The relationship between smoking and periodontal disease, health implications, and improvements with quitting

What is the biggest risk factor for periodontal disease and the number one preventable cause of both death and cancer? You guessed it—smoking.¹

Why do people smoke?

To help patients to quit, you must first understand why people start smoking in the first place. Maybe they started when they were young or were influenced by marketing appeal, social media, video games, movies, the individual's parents, siblings, or peers who use tobacco or tobacco products that entice buyers by offering fruit or candy flavors.²

Even if we understand why many people start, why do they continue to smoke despite the indelible health risks? This question is a complex one, and we need to first understand the inequalities in the risk factors of smoking, specifically cancer.

Members of disadvantaged groups such as individuals living in deprived areas, those with mental health conditions, and the LGBTQ+ community are more likely to smoke and have more to overcome when trying to quit. Marketing also plays a big role in keeping people addicted; the tobacco industry encourages smoking through advertising and creating easy access to tobacco products in stores and shop display windows.³

Effects of smoking tobacco on the periodontium

Multiple studies have been conducted on the effects of smoking on the periodontium. One study found that individuals who smoke have a higher likelihood of having issues with tooth loss, bone loss, gingival recession, decreased immune defense, aggravated inflammatory response, and progression of disease. About 40% of cases with chronic periodontal disease were due to smoking. There are other effects on the periodontium that can occur when smoking, such as deep pocket depths, edentulism, and necrotizing ulcerative gingivitis (NUG). This occurs because smoking interrupts the periodontal tissue's balance by lowering the function and proliferation of periodontal cells, which leads to apoptosis. These effects are dose-dependent by the frequency and amount that is being smoked.⁴

Another study found that smoking causes a pathogen-rich environment and leads to the growth and development of Porphyromonas gingivalis (P. gingivalis), or a black- pigmented bacterium. This pathogen is responsible for the initiation and progression of periodontal disease. This pathogen also greatly impacts the amount of oral microbiota present along with its composition. It also manipulates the body's host immune response.⁵

Health implications of smoking tobacco

Around 480,000 people in the United States die each year from cigarette smoking, many from cancer. Smoking causes about 80% of lung cancers, which is the leading cause of cancer death in the United States. Individuals who smoke are also at an increased risk for kidney, liver, mouth, throat, cervical, stomach, colon, bladder, and pancreatic cancers. Smoking is also the most common cause of COPD, which is also one of the leading causes of death in the US. Some additional health risks include emphysema, coronary heart disease, stroke, heart attack, aortic aneurysm, peripheral arterial and vascular disease, ectopic pregnancy, premature birth, miscarriage, and birth defects.¹

Why do people think vaping is better?

Promoters of e-cigarettes falsely advertise that vapes do not contain nicotine, therefore making them "safer.". Vape companies claim their products are nonaddictive and do not contain "harmful" ingredients, instead purporting that they actually help stop people from smoking conventional cigarettes. According to a study by New York University's Langone Medical Center, nicotine-laced e-cigarettes affected more than 148 genes in the brain, which led to major behavioral changes. However, non-nicotine e-cigarettes were shown to affect 830 genes within the same area.⁶

Effects of smoking e-cigarettes on the periodontium

A 2016 study was conducted to see what effects smoking e-cigarettes had on the periodontium. Results showed that smoking e-cigarettes alters the tissues' wound healing and repairing abilities, causing increased inflammation response and oxidation stress. Some other effects included deep pocket depths, an increase in plaque score, bleeding, and clinical attachment loss.⁷

Health implications of smoking e-cigarettes

According to a study by the University of Louisville in Kentucky, smokers of e-cigarettes are more prone to cardiovascular plaque that can lead to heart attacks and other severe cardiovascular problems than nonsmokers.⁷ Smoking e-cigarettes can cause swelling, irritation, and damage to the lungs and other organs. It can lead to scarring of the lungs, asthma, and can hurt the brain and heart. It can also lead to lung injury, which can be fatal.8

Benefits of quitting

When a person stops smoking, many health benefits follow. Quitting smoking improves a person's quality of life and reduces the risk of premature birth death, cardiovascular diseases, COPD, and cancer. It can also add 10 years to life expectancy.⁸

Within minutes of cessation, the individual's heart rate decreases. In 24 hours, the individual's nicotine level in the blood drops to zero. After several days, the carbon monoxide levels in the blood drop to the same level as a nonsmoker. Within one to 12 months, the individual will experience a reduction in coughing and shortness of breath.⁹

Between one and two years, the risk for heart attacks drops significantly. In three to six years, the risk for coronary heart disease is cut in half. In five to 10 years, the risk for oral and throat cancers is cut in half, and the risk for stroke is reduced. After 10 years, the risk for bladder, kidney, and esophageal cancer is reduced. After 15 years, the risk for coronary heart disease is almost the same as a nonsmoker. Then, after 20 years of quitting smoking, the risk for oral, throat, and pancreatic cancers is close to that of a nonsmoker, and the risk for cervical cancer is cut in half.⁹

Inform, educate, support

When treating a patient who smokes, it is important to understand and utilize the five A's of tobacco intervention:

1. Ask all patients at every appointment about their tobacco use.

2. Advise the patient to quit smoking.

3. Assess readiness to quit by asking questions to gauge their attitude toward smoking.

4. Assist the patient by helping to develop a manageable and achievable plan to quit.

5. Arrange a follow-up visit with the patient to check on how they are doing and refer them to a specialist if needed.

Tobacco cessation plays an important role in the treatment of dental patients. As dental professionals, it is our job to inform our patients of the risks smoking has on their oral and overall health. It's also important to not judge, be honest, and be knowledgeable when treating patients who smoke, and to be their advocate for better quality of life.

Editor's note: This article appeared in the November/December 2025 print edition of RDH magazine. Dental hygienists in North America are eligible for a complimentary print subscription. Sign up here.

References

1. Health Risks of smoking tobacco. American Cancer Society. November 19, 2024. https://www.cancer.org/cancer/risk-prevention/tobacco/health-risks-of-smoking-tobacco.html

2. Why people start using tobacco, and why it's hard to stop. American Cancer Society. November 19, 2024. https://www.cancer.org/cancer/risk-prevention/tobacco/guide-quitting-smoking/why-people-start-using-tobacco.html#:~:text=Dopamine%20and%20adrenaline,Withdrawal%20symptoms

3. Orritt R. Health inequalities: Why do people smoke if they know it's bad for them? Cancer Research UK. April 1, 2022. https://news.cancerresearchuk.org/2022/04/01/health-inequalities-why-do-people-smoke-if-they-know-its-bad-for-them/

4. Abraham JJ, et al. Smoking and periodontal disease. IOSR J Dent Med Sci. 2022;21(5):18-25. https://doi.org/10.9790/0853-2105071825

5. Jiang Y, Zhou X, Cheng L, et al. The impact of smoking on subgingival microflora: from periodontal health to disease. Front Microbiol. 2020;11:66. doi:10.3389/fmicb.2020.00066

6. Johar RS. E-cigarettes: safer than tobacco? Mo Med. 2016;113(5):342-343.Charde P, Ali K, Hamdan N. Effects of e-cigarette smoking on periodontal health: a scoping review. PLOS Glob Public Health. 2024;4(3):e0002311. doi:10.1371/journal.pgph.0002311

7. Charde P, Ali K, Hamdan N. Effects of e-cigarette smoking on periodontal health: a scoping review. PLOS Glob Public Health. 2024;4(3):e0002311. doi:10.1371/journal.pgph.0002311

8. Vaping (e-cigarettes): What it is, side effects & dangers. Cleveland Clinic. June 21, 2021. https://my.clevelandclinic.org/health/treatments/21162-vaping

9. Milko T. Toolkit for delivering the 5A's and 5R's brief tobacco interventions in primary care. World Health Organization. March 19, 2025. https://iris.who.int/bitstream/handle/10665/112835/9789241506953_eng.pdf