THE CE ANSWER SHEET APPEARS ON PAGE 37 adolescents.4,9 In addition, ENDS use is also associated with the utilization of other tobacco products among youth and young adults.9,11 The Tobacco Products and Risk Perceptions Survey found that 1% of adults who had never smoked reported using ENDS in the past 30 days, with almost 5% of those who had never smoked using these products at some point.12 It is concerning that individuals who identify as nonsmokers are using ENDS, suggesting a widespread belief they are less harmful than other tobacco products.9 reported using ENDS.12 the harmful effects of cigarette smoking and decrease smoking frequency suggest ENDS may be helpful in tobacco cessation,13,14 Oral health pro- The survey also found nearly 21% of current smokers Although systematic reviews of ENDS use to reduce the long-term safety and health effects of ENDS use are unknown. Additionally, the evidence about the ability of ENDS to reduce smoking is of low quality.13,14 fessionals should monitor emerging information on this topic and be wary of e-cigarette vendors wanting to advertise their products in the dental office. Hookah tobacco is known by a number of names, including water pipe tobacco, maassel, shisha, narghile and argileh.15 used socially at parties, cafes and lounges.16 Hookah pipes tend to be Flavor enhancers may also be added, and almost 79% of youth who used a hookah reported choosing it because of the flavors available.17 Many users believe hookah smoking is less harmful than cigarettes, but evidence suggests the health outcomes and addiction issues are similar.18 Water pipe smoking sessions tend to last 30 to 90 minutes. A systematic review and meta-analysis found one session of hookah smoking resulted in 74.1 liters of smoke inhalation versus 0.6 liters for smoking a cigarette.19 Higher levels of carbon monoxide, nicotine and tar are also released during a hookah session. Although the prevalence of water pipe use among adults is approx- imately 4%,3 prevalence among youth is higher. About 7% of high school students report hookah use, an increase from 4% in 2011.5 Among middle school students, the prevalence of hookah use increased from 1% in 2011 to 2% in 2015.5 Smokeless tobacco products include chewing tobacco (also known as spit tobacco), dry snuff, and moist snuff or snus. These products contain high- intensity sweeteners, such as sucralose, in higher concentrations than is found in candy and soda.20 make it more appealing, especially to youth.20 Sweeteners mask the unpleasant taste of tobacco and In 2014, 59% of youth who used smokeless tobacco reported choosing a flavored variety.21 About 2.5% of adults report using smokeless tobacco products;3 how- ever, 6% of high school students and almost 2% of middle school students report using smokeless tobacco.5 tobacco decreased about 1% between 2011 to 2015.5 The percentage of youth using smokeless Despite this decrease, frequent use (defined as > 20 days in the last 30 days) of smokeless tobacco was most prevalent among high school students (42%) and middle school students (29.2%).4 Dissolvable tobacco come in strips (placed on the tongue to dissolve), sticks (similar to large toothpicks), and lozenges or orbs.22 The nicotine con- tent varies, but these products can contain as much or more than a typical cigarette. Data on the prevalence of dissolvable tobacco use are not available because it is typically combined with smokeless tobacco in national surveys. Cigars, little cigars and cigarillos, as well as tobacco wrapped in a tobacco leaf, are additional forms of tobacco use.23 as a pack of cigarettes.23 One cigar contains as much tobacco Little cigars and cigarillos may be flavored to enhance appeal, especially to youth and young adults. Adolescents reported using DecisionsInDentistry.com cigars because they liked the flavors (73.8%) and considered them affordable (58.2%).17 In the study by Singh et al,5 approximately 9% of high school stu- dents and 5% of adults reported using cigars in the past 30 days. HEALTH EFFECTS In addition to the well-known negative health effects of tobacco use, nico- tine exposure significantly harms the developing adolescent brain.9 The fact that use of ATPs among youth is increasing emphasizes the need for effective prevention and cessation programs. Like traditional cigarette smoking, hookah smoking harms cardiovas- cular and respiratory health by increasing blood pressure, decreasing immunity, and raising the risk for chronic obstructive pulmonary dis- ease.18,24 A systematic literature review found five studies that evaluated the association between periodontal disease and hookah smoking.24 Of these to suggest that it is unclear whether an association exists between water pipe smoking and periodontal disease. The health effects of heated and aerosolized components of e-cigarette liquids (e.g., nicotine, solvents, flavoring and toxicants) are unknown at this time.9 Another emerging trend is polytobacco use, or the use of more than one type of tobacco product. Polytobacco use is increasing among those who use ATPs and is associated with increased risk of nicotine addiction.25,26 This addiction leads to more problems with tobacco dependence and can hinder the success of tobacco cessation efforts.25,26 health effects of polytobacco use warrant further research. Thus, the long-term PREVENTION AND CESSATION Tobacco prevention and cessation programs have been focused on smok- ing, leaving few resources to address ATPs. According to the U.S. Preventive Services Task Force’s (USPSTF) guidelines for children and adolescents, efforts LINDA D. BOYD, RDH, RD, EdD, is the dean and a professor at the Forsyth School of Dental Hygiene at MCPHS University in Boston. She can be reached at [email protected]. The author has no commercial conflicts of interest to disclose. December 2017 • Decisions IN DENTISTRY 45 studies, four were with the same participants, limiting the sample size. This led Waziry et al24 TABLE 1. Questions to Use During the Ask Phase of Tobacco Cessation Intervention Type of Tobacco Cigarettes Cigars E-cigarettes Water pipe/hookah Smokeless Cigarettes per day/week Number per week Cartridges per day/week Approximate times per day/week Cans/pouches per day/week Dissolvable strips, sticks, orbs, etc. Amount per day/week Other types of tobacco products? Amount per day/week Last Quit Attempt Tell me some of the reasons you have been motivated to quit tobacco use in the past. How long did you quit last time? Have you used any products to help you quit? What have you tried that worked best? What is the longest period of time you have quit? What kinds of things caused you to relapse?
