Oulun ammattikorkeakoulu
ePooki 49/2019

Effects of Smoking and Nicotine Products on Oral Health

Metatiedot

Nimeke: Effects of Smoking and Nicotine Products on Oral Health. In A-L. Jussila & M. Oinonen (eds.) Oral Health Promotion

Tekijä: Cozzio Marta; Heikkinen Roosa; Kesti Minna; Lepola Saana; Määttä Jonna; Poikajärvi Laura-Kaisa; Ristaniemi Heli; Jussila Aino-Liisa

Aihe, asiasanat: tupakkatuotteet, suun terveys, tobacco products, oral health

Tiivistelmä: Smoking is one of the most significant risk factor in many diseases. That’s why prohibiting the beginning of smoking and encouraging quitting is very effective way to boost general health. Youngsters are especially vulnerable to start smoking and by targeting adolescents for anti-smoking information, smoking in the future will decrease nationwide.

Smoking has side effects on oral health, from aesthetic drawbacks to fatal diseases. The appearance is affected by the discoloration of the teeth, dentures and restorations. The sense of taste and smell deteriorates, and the breath of the smoker smells bad. Smoking can also lead to gum disease, tooth loss and in more severe cases mouth cancer.

Unfortunately, e-cigarettes seem to be increasingly popular and due to lack of information, often consider healthy option. More information about modern nicotine products would be needed for oral health care professionals as well. Then professionals would be able to give better advices for patients and there would be less misinformation.

Julkaisija: Oulun ammattikorkeakoulu, Oamk

Aikamääre: Julkaistu 2019-06-28

Pysyvä osoite: http://urn.fi/urn:nbn:fi-fe2019061019849

Kieli: englanti

Suhde: http://urn.fi/URN:ISSN:1798-2022, ePooki - Oulun ammattikorkeakoulun tutkimus- ja kehitystyön julkaisut

Oikeudet: CC BY-NC-ND 4.0

Näin viittaat tähän julkaisuun

Cozzio, M., Heikkinen, R., Kesti, M., Lepola, S., Määttä, J., Poikajärvi, L-K., Ristaniemi, H. & Jussila, A-L. 2019. Effects of Smoking and Nicotine Products on Oral Health. In A-L. Jussila & M. Oinonen (eds.) Oral Health Promotion. ePooki. Oulun ammattikorkeakoulun tutkimus- ja kehitystyön julkaisut 49. Hakupäivä 9.12.2019. http://urn.fi/urn:nbn:fi-fe2019061019849.

Smoking is one of the most significant risk factor in many diseases. That's why prohibiting the beginning of smoking and encouraging quitting is very effective way to boost general health. Youngsters are especially vulnerable to start smoking and by targeting adolescents for anti-smoking information, smoking in the future will decrease nationwide. That is why we wanted to study smoking and other nicotine product usage amongst adolescents and their effects on oral health. Regarding the subject we visited ninth graders in Oulu International School and gave them a presentation on nicotine products such as tobacco, smokeless tobacco and e-cigarettes.

Introduction

Smoking and other nicotine product usage amongst Finnish youngsters is generally decreasing. According to the latest statistics of The Adolescent Health and Lifestyle Survey 2017 conducted by Ministry of Social Affairs and Health, experimenting with smoking has decreased especially among 14–16-year-olds. Daily smoking among Finnish 12–18-year-olds has been decreasing year by year. Still, in 2017, daily smoking occurred in 2 % of 14-year-old girls and 1 % of 14-year-old boys, and correspondingly, in 8 % of 16-year-old girls and 9% of 16-year-old boys. About 16–17 % of 14-year-olds and about 37–38 % of 16-year-olds had experimented with smoking. Experimenting with snus and use of and experimenting with electronic cigarettes had not significantly changed when compared to the comparable survey of 2015. However, occasional or daily use of snus among 18-year-old boys increased when compared to 2015. Repeated use of water pipe was rare. Kinnunen, JM., Pere, L., Raisamo, S., Katainen, A., Ollila, H. & Rimpelä, A. 2017. Nuorten terveystapatutkimus 2017: Nuorten tupakkatuotteiden ja päihteiden käyttö sekä rahapelaaminen. Reports and Memorandums of the Ministry of Social Affairs and Health 28. Referred 7.2.2019. http://urn.fi/URN:ISBN:978-952-00-3878-6

Smoking among upper secondary school students

Smoking among young, teenagers has decreased over years. According to a study made in Norway, daily-smoking in adolescence declined 9,5 % in 17 years Braverman, M., Stawski, R., Samdal, O. & Aarø, L. 2017. Daily Smoking and Subjective Health Complaints in Adolescence. Nicotine & Tobacco Research 19 (1), 102–110. Referred 25.3.2019. https://academic.oup.com/ntr/article-abstract/19/1/102/2631682?redirectedFrom=fulltext. Another study made in Europe reveals that 30,9 % of teenage people smokes daily and 12,5 % are non-daily smokers Banzer, R., Haring, C., Buchheim, A., Oehler, S., Carli, V., Wasserman, C., Kaess, M., Apter, A., Balazs, J., Bobes, J., Brunner, R., Corcoran, P., Cosman, D., Hoven, C., Kahn, J., Keeley, H., Postuvan, V., Podlogar, T., Sisask, M. & Värnik, A. 2017. Factors associated with different smoking status in Europeanadolescents: results of the SEYLE study. European Child & Adolescent Psychiatry 26 (11), 1319–29. Referred 25.3.2019. https://www.ncbi.nlm.nih.gov/pubmed/28386649.

What are the reasons to justify smoking then? Most young smokers say that smoking relaxes them and some confirm that they are addicted to nicotine. Borderías, L., Duarte, R., Escario, J. & Molina, J. 2015. Addiction and Other Reasons Adolescent Smokers Give to Justify Smoking. Subst Use Misuse 50 (12), 1552–59. Referred 25.3.2019. https://www-tandfonline-com.ezp.oamk.fi:2047/doi/full/10.3109/10826084.2015.1023453 Young people start to smoke because their parents are smokers and that effects to the level of consumption also Borderías, L., Duarte, R., Escario, J. & Molina, J. 2015. Addiction and Other Reasons Adolescent Smokers Give to Justify Smoking. Subst Use Misuse 50 (12), 1552–59. Referred 25.3.2019. https://www-tandfonline-com.ezp.oamk.fi:2047/doi/full/10.3109/10826084.2015.1023453. On the other hand, great parental supervision is a factor to lower the risk of smoking among children Kim, H. & Chun, J. 2018. Analyzing Multilevel Factors Underlying Adolescent Smoking Behaviors: The Roles of Friendship Network, Family Relations, and School. Environment. Journal of School Health 88 (6), 434–443.. Overt peer pressure and impulsivity affect on starting smoking Defoe, I., Semon Dubas, J., Somerville, L., Lugtig, P. & van Aken, M. 2016. The Unique Roles of Intrapersonal and Social Factors in Adolescent Smoking Development. Developmental Psychology 52 (12), 2044–56. Referred 25.3.2019. https://psycnet.apa.org/record/2016-56613-004. Having ties with delinquent friends rises the risk of starting smoking Kim, H. & Chun, J. 2018. Analyzing Multilevel Factors Underlying Adolescent Smoking Behaviors: The Roles of Friendship Network, Family Relations, and School. Environment. Journal of School Health 88 (6), 434–443..

We visited Oulu international school to talk about nicotine products and their health effects on oral health. After our presentation, we asked the pupils to fill out a questionnaire. We wanted to map the nicotine usage among the group anonymously. Smoking in adolescence predicts smoking in young adulthood. If an adolescent is smoking one day per month, there is a tripled change to smoking also in young adulthood. Whereas, if an adolescent is smoking daily, the change of smoking as a young adult is almost quintupled. Dutra, LM. & Glantz, SA. 2018. Thirty-day smoking in adolescence is a strong predictor of smoking in young adulthood. Preventive Medicine 109. Referred 8.2.2019. https://doi.org/10.1016/j.ypmed.2018.01.014 The first question was "Do you use any nicotine products?", and we gladly found out that major part of the group doesn't use any nicotine products. Only one person out of 45 was using some nicotine products (figure 1).

Nicotine usage among ninth graders

FIGURE 1. Nicotine usage among ninth graders, n=45

After this question we were discussing that at this age group many may have tried some nicotine products but don't consider themselves active users. Adolescence is an especially vulnerable period to smoking initiation and evolution of nicotine addiction. Towns, S., DiFranza, JR., Jayasuriya, G., Marshall, T. & Shah, S. 2017. Smoking Cessation in Adolescents: targeted approaches that work. Paediatric Respiratory Reviews 22, 11–22. Re-ferred 8.2.2019. https://doi.org/10.1016/j.prrv.2015.06.001 That's why we decided to ask if they have tried any nicotine products even once.

With this question we found few more "yes" answers than before. Seven of the 45 pupils had tried nicotine products (figure 2). Positive aspect is that still major part, 87 %, haven't tried any. And because we got only one yes for active usage most of the pupils that have tried, didn't find it worth continuing.

Pupils that have tried some nicotine products

FIGURE 2. Pupils that have tried some nicotine products, n=45

Disadvantages of smoking and nicotine-containing e-cigarette liquids in the mouth

The use of tobacco products is a significant risk factor for several chronic diseases such as cancer, lung diseases and cardiovascular diseases. Tobacco products contain nicotine, which is a highly addictive psychoactive substance. WHO. 2019. Tobacco. Health Topics. Referred 11.3.2019. https://www.who.int/topics/tobacco/en/ Smoking has side effects on oral health, from aesthetic drawbacks to fatal diseases. The appearance is affected by the discoloration of the teeth, dentures and restorations. The sense of taste and smell deteriorates, and the breath of the smoker smells bad. Smoking can also lead to gum disease, tooth loss and in more severe cases mouth cancer. (Photo 1.) Heikkinen, A. & Keskinen, H. 2015. Tupakoinnin vaikutukset suun terveyteen. Duodecim 10.6. Referred 14.3.2019. https://www.terveyskirjasto.fi/terveyskirjasto/tk.koti?p_artikkeli=trv00076

Pupils trying to connect effects of nicotine products under the right title

PHOTO 1. Pupils trying to connect effects of nicotine products under the right title (photo: Poikajärvi Laura-Kaisa)

Electronic cigarette is a relatively new product. That's why there isn't reliable information on their long-term health risks. Cell and animal testing have made it possible to determine that e-cigarettes are harmful, both in short and in long term usage. Studies have found for example COPD like symptoms (chronic obstructive pulmonary disease) and also cancerous cell changes have been reported. E-cigarettes effect oral health nearly like regular cigarettes. Immediate effects are irritation of airways and stubborn cough. Users have reported many negative effects, for example metallic taste, diminished salivation, gum problems, "sugar coated" teeth (resulted mainly from the sugar intended to improve the taste of e-liquids), burning sensation in mouth and throat, irritation on mucous membrane and mouth numbing. Hua, M., Alfi, M. & Talbot, P. 2013. Health-Related Effects Reported by Electronic Cigarette Users in Online Forums. J Med Internet Res 15 (4), e59. Referred 18.1.2019. https://www.jmir.org/2013/4/e59/

E-cigarette users inhale water vapor formed from the liquid that the user has chosen. Often these liquids contain some flavorings and nicotine. Sugar is used to improve the taste of e-cigarette and like otherwise consumed sugar it can cause plaque, calculus, caries and gum problems. Food and Drug Administration of the USA has found small amounts of nitrosamines and diethylene glycol. Also, drug residues such as tadalafil and rimonabant has been found in these liquids. Often the announced nicotine content didn't match the one in the product and there may be variations also in pods of the same liquid. Terveyden ja hyvinvoinnin laitos. 2018. Sähkösavukkeiden turvallisuus ja terveyshaitat. Referred 18.1.2019. https://thl.fi/fi/web/alkoholi-tupakka-ja-riippuvuudet/tupakka/tupakkatuotteet-ja-sahkosavuke/sahkosavuke/sahkosavukkeiden-turvallisuus-ja-terveyshaitat

Smokeless tobacco has known harmful effects

Smokeless tobacco is emerging as a major public health hazard but it is often neglected as a risk factor by many clinicians Kulkarni, V., Uttamani, JR. & Bhatavadekar, NB. 2015. Comparison of clinical periodontal status among habitual smokeless-tobacco users and cigarette smokers. Referred 8.2.2019. https://onlinelibrary.wiley.com/doi/full/10.1111/idj.12192. Typical oral effects of smokeless tobacco are seen on the mucosal surfaces where the product is placed, as well as on the adjacent periodontium. Clinically, the lesion usually clearly marks out from the normal tissues. The lesion can be a white or yellow-brown colour and it may also have wrinkled appearance with increased use of oral tobacco. Other typical oral effects are for example staining of composite restorations and teeth, bad breath and reduction of taste and smell acuity. Epstein, B. & Walsh, M. 2000. The Oral Effects of Smokeless Tobacco. J Can Dent Assoc 66, 22–25. Referred 8.2.2019. http://cda-adc.ca/jadc/vol-66/Issue-1/22.pdf

According to research carried out in the United States of America the smokeless tobacco causes periodontal diseases as well as smoking. A research indicated that amount of plaque was higher in a smokeless tobacco group than in a smoking group and was statistically significantly higher than in the non‐tobacco‐consuming group. Probing depth and gingival inflammation were also higher in the smokeless tobacco group than in the smoking group and non‐tobacco‐consuming groups, but this was not statistically significant. Kulkarni, V., Uttamani, JR. & Bhatavadekar, NB. 2015. Comparison of clinical periodontal status among habitual smokeless-tobacco users and cigarette smokers. Referred 8.2.2019. https://onlinelibrary.wiley.com/doi/full/10.1111/idj.12192

Smokeless tobacco has been linked previously with tooth loss. Tooth loss was found to be statistically higher in smokeless tobacco users (56 %) and in patients smoking tobacco (58 %) com-pared with non‐users of tobacco (28 %). After all, this research proved smokeless tobacco is also a significant factor to periodontal diseases, as well as smoking, and the patients must be counseled about that by professionals of oral health care. Kulkarni, V., Uttamani, JR. & Bhatavadekar, NB. 2015. Comparison of clinical periodontal status among habitual smokeless-tobacco users and cigarette smokers. Referred 8.2.2019. https://onlinelibrary.wiley.com/doi/full/10.1111/idj.12192

The usage of nicotine products and health promotion in Italy

We co-operated with an Italian exchange student for this article to get more international view. In 2018 there were 12.2 million smokers in Italy, that was 23.3% of the population. 19.2 % of women smoke against 27.7 % of men. Survey of 15 000 young people in collaboration with EXPLORA 11.1 % of young people between 14 and 17 years old are regular smokers, 13.9 % are occasional smokers and young who have tried smoking are 20.2 %. There are also around 2 % of ex-smokers. This means that over 47 % of young minors have some contacts with tobacco products. 51.8 % of these young smokers started smoking during high school (over 14 years old), 43.7 % during middle school (between 11 and 13), and 4.5 % in elementary school (between 9 and 10).

Users of e-cigarettes are around 1.1 million in Italy. The majority of users (75.3 %) are represented by dual consumers who smoke traditional cigarettes and at the same time e-cig. About 1.4 million people (2.7 % of the population) tested the new generation tobacco products (heated tobacco). Of these, 54.5 % are smokers, 11.4 % are ex-smokers and 34.1 % have never smoked. These products increase their popularity, their fame in three years increased from 21.5 % to 52.3 %. 

Examples of health promotion

  1. Shock images: The strong images and warnings about the risks reported on the packages were not indifferent to the smokers. A survey finds that they were noted by 91,1 % of the smokers. Smokers thought about health risks in 77.7 % of the cases. 

  2. Telephone number: The "Numero Verde Fumo" (TVF) 800 45 40 88 has received around 50 000 phone calls in 15 years of activity. The service team proposes personalized interven-tions, offering counseling and helping to reach the local health structures. 

  3. Campaigns by the Health Ministry: In 2018 the Ministry produced a spot, in which an Italian actor Nino Frassica is a psychoanalyst who has two particular patients: the stepmother of Snow White and the Wolf of Little Red Riding Hood. The characters complain about their lives because they smoke. The psychoanalyst advises them to stop, because who doesn’t smoke is happier and especially because smoking is the first cause of cancers. In the conclusion the stepmother and the wolf stop smoking and create a happy ending. 

Future without smoking

Organization called "Savuton Suomi 2030" is working for smoke free Finland and hopes to reach their goal, maximum 5 % of adult population smoking, till 2030. Important part of reducing the amount of adults smoking is to prevent beginning of smoking in their teenage years. This is partly the reason why we wanted to talk about how hazardous smoking is with these ninth graders. Unfortunately, we felt that we didn't have enough time to present our topics properly due to limited time and vast information that we wanted to share. In the end questionnaire we asked if there was anything that made them think about their nicotine usage. Only 18 % answered yes (figure 3). But consider that majority of this group hadn't even tried any nicotine products, they might be perfectly happy with their lack of nicotine usage after the presentation. Maybe this question could have been more determined to get more specific answers.

Per cents of pupil’s that started to think about their nicotine products usage after the presentation

FIGURE 3. Per cents of pupil's that started to think about their nicotine products usage after the presentation, n=45

Conclusions

Thankfully smoking is decreasing amongst adolescents and by our perspective the target group seemed rather disgusted by the pictures of smokers' mouths. Unfortunately, e-cigarettes seem to be increasingly popular and due to lack of information, often consider healthy option. We wish that more information about modern nicotine products would be distributed for oral health care professionals as well. Then professionals would be able to give better advices for patients and there would be less misinformation.

The figure 4 demonstrates pupils' answers to question: "Did you learn anything new regarding oral health today?". And we were happily surprised that most of the answers told that they learned something new. Because question was general question about the whole lesson, oral self-care, xylitol, nutrition and drinks and nicotine products, we can't make conclusions whether they learned something new about nicotine products and their harmful effects. But overall results are positive.

Pupil’s learning after the lecture

FIGURE 4. Pupil's learning after the lecture, n=45

References

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