the posterior regions of the ridge, topped with small gold healing caps. The surrounding soft tissue appears pink and relatively healthy compared to the left image, though slight inflammation may be present. <table> <tr> <th>CASE-BASED QUESTIONS</th> <th>SOLUTION AND EXPLANATION</th> </tr> <tr> <td>1. Smokers who receive dental implants are at increased risk for which of the following? A. Failure of osseointegration B. Periimplantitis C. Wound healing complications D. All of the above</td> <td><b>Answer:</b> D<br/><b>Explanation:</b> Smoking has myriad effects that will influence the prognosis of a dental implant in both the short and long term. Similar to the effects seen in periodontitis, smokers with implants will have adverse effects on their vasculature, immune and inflammatory responses, and microbiology.</td> </tr> <tr> <td>2. If this patient was a current smoker at the time of dental implant placement, would he have been at increased risk of suffering from a dental implant failure? A. No increased risk B. 1.5 times the risk C. 2 times the risk D. 5 times the risk E. None of the above</td> <td><b>Answer:</b> C<br/><b>Explanation:</b> There have been numerous systematic reviews on this topic. Overall, they find that smokers are at approximately double the risk of implant failure compared to nonsmokers. Patients should be made aware of this increased risk and every effort made to support them in their efforts to quit smoking.</td> </tr> <tr> <td>3. If a patient successfully quits smoking, how long should you wait until placing dental implants? A. 1 week B. 2 months C. 2 years D. Not known</td> <td><b>Answer:</b> D<br/><b>Explanation:</b> There is insufficient evidence to say with confidence at what time point a former smoker should receive a dental implant. Some early protocols suggested abstinence for 1 week before, and 8 weeks after dental implant placement, showing significantly improved early outcomes compared to those who continued to smoke.<sup>7</sup> More contemporary studies have suggested a 2-year cutoff is more useful, with those having dental implant placement earlier than 2 years from the time of cessation having a 2.7 times greater risk of implant failure compared to those who had been abstinent for longer than 2 years.<sup>144</sup> Further research is needed on this topic.</td> </tr> <tr> <td>4. What should you advise e-cigarette users (former smokers) who are considering dental implant treatment? A. Stop e-cigarettes immediately. B. Consider cutting down. C. Use nicotine free e-liquids. D. Change the e-liquid flavor. E. Use an individualized approach.</td> <td><b>Answer:</b> E<br/><b>Explanation:</b> E-cigarettes are a recent invention (see <b>Box 23.6</b>). Research studies have yet to explore these questions, and no official guidance exists. However, it is likely that e-cigarette aerosol (vapor) is likely to be significantly less harmful than tobacco smoke. Given this situation, it would be most suitable to provide individualized advice to the patient. For example, a patient who has recently given up a habit of smoking 20 cigarettes a day and is using an e-cigarette should not be pressured into immediately abstaining from the e-cigarette, for fear of relapse to cigarette smoking. Indeed, long-term e-cigarette use can be a protective factor against relapse back to smoking (relapse rates of 70% can be expected between 4 and 52 weeks). Because patients highly respect the opinions of health care professionals, it is important that we give the most up-to-date, evidence-based advice.</td> </tr> </table> _figures/img_d35f5cb38d57031d.webp) <table> <tr> <th>CASE-BASED QUESTIONS</th> <th>SOLUTION AND EXPLANATION</th> </tr> <tr> <td>1. Smokers who receive dental implants are at increased risk for which of the following? A. Failure of osseointegration B. Periimplantitis C. Wound healing complications D. All of the above</td> <td><b>Answer:</b> D<br/><b>Explanation:</b> Smoking has myriad effects that will influence the prognosis of a dental implant in both the short and long term. Similar to the effects seen in periodontitis, smokers with implants will have adverse effects on their vasculature, immune and inflammatory responses, and microbiology.</td> </tr> <tr> <td>2. If this patient was a current smoker at the time of dental implant placement, would he have been at increased risk of suffering from a dental implant failure? A. No increased risk B. 1.5 times the risk C. 2 times the risk D. 5 times the risk E. None of the above</td> <td><b>Answer:</b> C<br/><b>Explanation:</b> There have been numerous systematic reviews on this topic. Overall, they find that smokers are at approximately double the risk of implant failure compared to nonsmokers. Patients should be made aware of this increased risk and every effort made to support them in their efforts to quit smoking.</td> </tr> <tr> <td>3. If a patient successfully quits smoking, how long should you wait until placing dental implants? A. 1 week B. 2 months C. 2 years D. Not known</td> <td><b>Answer:</b> D<br/><b>Explanation:</b> There is insufficient evidence to say with confidence at what time point a former smoker should receive a dental implant. Some early protocols suggested abstinence for 1 week before, and 8 weeks after dental implant placement, showing significantly improved early outcomes compared to those who continued to smoke.<sup>7</sup> More contemporary studies have suggested a 2-year cutoff is more useful, with those having dental implant placement earlier than 2 years from the time of cessation having a 2.7 times greater risk of implant failure compared to those who had been abstinent for longer than 2 years.<sup>144</sup> Further research is needed on this topic.</td> </tr> <tr> <td>4. What should you advise e-cigarette users (former smokers) who are considering dental implant treatment? A. Stop e-cigarettes immediately. B. Consider cutting down. C. Use nicotine free e-liquids. D. Change the e-liquid flavor. E. Use an individualized approach.</td> <td><b>Answer:</b> E<br/><b>Explanation:</b> E-cigarettes are a recent invention (see <b>Box 23.6</b>). Research studies have yet to explore these questions, and no official guidance exists. However, it is likely that e-cigarette aerosol (vapor) is likely to be significantly less harmful than tobacco smoke. Given this situation, it would be most suitable to provide individualized advice to the patient. For example, a patient who has recently given up a habit of smoking 20 cigarettes a day and is using an e-cigarette should not be pressured into immediately abstaining from the e-cigarette, for fear of relapse to cigarette smoking. Indeed, long-term e-cigarette use can be a protective factor against relapse back to smoking (relapse rates of 70% can be expected between 4 and 52 weeks). Because patients highly respect the opinions of health care professionals, it is important that we give the most up-to-date, evidence-based advice.</td> </tr> </table> A structured table containing 'CASE-BASED QUESTIONS' and their corresponding 'SOLUTION AND EXPLANATION'. The table is divided into four rows. Row 1 discusses smokers receiving dental implants and lists 'All of the above' as the answer regarding risks like osseointegration failure and periimplantitis. Row 2 addresses the risk of implant failure for current smokers, citing a double risk compared to nonsmokers. Row 3 asks about waiting periods after quitting smoking, noting insufficient evidence but mentioning a 2-year cutoff for lower failure risk. Row 4 advises on e-cigarette users, suggesting an individualized approach rather than immediate cessation. BIGG PRESENTATION REFERENCE **Smoking, periodontal disease and the role of the dental profession** K K Hilgers D F Kinane PMID: 16451463 **Smoking and periodontal disease** K-Y Zee* *Westmead Centre for Oral Health and Faculty of Dentistry, The University of Sydney, New South Wales. **Smoking, periodontal disease and the role of the dental profession** K K Hilgers, D F Kinane PMID: 16451463 **Smoking and periodontal disease** K-Y Zee* *Westmead Centre for Oral Health and Faculty of Dentistry, The University of Sydney, New South Wales. Reference List: * Lindhes Clinical Periodontology and Implant Dentistry Chapter 11, 7th Edition 2022 * Electronic cigarettes :un update on products, regulations public health approaches and oral health, Anthony Weke and Richard Holliday, Community Dental health 2022 * Electronic cigarettes and Oral Health, JDR, R. Holliday et al 2021 Book Cover: CHAPTER 23 Risk Factors of Periodontal Disease (Smoking) Philip M. Preshaw | Leandro Chambrone | Richard Holliday CHAPTER OUTLINE The Smoking Epidemic Effects of Smoking on the Prevalence and Severity of Periodontal Disease Gingivitis Periodontitis Effects of Smoking on the Etiology and Pathogenesis of Periodontal Disease Microbiology Immune-Inflammatory Responses Physiology Effects of Smoking on the Response to Periodontal Therapy Nonsurgical Therapy Surgical Therapy and Implants Maintenance Therapy Effects of Smoking Cessation on Periodontal Treatment Outcomes _figures/img_0595551ea58032b0.webp) **References** * Lindhes Clinical Periodontology and Implant Dentistry Chapter 11, 7th Edition 2022 * Electronic cigarettes :un update on products, regulations public health approaches and oral health, Anthony Weke and Richard Holliday, Community Dental health 2022 * Electronic cigarettes and Oral Health, JDR, R. Holliday et al 2021 --- **CHAPTER 23** **Risk Factors of Periodontal Disease (Smoking)** Philip M. Preshaw | Leandro Chambrone | Richard Holliday **CHAPTER OUTLINE** * The Smoking Epidemic * Effects of Smoking on the Prevalence and Severity of Periodontal Disease * Gingivitis * Periodontitis * Effects of Smoking on the Etiology and Pathogenesis of Periodontal Disease * Microbiology * Immune-Inflammatory Responses * Physiology * Effects of Smoking on the Response to Periodontal Therapy * Nonsurgical Therapy * Surgical Therapy and Implants * Maintenance Therapy * Effects of Smoking Cessation on Periodontal Treatment Outcomes Image of a book chapter outline page titled 'Risk Factors of Periodontal Disease (Smoking)' from Chapter 23. The authors listed are Philip M. Preshaw, Leandro Chambrone, and Richard Holliday. The layout is organized into three columns detailing the chapter structure: 'The Smoking Epidemic', 'Effects of Smoking on the Etiology and Pathogenesis...', and 'Effects of Smoking on the Response to Periodontal Therapy'. 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