Elaine qualified as a dental hygienist in the Royal Air Force in 1982. Serving for 25 years at home and abroad, Elaine ran the School of Dental Hygiene Training at Aldershot from 1994-2002. She has been an active member of the BSDHT since qualifying and has held a variety of roles. She was most recently employed by TePe Oral Hygiene Products Ltd, where she was involved with designing and implementing educational programmes for the dental and health care professions. Continuing to serve as an expert panel member of NICE for smoking cessation she successfully combined her commercial role with her passion for public health. An experienced, if reluctant author, Elaine has contributed to published clinical teaching text writing chapters on behavioural change, the patient’s role in home care and smoking and vaping impacts on oral health

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Can you tell us a little about yourself and your journey in dentistry?

I am a registered dental hygienist, and my career in dentistry began in the late 1970s when I joined the Royal Air Force as a dental nurse. I later trained as a hygienist within the Air Force and qualified in 1982. I served both in the UK and overseas, treating service personnel and their families. During postings in Hong Kong, Nepal and Borneo, I combined clinical work with health promotion roles.

In the final ten years of my service, I was commissioned as the Officer in Charge of the Dental Hygienist Training School in Aldershot. My career therefore evolved from clinical dental nursing to clinical hygiene and then into education and training. After 25 years in the military, I moved into a commercial role as Clinical and Education Projects Manager for TePe Oral Hygiene Products. I worked closely with dental schools and hygiene programmes, focusing on behavioural change and encouraging patients to adopt interdental cleaning.

I am now retired from paid employment but remain active in various areas of dentistry.

How did your military background shape your approach to prevention and public health?

Working within the military population, which is generally young and fit, I became particularly interested in behaviour. One notable issue was that smoking rates in the military were significantly higher than among comparable civilian groups.

That observation prompted me to explore why this was happening. I completed a master’s degree in health promotion, focusing on smoking behaviours and why young, otherwise healthy individuals were taking up the habit. I also examined how difficult cessation can be and what interventions might help. Comparing military and civilian populations highlighted cultural differences that influenced behaviour.

Did you identify why smoking habits differed in the military?

In the early 1990s, many recruits joined as non-smokers but began smoking shortly after enlistment. The reasons were largely cultural. Smoking was embedded in social and professional settings. For example, smoking was common in mess environments, and during recruit training, “NAAFI breaks” often revolved around having a cigarette. In some cases, breaks were informally associated with smoking, reinforcing the behaviour.

Although the military had historically supplied cigarettes in certain contexts, this period reflected a cultural carryover that normalised smoking. Ultimately, it came down to environment and social norms.

Are we simply replacing one problem with another when it comes to vaping and oral nicotine products?

Vaping was originally developed as a harm reduction tool to help people move away from combustible tobacco. It delivers nicotine without combustion, which makes it less harmful than smoking, although it is not risk-free. In the UK, vaping products are now regulated by the MHRA and subject to monitoring systems such as the Yellow Card scheme. Products sold legitimately are far more tightly controlled than when they first appeared in 2007.

Oral nicotine pouches are different. They are not the same as snus, which contains tobacco and is illegal to sell in the UK. Nicotine pouches contain powdered nicotine in a small pouch placed against the buccal mucosa. These products are not currently subject to the same regulatory framework. Labelling is not mandatory in the same way, and nicotine content can vary significantly.

Research reviewing over 260 brands found nicotine levels ranging from zero to 120 milligrams, despite 20 milligrams being the commonly advised upper limit in regulated products. This variability is concerning. While vaping may support smoking cessation, oral nicotine products represent another form of nicotine delivery, and there are clear concerns around regulation and long-term impact.

What oral health impacts are you seeing from long-term vaping and oral nicotine use compared with traditional tobacco?

Vaping is still relatively new, and many users are current or former smokers, which makes long-term comparisons challenging. However, we understand the effects of

nicotine on oral tissues. Nicotine contributes to oxidative stress, impaired wound healing and cellular changes, similar to those seen with combustible tobacco.

Clinically, we are seeing distinctive staining patterns in some vape users, particularly with certain flavourings. The staining can appear darker and more adhesive than traditional tobacco staining.

With nicotine pouches, we are observing localised mucosal changes at the placement site, typically in the anterior buccal mucosa. These include redness, blistering, and white patches resembling leukoplakia. Some patients experience minor salivary gland blockage, visible as small red spots, along with burning sensations and dry mouth. While long-term outcomes remain unclear, these products do produce observable oral manifestations.

Are regulations keeping pace with behaviour change, particularly among young people?

Technology is advancing more quickly than legislation. While vaping has become more regulated over time, nicotine pouches are discreet and harder to monitor. They can be purchased online with minimal age verification, and their high nicotine levels increase the risk of dependence.

There is growing evidence that young people who have never smoked are using these products. Because they are easy to conceal and provide an immediate nicotine hit, they present particular risks. Anecdotally, some young people are even using multiple pouches at once to intensify the effect, leading to nausea and significant nicotine exposure.

Nicotine exposure during adolescence is particularly concerning due to its effects on developing brains. The issue extends beyond oral health to potential long-term systemic consequences. Regulatory action is urgently needed.

What practical language or techniques should dental professionals use when discussing vaping or nicotine products with patients?

Questions about smoking and nicotine use should be part of every medical history. It is important to ask clearly and specifically about tobacco, vaping and oral nicotine products, and to document responses accurately.

Some patients may not wish to quit, and our role is not to police them but to support and inform them. If lesions or suspicious changes are identified, they should be managed appropriately, with awareness of the patient’s risk factors.

We can support smoking cessation through vaping as a harm reduction tool, while acknowledging it is not risk-free. If a patient chooses to use nicotine pouches to stop smoking, we can support them but should also encourage eventual nicotine cessation. Our responsibility is to inform, monitor and signpost to appropriate services.

Should smoking, vaping and oral nicotine use be a mandatory part of oral health assessment?

Yes. Under current guidance, clinicians should follow the three A’s approach: Ask, Advise, Act. This includes asking about all tobacco and nicotine products as part of routine assessment.

Even if patients do not initially disclose use, clinical signs may prompt further discussion. As clinicians, we must stay informed about emerging products and adapt our questioning accordingly. Although some patients are reluctant to discuss lifestyle habits, it remains part of our professional responsibility.

What is the one mindset shift you would like delegates to leave with?

I would like delegates to feel confident in supporting smoking cessation. Vaping has a role in harm reduction and is significantly less harmful than smoking, even though it is not harmless.

Nicotine pouches are newer, and long-term evidence is limited. However, we know that chronic irritation of oral tissues is unlikely to be without consequence. While definitive links to malignancy are not yet established, we are already observing tissue changes.

The key message is to stay informed and be prepared to guide and support patients appropriately.

Is there anything else you would like to share?

There are ongoing efforts from public health organisations and policymakers to address these issues, but legislative change takes time. Meaningful progress often follows visible harm.

Dental professionals can play an important role by supporting public health initiatives and advocating for appropriate regulation. Engagement in policy discussions and professional advocacy can help drive change.

Elaine will deliver a presentation on Smoking, Vaping and Oral Nicotine Patches – Out of the Frying Pan, Into the Fire? Don't miss it!