Hagel was among the oral-health professionals who lobbied for the newly approved ban on flavored tobacco products in Massachusetts, signed into law by Gov. Charlie Baker on November 27. The first such measure in the country, the law prohibits the sale of menthol cigarettes and flavored vaping products, cigars, and chewing tobacco.
One aim of the ban is to curb tobacco use among teenagers, particularly as the popularity of vapes, or e-cigarettes—which come in myriad flavors that appeal to adolescents—has led to a resurgence of smoking in young people after decades of decline. Studies have also shown that it’s easier to become hooked on menthol products, as menthol is a numbing agent that allows smokers to inhale more deeply, increasing nicotine dependence.
“I was up to half a pack a day in college,” Hagel said. “The thing that made me want to try to quit the first time was I knew how bad it was for the lungs. It wasn’t easy to quit at all—it took two, three, four times. What made me stop was becoming pregnant.” Indeed, the effects of cigarette smoking on the respiratory and cardiovascular systems, and on developing fetuses, are well known. Recently, attention has zeroed in on the potential harms of vaping—and more research is needed.
Smoking and vaping also take a toll on oral health, including increasing the risk of oral cancers. Tufts Now talked with Hagel, a registered hygienist who teaches dental students about interventions and tobacco-cessation techniques for their patients. She is a faculty advisor to the Tufts student chapter of the American Association for Public Health Dentistry and is active in the oral-health section of the American Public Health Association.
Tufts Now: What are the implication on oral health from tobacco use?
Natalie Hagel: With any tobacco, including regular cigarettes and vapes, the chance of oral cancer increases. So do the chances of getting periodontal disease, and dry mouth. With the higher rate of vaping, we are seeing a higher rate of dental decay, because the aerosols that are bombarding the mouth are filled with sweeteners. There hasn’t been a lot of research done yet on vaping, but what research there is shows an increase in dry mouth. And with dry mouth comes an increase in the risk for dental decay. Many medications have dry mouth as a side effect, so if you’re taking any of those, smoking can amplify that.
Also, a lot of children and adolescents don’t even realize there is nicotine in the vapes. They’re just enjoying the fact that they are acting cool and enjoying the delicious flavor. That’s the scary part. With some popular brands of vaping products, one cartridge can equal four or five cigarettes.
The mouth can offer up many telltale signs of lifestyle habits or medical conditions. Can a dentist or hygienist tell if a patient uses tobacco, even if the patient denies it?
With cigarettes, the big sign is tobacco stains on the teeth. Many times it goes along with dry mouth—you can actually see the fissured tongue. And dry mouth can lead to cavities. If someone’s been smoking a while, the tissues can be chronically inflamed. And then there’s the smell as you lean over the patient. Vapes are different—they are supposedly not going to give you all the same symptoms as cigarettes, because there is no combustion.
What role can the dentist and other dental professionals play to help patients quit?
We teach students how important the dentist and hygienist are to counseling patients about tobacco, and how they can be the ones to start the process of having the patient quit. A patient could see a dentist or hygienist several times a year, so discussions at the dentist may be more valuable than once-a-year checkups at the doctor. I encourage students—and dentists in general—to ask about tobacco use every time they take a medical history; if the patient is interested in quitting; and what we can do to help.
When I quit, I did it cold turkey. It was pretty tough. Nowadays, there are so many ways to help smokers quit: nicotine-replacement patches and gums; prescription drugs like Chantix or bupropion, most well-known as Wellbutrin. The best practice is to offer advice, assistance, and resources. Do not judge—smoking comes with such a stigma, and some people who have never smoked, or don’t have that addiction gene, don’t understand how addictive it can be. Ask them if they are interested in quitting—you can’t push someone who is not ready. If you can, work alongside their primary-care physician. The new Massachusetts law requires insurance companies and MassHealth, the state’s Medicaid program, to cover tobacco-cessation programs. Dentists in private practice can write prescriptions for Chantix and other drugs.
What about talking with teens who may be reluctant to have their parents know they’ve been vaping?
It can be a good idea to have parents out of the room when having this conversation with teens. In the DMD program, we teach about behavior modification techniques that can be used by both adult and pediatric patients, to quit smoking as well as to reinforce habits like brushing and flossing. We encourage our students to use these with their patients in the clinic. One of the best ways to work with teens is with motivational interviewing. Roll with the resistance and let them make the decision on their own; let them think it was their idea to quit, instead of you telling them what to do.
Helene Ragovin can be reached at firstname.lastname@example.org.