Sir, substantial evidence implicates tobacco use in multiple oral and systemic diseases, and oral health professionals are well positioned to provide tobacco cessation education and counselling for patients.1 Cigarette smoking has declined in many high-income nations, however, several other new and conventional tobacco products appear to be rising in popularity, including cigars, waterpipes, snus, dissolvable tobacco and electronic cigarettes. This recent trend could have significant health implications, particularly for adolescents, who might view certain tobacco products as 'safe' and for whom use might lead to nicotine dependence, smoking initiation, and/or dual use of multiple tobacco products.

Studies have reported that, despite the EU sales ban on smokeless tobacco, over 15% of young Finnish military recruits used snus daily,2 while in Norway, adolescent users of snus alone were more likely than non-tobacco users to be dual users of cigarettes and snus three years later.3 In the US, youth cigarette smoking declined to 14.0% of high school students in 2012, but use of hookahs (5.4%), other pipes (4.5%), electronic cigarettes (2.8%), and dissolvable tobacco (0.8%) all increased from 2011 estimates.4 It is plausible that rises in use will continue; for example, growth in awareness and use of electronic cigarettes among American adults has been rapid.5,6

We completed an IRB-approved pilot survey at a rural high school in California, USA, in which we asked male students (n = 22) about their tobacco-related experiences and beliefs. Use in the past 30 days of electronic cigarettes (n = 7) and waterpipes (n = 7) both exceeded that of cigarettes (n = 4) and smokeless (spit) tobacco (n = 4). Snus (n = 1) and dissolvable tobacco (n = 0) were not commonly used. More than half the students reported current tobacco use (n = 12). Among the 15 non-users of cigarettes and spit tobacco, five reported use of electronic cigarettes or hookah, of whom four had never smoked cigarettes or used spit tobacco. Of those who recognised the products, most believed spit tobacco (81%) and snus (88%) to be as harmful or more harmful than cigarettes; fewer shared the same belief for hookahs (68%) and electronic cigarettes (5%). While 100% of respondents thought cigarette users do 'some' or 'a lot' of harm to themselves by smoking, this percentage was lower for spit tobacco (90%), hookahs (68%), snus (56%), and electronic cigarettes (42%). Findings from our pilot survey suggest that a substantial percentage of adolescents are using new and conventional tobacco products. Much further research is needed to better describe global trends and to define the long-term oral and systemic health risks of new smokeless tobacco and non-combustible tobacco products, especially among adolescents. We urge oral health professionals to remain cognisant of current trends in adolescent tobacco use and to continue to serve as well-informed advocates for oral and general health.