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The 5 A's are Ask, Advise, Assess, Assist, and Arrange.

Most people are aware of smoking as a risk factor for many serious systemic conditions including cardiovascular disease, cerebrovascular disease, chronic obstructive pulmonary disease, low birth weight babies of smoking mothers, and cancer. Despite the ill-health risk associated with smoking, nearly 25% of adults and 35% of high school students in North America smoke.¹ Some smokers have mistakenly switched to smokeless tobacco as a safer substitute. Unfortunately smokeless forms of tobacco use are also associated with negative health effects. It is estimated that the lifetime prevalence of smokeless tobacco use in the US is 17.2%, with 3.1% of the population having used smokeless tobacco in the past month.²

The oral cavity often reflects the negative impact of tobacco product use whether smoke or smokeless although the presentation of the deleterious results can differ by type of product used. Smoking provides the following threats to oral health: cancer, gum diseases, and delayed healing. Malignant and premalignant lesions have a predilection to occur in a horseshoe shaped area of the mouth including the ventrolateral surfaces of the tongue, floor of the mouth, and retromolar areas.³ Most commonly the oral cancer type is squamous cell carcinoma. The survival rate for oral cancer is less than 60%.⁴ Approximately 30,000 new cases of oral cancer occur in the US each year.⁵ Other findings associated with smoking are stained teeth, tarter buildup, bad breath, and decreased taste.

Destructive periodontal disease is a common finding among smokers. They experience greater bone loss and attachment loss, as well as more pronounced frequency of periodontal pockets than non smokers. Tooth loss is more extensive.⁶ Furthermore, smoking is associated with poorer treatment outcomes irrespective of treatment modality and the risk of implant failure is increased.⁶

Another form of periodontal disease particularly affects young smokers with poor hygiene.⁷ It has also been associated with stress. It is called acute necrotizing ulcerative gingivitis (ANUG) but formerly "trench mouth" because of its prevalence among young Soldiers in war conditions. In ANUG a rapidly progressing necrosis of the interdental papilla occurs. A characteristic foul odor accompanies the condition.

Pipe smokers are prone to other maladies. They frequently suffer abrasion of the chewing edges of the teeth where the pipe is held and sometimes an open bite. Additionally an inflammation of the palate called nicotine stomatitis is often present.

Smokeless tobacco products are of two general types: chewing tobacco and snuff. Snuff is pulverized fire cured tobacco and comes in two varieties, moist and dry. The dry type is usually inhaled whereas the moist type is placed in the oral cavity between cheek and gum. Chewing tobacco is coarser than snuff and comes in three varieties, loose-leaf sold in pouches, plug in small blocks, and twisted in strands. Like moist snuff, chewing tobacco is placed between cheek and gum. All varieties of smokeless tobacco can cause harmful effects on the oral cavity. Almost 80% of daily smokeless tobacco users have an identifiable soft tissue lesion!²

Smokeless tobacco habits can result in the formation of a white patch in the area where the tobacco quid is held. This white patch, called leukoplakia, can be premalignant or even malignant. Localized destruction of gum tissue can also occur where the quid is held resulting in a stripping of the gum from the teeth. Since the quid often contains sugar, dental cavities can occur in the teeth.

Both smoke and smokeless tobacco products contain nicotine which can result in dependence and addiction. Although nicotine itself is not associated with cancer there are many other carcinogenic agents in tobacco products. It is estimated that there are 4000 chemicals and gases in smoking tobacco and some 3000 chemicals in smokeless tobacco.⁵

The habitual use of tobacco products is multifactorial and includes physiologic and sociologic components. Overcoming the addictive nature of nicotine includes cessation regimens that help address the effects of withdrawal while providing social support to the "quitter" for the lifestyle change that must occur. It has been shown that nicotine replacement therapy nearly doubles the success rate of cessation programs.⁵ Health care providers are encouraged to provide the 5-As - ask about tobacco use, advise users to quit, assess the users readiness to quit , assist motivated individuals with pharmacologic aids or referral, and arrange for follow up services.⁵

With popular culture's focus on youth and beauty it would seem that preventing the habituation or ceasing the habit would be strongly motivating for cosmetic reasons alone. However, the environment that encourages smoking is difficult to avoid. Many smokers will require many attempts to beat the habit of tobacco products but success over such a pernicious malefactor is truly something to smile about.

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References

2. Judith S. Gordon and Herbert H. Severson. Tobacco Cessation Through Dental Office Settings. JDE 2001; 65:4, pp 354-363.

3. Sayed M. Mirabod and Stephen I. Ahing. Tobacco-Associated Lesions of the Oral Cavity Part II. Malignant Lesions. JCDA 2000; 66:6 pp308-311.

4. Sol Silverman, Jr. Controlling oral and pharyngeal cancer can dental professionals make a difference? JADA 2005: 136 pp576-577.

5. Arden G. Christen, Stephen J. Jay, and Joan A. Christen. Tobacco cessation and nicotine replacement therapy for dental practice. General Dentistry 2003; 51:6, pp525-532.

6. Jan Bergstrom. Tobacco smoking and chronic destructive periodontal disease. Odontology 2004; 92 pp1-8.

7. Sayed M. Mirabod and Stephen I. Ahing. Tobacco-Associated Lesions of the Oral Cavity Part I. Nonmalignant Lesions. JCDA 2000; 66:5, pp252-256.