Vaping and Marijuana Complicate Kicking the Tobacco Habit

In this month’s letter, Dr. Rick Valachovic asks tobacco-cessation educators how their work has changed with the advent of vaping and some states’ legalization of recreational marijuana use.

You may recall the title of my May letter, “A Matter of Life and Death.” I could easily have used the same title this month, but whereas deaths from pediatric sedation (last month’s topic) are extremely rare and occur in a matter of minutes, deaths related to tobacco use remain all too common and occur over the course of decades. Will the availability of new, smokeless nicotine delivery systems reduce smoking-related deaths or introduce a new generation to the tobacco habit? Will the legalization of marijuana in more and more states introduce a new contaminant to people’s mouths and lungs or simply decriminalize a hidden behavior?

The research into these questions is incomplete and contradictory, but we have several reasons to be concerned about new practices that complicate the effort to reduce tobacco use. Smoking marijuana poses similar risks to smoking tobacco and may be responsible for some additional oral health effects. As an ADA topic page points out, THC, an appetite stimulant, encourages snacking, which may explain why using marijuana is associated with higher numbers of caries.

Vaping, which delivers nicotine without the smoke, has been heralded by some as a welcome alternative to tobacco use. In fact, the United Kingdom embraces the practice in its effort to help smokers quit.

“It’s part of the National Health Service’s treatment plan for those who want to quit to incorporate e-cigarettes and vaping,” says self-described tobacco nerd Joan Davis, RDH, Ph.D., Director of Research, Special Projects & Initiatives at the A.T. Still University Missouri School of Dentistry & Oral Health. “On the other hand, the CDC is 110% against it.”

Why are scientists at the Centers for Disease Control and Prevention concerned? You can get the full CDC assessment of e-cigarettes on the agency’s website and a summary of the evidence on the public health consequences of using them in a 2018 report from the National Academy of Sciences, Engineering, and Medicine. In a nutshell, while e-cigarette vapor typically contains fewer toxins than tobacco smoke, it is far from harmless.

• The primary ingredient, nicotine, is highly addictive and affects the developing brain.
• Vaping liquids contain flavorings and other chemical additives, some of which are linked to cancer and other serious diseases.
• The process of converting liquids into an inhalable vapor involves heat, which can damage cells in the mouth, potentially increasing the risk of such oral conditions as infection, inflammation and gum disease.
• Perhaps of most concern is the popularity of vaping among young people, leading many observers to fear that the practice may induce users to start smoking and expose them to all its attendant harms. (A recent issue of The New Yorker offers a vivid portrait of the phenomenon in affluent high schools.)

As we consider these risks, our experience with tobacco may be instructive. It took decades of concerted effort with substantial government support to bring smoking rates down to the current level, roughly 15% in the United States and Canada. Nevertheless, one in five deaths is still linked to tobacco use, a habit that also contributes to tooth loss, periodontal disease and oral cancer among the living.

“Somehow this problem has not gone away,” Joan points out, “and the most addicted populations are those who are poor, have limited education or are mentally ill.”

CDC statistics corroborate this statement. Almost a third of adults with less than a high school degree smoke cigarettes, as compared with 10.4% of college-educated adults. This disparity explains why many highly educated people think smoking is no longer an issue, despite the fact that 480,000 people die from it each year.

The good news is that smoking-cessation interventions work, and dental professionals are well positioned to deliver them effectively. A 2012 Cochrane review of 14 studies found that interventions conducted by oral health professionals roughly doubled the rate of tobacco abstinence at six months or longer. Unfortunately, the treatment of tobacco dependence continues to be inconsistent in many dental practices, suggesting a growing role for dental and other health professionals who are ready and willing to talk with their patients about what they are inhaling.

Joan would like to see everyone receive a tobacco-cessation intervention at every appointment, but she acknowledges that several barriers stand in the way. She told me many dentists don’t think tobacco-cessation counseling falls within their purview. Others lack the necessary skill set, and based on their limited experience, they believe that counseling doesn’t work. Joan attributes these failures to a lack of understanding about motivational interviewing and health behavior change.

“You need to ask open-ended questions as opposed to, ‘Did you quit yet?’” she says, and work in questions about tobacco and other substance use with routine questions about brushing and flossing. Many dentists are also pressed for time.

That’s certainly true for dental educators, who, research shows, also have a mixed record when it comes to preparing new providers to help their patients kick the tobacco habit. Joan and several colleagues have surveyed U.S. and Canadian dental schools and U.S. dental hygiene and dental assisting programs about tobacco dependence education (TDE). Among the researchers’ findings:

• As of 2016, TDE had not been consistently integrated into predoctoral education.
• At dental schools, 90% of respondents indicated that faculty members were “confident” to “extremely confident” in teaching tobacco-related pathology, but only 49% reported the same level of confidence in teaching students how to help patients quit.
• Three-quarters of dental hygiene programs reported expecting their graduates to be competent in a moderate-level tobacco-cessation intervention, but only one quarter reported having a formal competency that encompassed the U.S. Public Health Service’s Clinical Practice Guidelines for such an intervention.
• Almost all dental assisting programs addressed oral and systemic diseases related to tobacco use, but less than 30% of programs covered key topics related to tobacco cessation.

All dental providers should be versed in TDE, according to Laura Romito, D.D.S., M.S., M.B.A., Associate Professor at the Indiana University School of Dentistry (IUSD), Director of its Nicotine Dependence Program, and Associate Director for Faculty Development and Curriculum at the IU Interprofessional Practice & Education Center.
“Patients may share more readily with a dental assistant or a dental hygienist than with the dentist, so we advocate for tobacco interventions to involve the entire oral health team,” she says. “It’s one of the things that makes Indiana unique.”

IUSD has been a leader in tobacco research, education and cessation since Arden Christen, D.D.S., M.S.D., M.A., started the school’s first programs in these areas in 1980. Historically, the university’s Nicotine Dependence Program has ranked among the most successful in the field. According to a 2001 paper in the Journal of Dental Education, the program’s one-month quit rate was 58% and its one-year quit rate was 33%, well above the national averages for intensive interventions.

IUSD continues to be among a handful of schools that do an exemplary job when it comes to TDE. Led by Pamela Rettig, M.S., IUSD’s dental hygiene TDE program requires all students to work on their communication skills and to develop a personalized quit plan for a friend or family member. The dental assisting program makes sure students graduate with knowledge of tobacco’s oral health effects, various tobacco products, and behavioral and pharmacological interventions, enabling graduates to advance the oral health care team’s tobacco-dependence treatment efforts.

Dental students learn to:

• Take a social history that captures the use of tobacco, e-cigarettes and marijuana.
• Educate patients on the oral health implications of continued use of these substances, advise them of the benefits of quitting and gauge whether they are interested in doing so.
• Connect patients who want to reduce their tobacco use with resources, such as the state’s quitline, or providers who can prescribe pharmacotherapy for tobacco cessation.

Students may also choose to counsel patients themselves. During a clinical elective, which Laura supervises, students develop a behavioral and pharmacological treatment plan and initiate counseling. They seek to identify the triggers that influence each patient’s substance use and the barriers that discourage them from quitting. Laura then evaluates students on a range of competencies.
“Can they assess patients’ use of these substances? Can they develop a cessation treatment plan? Can they communicate effectively with the patient using the motivational interviewing techniques that they’ve been taught?” Laura asks.

In Joan Davis’s view, this assessment piece is key. If the Council on Dental Accreditation made evidence-based tobacco-cessation counseling a graded clinical competency, she believes it would be a game changer. “Schools would have to back it up with didactic education, make time in the curriculum and provide faculty with training,” she says. “A lot of schools teach students about tobacco using nongraded case studies. These don’t demonstrate students’ interpersonal skills, which are essential for tobacco cessation.”

Schools and programs that want to bolster their tobacco education will find a ready-made, open-access resource in Tobacco Free! Curriculum^©, which includes learning objectives, student activities and assessments. Joan designed the curriculum while on the faculty at Southern Illinois University Carbondale well before vaping and marijuana legalization were on everyone’s radar screens, but she believes it’s premature to change the fundamentals of tobacco cessation education until more definitive research emerges about how use of these additional substances influences people’s efforts to quit.

“Honestly, I think educators and clinicians need to just keep doing what they’re doing and up their game to provide more comprehensive treatment,” she says. “If everybody at least asks if people use tobacco products and encourages them to quit and gets them to a quitline, that’s good. It would be even better if they could work on motivating them to quit.” (A quitline is a tobacco cessation service available through a toll-free telephone number. Quitlines are staffed by counselors trained specifically to help smokers quit.)

One of the challenges of addressing tobacco use in today’s more complex social environment, Laura says, is identifying the practice in the first place. People who vape, or go to a hookah bar on the weekends, don’t always think of themselves as smokers. “They need to understand why we’re asking,” she says, “and that using these products may have oral health ramifications.”

As science sheds additional light on newer nicotine delivery systems and marijuana use, the principles underlying tobacco-dependence treatment will likely remain relevant, she says. At IUSD, they are currently studying the feasibility of integrating a clinical decision support system in the electronic health record that would trigger tobacco-cessation counseling. “This should help to standardize student oral health provider’s messaging,” Laura says, “and hopefully make their interventions more effective.”