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Compendium
April 2022
Volume 43, Issue 4

Tobacco and Nicotine: Helping Patients Break Free

Nevin Zablotsky, DMD

It is interesting how the deadly SARS-CoV-2 virus has evolved over time to survive, as its human hosts try to develop vaccines and medicines to combat it. As we know, hundreds of thousands of Americans have died from COVID-19, and unfortunately many more will probably die as well. Public health officials continue to struggle to devise policies to protect people amid swirling controversies over the balance between freedom of choice and communal efforts to fight this viral threat.

Over the past 20 years approximately 10 million Americans have died from tobacco-related illnesses.1Tobacco was first cultivated in South America between 5,000-3,000 BC and was used in religious rites and medicinal treatment, including relieving toothaches. Tobacco use continued, with the mode of its use "evolving" from pipes, to snuff, to cigars, to the papelote (tobacco wrapped in paper), to cigarettes.2 As it became clearer that cigarettes were sickening and killing many people, the tobacco industry in the United States developed a tobacco "harm reduction" strategy, with the introduction of filtered cigarettes in the 1950s and low-tar and "light" cigarettes in the 1960s.3

This led to the development of low-nicotine cigarettes in 19893 and "heat not burn" products (tobacco heated to 350°F) in the 1990s.4 E-cigarettes ("vaping") came along in 2004,1 followed by more recent entries of synthetic nicotine e-cigarettes,5 a newly FDA-approved return to low-nicotine cigarette,6,7 and new hemp cigarettes with cannabidiol (CBD). Whew! What will the tobacco industry think of next?

Just as the mode of tobacco use has evolved, so too has the nicotine molecule, which was first identified in 1828 in Heidelberg, Germany. In the 1960s, scientists at Philip Morris altered its structure by adding ammonia, creating a "free-based" nicotine molecule. This made it more readily absorbable into the lungs and able to pass through the blood brain barrier, making it more addictive to those using it.8

Fast forward to 2007 when JUUL Labs, Inc. mixed free-base nicotine with benzoic acid, making it even more absorbable, delivering twice the concentration of nicotine of other e-cigarettes and approaching the speed of the nicotine "hit" of regular cigarettes. Present-day concentrations now reach 5% to 7%. Moreover, this latest concoction is not harsh to smoke and has a pleasant smell and taste-a perfectly appealing draw to young, unsuspecting youths who don't realize they're inhaling addictive nicotine.7 Nicotine is well-known to have serious systemic side effects in addition to being highly addictive. It adversely affects the heart, reproductive system, lungs, kidneys, and more, and its carcinogenic potential has been consistently demonstrated.9 To say that its inhalation in an aerosol, or in any vehicle, is "safer" than smoking is misleading and disingenuous.

Many years ago two young female patients of mine died from lung cancer. They were heavy smokers and despite my urgings were unable to quit. This left me feeling angry at myself for not doing more to help them quit, and angry at them for not trying harder to stop. But my anger was misdirected. These patients had an addiction and had lost their ability to stop smoking, as their addiction was too powerful. Clearly, they needed professional help to do so, which I was ill-equipped to provide. Since then I have tried to learn as much as I can about tobacco and nicotine. The more I have learned, the more, in my opinion, I see comparisons between how the tobacco and nicotine industries have intentionally "evolved" their products to sustain their businesses in the guise of "helping" the public quit smoking cigarettes, and how a virus evolves to sustain itself.

The health consequences of smoking, including exposure to second-hand smoke, are wide-ranging and devastating. The negative influence of tobacco use on the oral cavity has been well-documented, causing stained teeth, bad breath, tooth loss, periodontal disease, loss of taste and smell, delayed and impaired wound healing, cleft lip and palate, dental caries, leukoplakia, and oral cancer.10 Studies have shown that a reduction or cessation of use 6 to 8 weeks prior to procedures can lead to more successful treatment outcomes.11

Dental professionals need to educate themselves about the influence of these products and tobacco cessation techniques, be it in dental school or through continuing education courses. It is important to identify patients who use these products and discuss with them their impact on oral and overall health and guide them to resources to help them quit. This link at cancer.net can help do that: https://www.cancer.net/navigating-cancer-care/prevention-and-healthy-living/stopping-tobacco-use-after-cancer-diagnosis/resources-help-you-quit-smoking.

Over the years, I have been only modestly successful in getting patients to break this addiction. And yet, it has proven to be one of the most appreciated and gratifying things I have experienced in my 40 years of practice. Let it be for you as well.

About the Author

Nevin Zablotsky, DMD
A senior consultant and lecturer at Nova Southeastern University College of Dental Medicine, Fort Lauderdale, Florida, Dr. Zablotsky lectures nationally and internationally and has written
extensively on tobacco and oral health.

References

1. Franck C, Budlovsky T, Windle SB, et al. Electronic cigarettes in North America: history, use, and implications for smoking cessation. Circulation. 2014;129(19):1945-1952.

2.Gately I. Tobacco: A Cultural History of How an Exotic Plant Seduced Civilization. New York, NY: Grove Press; 2001:179.

3. Shopland DR. Historical perspective: the low tar lie. Tob Control. 2001;10 suppl 1(suppl 1):i1-i3.

4. Elias J, Ling PM. Invisible smoke: third-party endorsement and the resurrection of heat-not-burn tobacco products. Tob Control. 2018;27(suppl 1):s96-s101.

5. Jordt SE. Synthetic nicotine has arrived. Tob Control. 2021. doi: 10.1136/tobaccocontrol-2021-056626. https://tobaccocontrol.bmj.com/content/early/2021/09/07/tobaccocontrol-2021-056626. Accessed March 3, 2022.

6. Food and Drug Administration. FDA Authorizes Marketing of Tobacco Products that Help Reduce Exposure to and Consumption of Nicotine for Smokers Who Use Them. FDA News Release. December 23, 2021. https://www.fda.gov/news-events/press-announcements/fda-authorizes-marketing-tobacco-products-help-reduce-exposure-and-consumption-nicotine-smokers-who. Accessed March 3, 2022.

7. Bhatnagar A, Whitsel LP, Blaha MJ, et al. New and emerging tobacco products and the nicotine endgame: the role of robust regulation and comprehensive tobacco control and prevention: a presidential advisory from the American Heart Association. Circulation. 2019;139(19):e937-e958.

8. Talih S, Salman R, El-Hage R, et al. Effect of free-base and protonated nicotine on nicotine yield from electronic cigarettes with varying power and liquid vehicle. Sci Rep. 2020;10(1):16263.

9. Mishra A, Chaturvedi P, Datta S, et al. Harmful effects of nicotine. Indian J Med Paediatr Oncol. 2015;36(1):24-31.

10. American Dental Association. Smoking and tobacco. Mouth Healthy website. https://www.mouthhealthy.org/en/az-topics/s/smoking-and-tobacco. Accessed March 3, 2022.

11. Møller AM, Villebro N, Pedersen T, Tønnesen H. Effect of preoperative smoking intervention on postoperative complications: a randomised clinical trial. Lancet. 2002;359(9301):114-117.

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