Dentists,are you ready to deal with the “smokers of the future ”?

Every dental student is taught the importance and impact of smoking on patients' general and oral health. They are advised that this habit is a risk factor for the development of various oral lesions; thus, dentists include it as one of the questions posed during anamnesis. However, is the profile of the smoker of past decades the same as the smoker of the present/future? Are dentists prepared to treat “new smokers”, and to identify possible injuries associated with the use of new forms of tobacco consumption?

Consumption of manufactured cigarettes has traditionally been the main form of tobacco consumption. However, in the last few decades, alternative forms of consumption, such as hookahs and electronic nicotine delivery systems (ENDS) (electronic cigarettes, vapes, or pods) have gained popularity, especially among the younger generations who have never previously smoked manufactured cigarettes.^1,2

In Brazil, despite advances in specific regulatory policies, there has been an increase in the popularization of the use of ENDS by young people and adolescents. This is largely due to the commercial appeal promoted in social media, the fascination with the technology, the production of a large amount of smoke, and the use of flavoring agents, which allow a pleasant taste and smells, increasing the social acceptability of these devices.^3,4

Although the use of ENDS has been publicized as harmless, several studies have shown it to be a risk factor for cardiac arrhythmias, lung diseases, deaths related to EVALI (e-cigarette or vaping product use-associated lung injury), as well as a high rate of accidents and oral injuries.^2,5 In addition, some e-liquids and flavors appear to exert cytotoxic, mutagenic, and carcinogenic effects. This is due to the presence of compounds such as formaldehyde, acrolein, nitrosamines, and heavy metals that can be found in their formulations, or can be formed secondarily due to the high heating temperature of these liquids.^6,7

Our research group evaluated exfoliative cytology samples from the clinically normal oral mucosa of ENDS users and observed that when associated with alcohol consumption, ENDS are capable of promoting cytotoxic and genotoxic changes. ⁸ These data lead us to reinforce once again the importance of knowledge on the part of dentists of these “new smoking habits”. Thus, even in the face of a clinically normal oral mucosa, we have to guide patients undergoing periodic follow-up consultations.

Dentists should be aware of the impact of ENDS use on the oral health of their patients. Changes, such as xerostomia, exacerbation of periodontitis, nicotinic stomatitis, hairy tongue, hyperplastic candidiasis, and angular cheilitis may all be associated with the use of ENDS.^9,10

Although ENDS users appear to have a lower risk of developing oral and oropharyngeal cancer than industrialized cigarette smokers, the real risk factors for ENDS remain unclear. Therefore, long-term follow-up studies are required to verify these findings.^2,5,10

We believe that a large proportion of "the smokers of the future" will be made up of young people who have never smoked industrialized cigarettes, but who use hookah or ENDS. Therefore, dentists must be aware of these devices during anamnesis, especially in the young population or in the population that is in the process of smoking cessation.