Science Policy


R.C. Moffat, K.M. Byrd, X. Li, Y-H. Yu, C.H. Fox, M.K.S. Charles-Ayinde

The American Association for Dental, Oral, and Craniofacial Research (AADOCR) recognizes that tobacco use is one of the largest public health threats in the world1,2. Tobacco products come in many forms. Some are smoked, and others are not, but none is safe for human consumption3. Despite this common knowledge, reports show that most people who use cigarettes began smoking as an adolescent4; and nearly nine out of 10 smokers started smoking by age 184. In 2021, of the 2.55 million high- and middle- students that reported current (past 30-day) use of a tobacco product, e-cigarettes were the most commonly used tobacco-derived product*, cited by 2.06 million5. Among adolescent and adult users, smokeless tobacco (spit tobacco), snus, and electronic nicotine delivery systems (ENDS) are considered harm reduction alternatives to smoked tobacco; however, they contain their own risks for oral and overall health. After years of rigorous and extensive research, chronic tobacco use has been shown as a primary risk factor for six of the eight leading causes of death worldwide, and tobacco use is estimated to contribute to the death of eight million people each year6.

Tobacco use can result in acute and chronic oral diseases. Head and neck cancers1,2,7 and periodontitis2,8,9, compromised wound healing10,11, a reduction in the ability to smell and taste12, melanoses (dark pigmentation of the oral tissues)13, smoker’s palate (harder white thickened mucosal tissues)13, staining of teeth14 and restorations14,15, and peri-implant diseases16 are all seen at higher rates in tobacco users than in nonusers. Smokeless tobacco use is a risk factor for oral cancer, erythroplakia, leukoplakia, periodontal disease, and staining of teeth and restorations17. Caries risk in the primary dentition is increased due to secondhand smoke exposure18. Poorly developed enamel in the primary and permanent dentition may be related to secondhand cigarette smoke exposure during childhood19. Smoking increases the risk for stroke by about three-fold coronary heart disease by 2–4 times, lung cancer by twenty-five-fold, and head and neck cancer by 10-fold7,20. Smoking also causes reproductive problems, cardiovascular disease, leukemia, cataracts, pulmonary disease, and cancers of the liver, blood, cervix, kidney, pancreas, stomach, lung, larynx, bladder, oropharynx, and esophagus7.

Furthermore, each day in the United States, about 1600 youth smoke their first cigarette, and nearly 200 become daily cigarette smokers4. Adolescents report various factors leading to the initiation of smoking, including peer pressure, parents that are smokers, rebelliousness, clever marketing tactics from the tobacco industry, and nicotine as a “feel-good” drug without intoxication21. If smoking persists at the current rate among youth in this country, 5.6 million of today’s population younger than 18 years of age are projected to die prematurely from a smoking-related illness2. This represents about one in every 13 American youth. If youth can be discouraged from starting smoking, it is less likely that they will start smoking as adults.

Since 2014, ENDS, specifically e-cigarettes, have been the most commonly used tobacco-derived product* among U.S. youth5. Between 2011 and 2019, the proportion of high school students who were current e-cigarette users increased from 1.5% to 27.5%22. Ninety-nine percent of e-cigarettes contain nicotine23. Therefore, the use of e-cigarettes with this addictive component can result in short- and long-term health effects in adolescents. These effects include damage to regions of the developing brain that control attention, learning, mood, and impulse control24, increased risk for future addiction to other drugs24, increased mental health impacts25, respiratory function impairment, and structural changes in lung tissue26 as well as increased risk of coronary heart disease and heart attack27. Furthermore, health claims that e-cigarettes are effective smoking cessation aids are inconclusive based on current scientific evidence28. According to the 2020 Surgeon General’s report, the current evidence is suggestive but not sufficient to infer that the use of e-cigarettes containing nicotine is associated with increased smoking cessation compared with the use of e-cigarettes not containing nicotine, and the evidence is suggestive but not sufficient to infer that more frequent use of e-cigarettes is associated with increased smoking cessation compared with less frequent use of e-cigarettes28,29,30,31 indicating that much more research is needed.

Secondhand smoke (SHS) imposes significant risks as well. Tobacco smoke contains at least 7,000 chemicals, 70 of which can cause cancer and many more that are toxic or teratogenic32. Secondhand exposure results in the death of 41,000 nonsmoking adults and 400 infants each year32. SHS causes a 20 to 30 percent increased risk for lung cancer for those living with a smoker, and a 25 to 30 percent increased risk for coronary heart disease for non-smokers exposed to SHS33. Infants and children who are exposed to smoke are at risk for sudden infant death syndrome (SIDS)1,7,34,35, acute respiratory infection, bronchitis, pneumonia, middle ear infections, and asthma during infancy35. Prenatal exposure to secondhand smoke has been associated with thirdhand smoke, which refers to the residual toxins that are found on surfaces in the home due to smoking36. These volatile compounds become airborne particulate matter easily dispersed throughout the home over time37. Because children generally are found in areas close to the ground that is more highly contaminated and because infants ingest dust at a rate that is more than twice that of an adult, they are even more susceptible to thirdhand smoke37. Studies have shown that children exposed to thirdhand smoke have increased cognitive deficits in addition to the other associated risks of secondhand smoke exposure36,37.
Based on the scientific evidence, AADOCR supports the following recommendations: 


  1.  AADOCR opposes the use of all forms of tobacco. Subsequently, the public should be educated on the health and financial costs of tobacco use. Increased attention and resources should be devoted to prevention of tobacco use among children and adolescents, routine screening for tobacco use, treatment of tobacco dependence, and further quality research on this topic. It is incumbent on the health care community to reduce the burden of tobacco-related morbidity and mortality by supporting preventive measures, educating the public about the risks of tobacco, screening for tobacco use and nicotine dependence, and incorporating evidence-based approaches to tobacco use intervention into clinical practice.
  2.  AADOCR welcomes continued research to elucidate further the health effects of using established tobacco products and newly emerging tobacco-derived products and exposure to their emissions; identify the biological mechanisms, behavioral patterns, and relative risks involved in producing those health effects; and develop and evaluate effective methods for prevention and cessation. 
  3.  AADOCR supports collaboration with other organizations, healthcare providers, and institutions to inform the public of tobacco-related research findings and to advocate for appropriate public policy. 
  4.   AADOCR supports national, state, and local legislation that eliminates tobacco advertising, promotions, and sales that appeal to or influence children and adolescents. Additionally, AADOCR also supports the continued enactment and enforcement of state and local clean indoor air policies or ordinances prohibiting smoking in public places. In choosing meeting sites, AADOCR gives preference to cities that have enacted comprehensive clean indoor air policies that include restaurants, hotels, conference centers, and other public spaces.

*Electronic nicotine delivery systems (ENDS) in this context refers to products comprised of an “e-liquid” containing nicotine derived from tobacco, as well as flavorings, propylene glycol, vegetable glycerin, and other ingredients38

Author Contributions
R.C.M. and K.M.B. contributed to the design, interpretation, and drafting, of the position statement. X. Li, C.H.F., M.K.S.C.A, and all members of the IADR Science Information Subcommittee critically revised the statement. All authors gave final approval and agree to be accountable for all aspects of the work.

The members of the 2022 AADOCR Science Information Subcommittee were K.M. Byrd, X. Li, R.C. Moffat, and Y-H. Yu. The AADOCR Science Information Committee thanks all members of the Subcommittee for providing subject matter expertise during the drafting of the policy statement.
The authors received no financial support and declare no potential conflicts of interest concerning the authorship of this article.


  1. World Health Organization. (2022). Tobacco Key Facts. Retrieved from: .2022. Accessed July 21, 2022.
  2. U.S. Department of Health and Human Services. (2014). The Health Consequences of Smoking – 50 years of Progress: A Report of the Surgeon General. Retrieved from:  Accessed July 21, 2022.
  3. National Cancer Institute. (2021). Cigarette Smoking: Health Risks and How to Quit (PDQⓇ) - Patient Version. Retrieved from: Accessed August 15, 2022.
  4. Centers for Disease Control and Prevention. (2022). Smoking and Tobacco Use: Youth and Tobacco Use. Reviewed 2022. Available at  Accessed July 21, 2022.
  5.  Food and Drug Administration. (2022). Results from the Annual National Youth Tobacco Survey: 2021 Findings on Youth Tobacco Use. Retrieved from; Accessed August 15, 2022.
  6. Pan American Health Organization – Institutional Repository for Information Sharing. (2016). Report on Tobacco Control for the Region of the Americas. WHO Framework Convention on Tobacco Control: 10 years later. Retrieved from: Accessed July 21, 2022.
  7. Centers for Disease Control and Prevention. (2021). Smoking and Tobacco Use: Health Effects of Cigarette Smoking. Retrieved from: Accessed July 21, 2022.
  8. Zee, K.Y., 2009. Smoking and Periodontal Disease. Australian Dental Journal, 54, pp. S44-S50[7]
  9. Kinane DF, Chestnutt IG. (2000). Smoking and Periodontal Disease. Critical Reviews in Oral Biology & Medicine. 11(3):356-365.
  10. Fan Chiang, Y.H., Lee, Y.W., Lam, F., Liao, C.C., Chang, C.C. and Lin, C.S. (2022). Smoking Increases the Risk of Postoperative Wound Complications: A Propensity Score‐Matched Cohort Study. International Wound Journal. PMID: 35808947. doi: 10.1111/iwj.13887.
  11. Lane CA, Selleck C, Chen Y, Tang Y. (2016). The Impact of Smoking and Smoking Cessation on Wound Healing in Spinal Cord-Injured Patients With Pressure Injuries: A Retrospective Comparison Cohort Study. J Wound Ostomy Continence Nurs.43(5):483-7.
  12. Fjaeldstad, A.W., Ovesen, T. and Hummel, T. (2021). The Association Between Smoking on Olfactory Dysfunction in 3,900 Patients with Olfactory Loss. The Laryngoscope, 131(1), pp.E8-E13.
  13. Sharrad, R., Taleb, G. and Al Radhi, A. (2022). Association of Tobacco Smoking with Systemic Co-Morbidities among Patients Seeking for Dental Care Services: Across Section Study. Kufa Journal for Nursing Sciences, 12(1).
  14.  Ahmed, N., Arshad, S., Basheer, S.N., Karobari, M.I., Marya, A., Marya, C.M., Taneja, P., Messina, P., Yean, C.Y. and Scardina, G.A. (2021). Smoking a Dangerous Addiction: A Systematic Review on an Underrated Risk Factor for Oral Diseases. International Journal of Environmental Research and Public Health, 18(21), p.11003.
  15. Wang, Y., Ryu, R., Seo, J.M. and Lee, J.J. (2021). Effects of Conventional and Heated Tobacco Product Smoking on Discoloration of Artificial Denture Teeth. The Journal of Prosthetic Dentistry. S0022-3913(20)30444-3.
  16. Naseri, R., Yaghini, J. and Feizi, A. (2020). Levels of Smoking and Dental Implants Failure: A Systematic Review and Meta‐Analysis. Journal of Clinical Periodontology. 47(4), pp.518-528.
  17. Muthukrishnan, A. and Warnakulasuriya, S. (2018). Oral Health Consequences of Smokeless Tobacco Use. The Indian Journal of Medical Research. 148(1), p.35.
  18. Dhanuka, S. and Vasthare, R. (2019). The Association of Secondhand Smoke Exposure and Dental Caries in Children and Adolescents: a Literature Review. General Dentistry. 67(6), pp.20-24.
  19. Sagawa, Y., Ogawa, T., Matsuyama, Y., Nakagawa Kang, J., Yoshizawa Araki, M., Unnai Yasuda, Y., Tumurkhuu, T., Ganburged, G., Bazar, A., Tanaka, T. and Fujiwara, T. (2021). Association Between Smoking During Pregnancy and Short Root Anomaly in Offspring. International Journal of Environmental Research and Public Health. 18(21), p.11662.
  20. Jethwa AR, Khariwala SS. (2017). Tobacco-related Carcinogenesis in Head and Neck Cancer. Cancer Metastasis Rev. 36(3):411-423. 
  21.  American Lung Association. (2022). Why Kids Start Smoking. Retrieved from:  Accessed July 21, 2022.
  22. Stokes AC. Declines in Electronic Cigarette Use Among US Youth in the Era of COVID-19—A Critical Opportunity to Stop Youth Vaping in Its Tracks. JAMA Netw Open. 2020;3(12):e2028221. doi:10.1001/jamanetworkopen.2020.28221.
  23. Marynak KL, Gammon DG, Rogers T, Coats EM, Singh T, King BA. (2017). Sales of Nicotine-Containing Electronic Cigarette Products: United States, 2015. American Journal of Public Health. 107(5):702-705.
  24. Taylor G, McNeill A, Girling A, Farley A, Lindson-Hawley N, and Aveyard P. (2014). Change in Mental Health After Smoking Cessation: Systematic Review and Meta-Analysis. British Medical Journal. 348:g1151.
  25.  Jones K, Salzman GA. (2020). The Vaping Epidemic in Adolescents. Missouri Medicine. 117(1):56-58. 
  26. Callahan-Lyon P. (2014). Electronic Cigarettes: Human Health Effects. Tobacco Control. 23 Suppl 2(Suppl 2):ii36-40. 
  27. National Academies of Sciences, Engineering, and Medicine. (2018). Public Health Consequences of e-Cigarettes: Conclusions by Levels of Evidence. National Academies Press. Retrieved from: Accessed August 16, 2022.
  28. Jenssen BP, Wilson KM. (2019). What is New in Electronic-Cigarettes Research? Curr Opin Pediatr. 31(2):262-266. 
  29. Centers for Disease Control and Prevention. (2020). Adult Smoking Cessation—The Use of E-Cigarettes. Retrieved from: Accessed August 17, 2022. 
  30. Al-Hamdani M, Manly E. (2021). Smoking Cessation or Initiation: The Paradox of Vaping. Prev Med Rep. 22:101363. 
  31. Chen R, Pierce JP, Leas EC, Benmarhnia T, Strong DR, White MM, Stone M, Trinidad DR, McMenamin SB, Messer K. (2022). Effectiveness of E-Cigarettes as Aids for Smoking Cessation: Evidence from the PATH Study Cohort, 2017–2019. Tobacco Control. doi: 10.1136/tobaccocontrol-2021-056901.
  32. Centers for Disease Control and Prevention. (2021). Smoking and Tobacco Use: Secondhand Smoke. 2021. Retrieved from: Accessed July 21, 2022.
  33. Centers for Disease Control and Prevention. (2020). Smoking and Tobacco Use: Health Effects of Secondhand smoke. Retrieved from: Accessed July 21, 2022.
  34. Center for Disease Control and Prevention. (2014). Surgeon General’s Report: The Health Consequence of Smoking – 50 years of Progress. Reviewed 2021. Retrieved from: Accessed July 21, 2022.
  35. Campaign for Tobacco-Free Kids. (2021). Tobacco Products and Health Harms: Secondhand Smoke. Retrieved from: Accessed July 21, 2022.
  36. Díez-Izquierdo, A., Cassanello-Peñarroya, P., Lidón-Moyano, C., Matilla-Santander, N., Balaguer, A. and Martínez-Sánchez, J.M. (2018). Update on Thirdhand Smoke: A Comprehensive Systematic Review. Environmental Research, 167, pp.341-371.
  37.  Drehmer, J.E., Nabi-Burza, E., Hipple Walters, B., Ossip, D.J., Levy, D.E., Rigotti, N.A., Klein, J.D. and Winickoff, J.P. (2019). Parental Smoking and E-cigarette Use in Homes and Cars. Pediatrics, 143(4).
  38. Food and Drug Administration. (2022). E-Cigarettes, Vaping, and Other Electronic Nicotine Delivery Systems (ENDS). Retrieved from: Accessed January 4, 2023. 

(Adopted 2023)