Open research questions in Smoking Behavior and Cessation

What the literature leaves open

• OBJECTIVE Degenerative cervical myelopathy (DCM) is a progressive spinal cord disorder, yet modifiable risk factors that accelerate its progression remain poorly understood.

  Cervical myelopathy responses to extracts derived from combustible cigarettes and heated tobacco products: in vivo and in vitro evidence · 2026 · DOI

• 40 Health systems must play their part by introducing The main limitations of this study are those inherent in any it was the most survey administered to professionals, but feasible method for this study.

  Exploring factors that influence the implementation of presurgical smoking cessation interventions: a cross-sectional survey · 2026 · DOI

• Year-specific weighted preva- lence remained broadly stable between 2017 and 2024, with a transient decline in 2021 attributable to pandemic-related disruption; formal trend testing provided mixed evidence of secular change.

  Prevalence and correlates of e-cigarette use among older adults aged 60 years and over · 2026 · DOI

• Tobacco retailer placement and youth exposure to advertisements and products through brick-and-mortar locations may be associated with increased e-cigarette use and susceptibility among youth, yet youth exposure to tobacco retail locations as a potential influential factor for tobacco use is largely under-researched.

  Proximity and density of tobacco retail locations to Kentucky schools and the relationship to youth perceptions of harm and susceptibility to e-cigarette use · 2026 · DOI

• Background As oral nicotine pouches (ONPs) have gained popularity in the US, little is known from nationally representative data about who uses them and how they are being used.

  Correlates of oral nicotine pouch use, use frequency and flavour use among US adults · 2026 · DOI

• This study is crucial because it serves as a basis for future research that will concentrate on the variables influencing pulpal sensibility. Clinicians should be aware that responses to pulp sensibility tests may be altered in smokers, potentially due to altered neural transmission or vascular changes. These factors can compromise the reliability of sensibility testing and lead to false-negative results even in vital pulps. Sensibility testing, especially if test results are equivocal, may be beneficial in conjunction with clinical examination, radiographic evaluation, and possibly advanced pulp vitality testing (e.g. pulse oximetry, laser Doppler flowmetry). Because thresholds may be elevated, clinicians should interpret lower-than-normal EPT values cautiously and consider repeat testing or additional diagnostic methods before initiating invasive treatment. In smokers, baseline sensibility testing at multiple time points, rather than relying on a single measurement, can help identify trend changes. CONCLUSIONS Within the limitations of this cross-sectional study, daily cigarette consumption was found to be associated with altered dental pulp sensibility responses, as reflected by increased EPT thresholds and prolonged cold-test response times. In contrast, smoking duration did not demonstrate a significant association with pulpal sensibility outcomes. These findings suggest that the quantity of cigarettes consumed per day may be a more relevant indicator of modified pulpal neural responsiveness than cumulative smoking exposure. Clinically, smoking status should be considered when interpreting pulp sensibility results, as attenuated responses in smokers may increase the risk of false-negative findings.

  Effect of smoking on dental pulp responses to thermal and electrical sensibility tests · 2026 · DOI

• Consequently, it remains unclear whether vaping directly causes sleep disruption, whether poor sleep predisposes individuals to nicotine use, or whether both are influenced by shared factors such as anxiety, depression, stress, screen use, substance use, and family or peer environments [10].

  The Association Between E-cigarette Use and Sleep Duration Among Adolescents and Young Adults: A Structured Narrative Review · 2026 · DOI

• Strengths and limitations of this studyO_LIThe study uses a large national health-insurance claims sample (54,820 members; >2 million referral-hospital visits over nine years) with verified payment amounts (converted from Indonesian rupiah to US dollars), applying official sampling weights and a survey-design (stratified) variance estimator.

  Tobacco Associated Disease Claims and ICD 10 F17 Tobacco Dependence Coding Among Psychiatric Patients in Indonesia National Health Insurance Dataset: A Retrospective Claims-Based Observational Study, 2015 2023 · 2026 · DOI

• The findings from this study show the need for practical actions to address e-cigarette use among undergraduate students. Easy access and frequent exposure, especially in urban areas, make vaping more common, so authorities should tighten controls on online sales and informal distribution. Stronger and more consistent enforcement around campuses can also help reduce the availability of these substances. Universities can support these efforts by establishing clear e-cigarette-free campus policies, providing straightforward health education, and monitoring students who exhibit multiple high-risk behaviors. Because peer influence plays a significant role, prevention leaders, friends, and families is likely to be more effective information alone. Regular than monitoring and updated guidelines are needed to keep up with changing trends and ensure that policies remain practical and effective. Future research should employ longitudinal study designs to better understand the causal pathways underlying the observed associations. Studies involving larger and more representative samples across different regions of Thailand are also recommended. In addition, intervention-based research is needed to evaluate the effectiveness prevention programs, digital health interventions, and policy enforcement strategies. Future studies should also social media explore influences, and emerging vaping products to provide a more comprehensive understanding of vaping behavior among Thai youth and young adults.

  E-Cigarette Use and Predictors of Vaping Behavior among Undergraduate Students in Thailand’s Health Region 10 · 2026 · DOI

• Furthermore, the PUMA screening tool has lim- itations in its applicability to e-cigarette users, as risk scores derived from e-cigarette use may not be generalizable to those associated with conventional cigarette smoking (Gadam et al.

  The Relationship Between Sociodemographics and Chronic Obstructive Pulmonary Disease Risk among Smokers in Podosoko Village · 2026 · DOI

• Future research is recommended to employ mixed-method or ethnographic approaches to examine how smoking meanings vary across age groups, regions, and digital communities, as well as to assess the effectiveness of specific digital interventions in reshaping smoking-related social norms.

  Reducing Smoking Culture in Indonesian Communication Practices: An Intercultural Communication Perspective · 2026 · DOI

• Several limitations should be acknowledged. First, this study relied on analysis of hotline call records and therefore cannot establish causal relationships between the implementation of the smoking ban amendment and changes in smoking-related behaviors. In addition, due to data anonymization requirements, individual-level demographic information – such as age, gender, and socio-economic status – was unavailable, limiting examination of population-specific reporting patterns. Second, hotline users may represent a subset of individuals who are more engaged or aware of the smoking ban amendment, which could introduce selection bias and limit generalizability. Although data cleaning procedures were applied, multiple calls related to the same incident or location may still have occurred, contributing to potential duplicate- reporting bias. Finally, residual confounding cannot be ruled out. Variations in enforcement intensity, media exposure, public education activities, or local implementation practices over time and across settings may have influenced reporting behavior independently of the smoking ban amendment. CONCLUSIONS This study examined public responses to the smoking ban amendment in Shanghai using hotline-based data and text-mining methods, highlighting the value of citizen-generated reports for monitoring policy implementation and public engagement. The findings demonstrate that hotline data can capture public reactions following implementation of the smoking ban amendment and provide actionable insights into Tob. Induc. Dis. 2026;24(June):97 https://doi.org/10.18332/tid/218152 7 Tobacco Induced Diseases Research Paper location-specific enforcement challenges, as well as emerging regulatory issues such as e-cigarette use.

  Analyzing public responses to Shanghai's strict smoking ban: A data mining study based on 12320 Health Hotline calls · 2026 · DOI

• be Nevertheless, acknowledged. First, the cross-sectional nature of the study prevents causal interpretation and does not allow for establishing the temporal order between predictors and e-cigarette use. Second, the use of self-reported measures may have introduced recall and social desirability biases, especially in light of the stigma associated with smoking behaviors among youth. Third, while the study included key determinants, other important influences such as exposure to e‑cigarette advertising, parental smoking, and peer network characteristics were not assessed. Finally, the analysis did not capture longitudinal trajectories of use, which would be essential for understanding progression from experimentation to regular use. Future investigations would benefit from employing longitudinal study designs and integrating contextual variables such as policy landscapes and exposure to digital marketing to generate a more comprehensive understanding of e-cigarette use among youth in Indonesia.

  Predictors of e‑cigarette use among Indonesian youth: Evidence from the 2019 Global Youth Tobacco Survey · 2026 · DOI

• This study has several limitations that should be acknowledged. First, its cross-sectional design precludes causal inferences and limits the ability to assess changes over time or the long-term impact of coping strategies. Second, the reliance on selfreported data may introduce response and social desirability biases, particularly regarding health behaviors and awareness. Furthermore, recall bias may have influenced participants' responses concerning past smoking patterns and the perceived effectiveness of previous cessation attempts. Third, although the sample size met predefined representativeness criteria, it may not fully capture the heterogeneity of smokers with osteoarticular pathologies in Spain. Fourth, the use of online surveys may have excluded participants with limited digital literacy, potentially introducing selection bias. Fifth, although the study identified the perceived effectiveness of coping strategies, it did not directly measure behavioral outcomes, such as quit or relapse rates, which should be addressed in future longitudinal or interventional studies. Despite these limitations, this study provides a necessary foundation for understanding the specific cessation needs and perceptions of this clinical popula tion. FUNDING No funding was received for the conduct of this research. CONFLICT OF INTEREST The authors declare that they have no conflicts of interest. They also declare no use of artificial intelligence tools. All content was verified and edited by the authors, who assume full responsibility for the final version of the manuscript. AUTHORS CONTRIBUTION Jose Luis Baquero: conceptualization, methodology, formal analysis, data curation, writing original draft, writing review and editing. Nina Martínez: formal analysis, data curation, writing original draft, writing review and editing. Josep Vergés Milano: conceptualization, methodology and writing review. Manuel Santiñà: methodology and writing review. Josep Vilajoana Celaya: methodology and writing review. Gabriel Dávalos Picazo: writing review. REFERENCES Al-Bashaireh, A. M., Haddad, L. G., Weaver, M., Kelly, D. L., Chengguo, X., & Yoon, S. (2018a). The Effect of Tobacco Smoking on Musculoskeletal Health: A Systematic Review. Journal of Environmental and Public Health, 2018(1). https://doi. org/10.1155/2018/4184190 Al-Bashaireh, A. M., Haddad, L. G., Weaver, M., Chengguo, X., Kelly, D. L., & Yoon, S. (2018b). The Effect of Tobacco Smoking on Bone Mass: An Overview of Pathophysiologic Mechanisms. Journal of Osteoporosis, 2018(1). https://doi.org/10.1155/2018/1206235 Anhang, R., Elliott, M. N., Zaslavsky, A. M., Hays, R. D., Lehrman, W. G., Rybowski, L., & Cleary, P. D. (2014).

  Perceived Barriers and Coping Strategies to Smoking Cessation in Patients with Osteoarticular Pathology in Spain · 2026 · DOI

• Several limitations should be acknowledged. First, evidence evaluating exercise interventions specifically among exclusive e-cigarette users remains limited, and part of the interpretation relied on findings derived from studies involving conventional cigarette smokers. Consequently, direct extrapolation of current observations to vaping populations should be approached cautiously. Second, heterogeneity was observed across the included studies regarding intervention design, exercise characteristics, outcome assessment, and participant populations. These differences limited direct comparisons and complicated interpretation of the available evidence. Finally, only studies published in English were included, which may have resulted in omission of relevant findings reported in other languages.

  Exercise Interventions for Reducing Nicotine Dependence and Craving in E-Cigarette Users: A Narrative Review · 2026 · DOI

• The nationwide and multi-ethnic scope of our study, based on the NHANES database with its complex sampling design, enhances the applicability and generalizability of our findings to the noninstitutionalized US adult population. Furthermore, the large sample size (N=31124) provided adequate statistical power to detect the association of interest. In addition, a key methodological strength is the use of serum cotinine, an objective and quantitative biomarker, to assess tobacco smoke exposure. To our knowledge, this represents the first large-scale, population-based study to examine the specific relationship between tobacco smoke exposure (objectively measured by serum cotinine) and spine fracture risk. This approach minimizes misclassification bias inherent in self-reported smoking data and strengthens the internal validity of our exposure-outcome association. Finally, the application of complex survey weights in all analyses ensured that our estimates are representative of the non-institutionalized US adult population, further bolstering the external validity of our results. However, several limitations should be noted. Firstly, the generalizability of our results may be constrained by the exclusive focus on the US population; external validation in diverse international cohorts is necessary. Secondly, the inherent constraints of the cross-sectional design preclude definitive causal inference regarding the relationship between tobacco smoke exposure and spine fracture. Thirdly, the assessment of serum cotinine at a single timepoint may not accurately reflect long-term Tob. Induc. Dis. 2026;24(June):83 https://doi.org/10.18332/tid/217959 10 Tobacco Induced Diseases Research Paper exposure patterns, as it cannot account for intraindividual variability over time. Fourth, despite adjusting for a comprehensive set of covariates, residual confounding from unmeasured or imperfectly measured variables remains possible. Specifically, we lacked data on important potential confounders such as physical activity levels, dietary calcium and vitamin D intake, bone mineral density (BMD), history of falls, and use of medications affecting bone metabolism (e.g. glucocorticoids, bisphosphonates). Previous studies have identified these factors as significant predictors of fracture risk and may also be associated with smoking behavior, thus potentially confounding the observed association28. Fifth, the use of self-reported data for several variables, including spine fracture status and comorbidities, introduces the potential for recall bias and outcome misclassification.

  Tobacco smoke exposure and spine fracture risk in US adults: A cross-sectional analysis of the National Health and Nutrition Examination Survey 1999–2010, 2013–2014, 2017–2020 · 2026 · DOI

• The main strength of this study lies in the integration of data that captures the complete nicotine-delivery pathway, from user behavior to aerosol generation to systemic uptake, using objective, laboratory-validated measurements rather than simulated or indirectly inferred inputs. This study also enabled the assessment of a non-linear relationship, providing a more plausible integration of the data that was previously thought to be linear. Having the e-cigarette sessions after 12 hours, plasma nicotine validated abstinence homogenized the baseline assessment and ensured that all subsequent measurements were mainly device and user-determined (e.g., not influenced by pre-assessment use of any tobacco product). Nonetheless, several limitations warrant consideration. The sample was restricted to fourth-generation closed-system devices, three nicotine concentrations (2.4%, 3%, 5%), and two flavors (menthol, tobacco), which may limit the generalizability of our findings. However, when we evaluated the models across devices with different powers (e.g., JUUL ~4.3 watts vs. NJOY/SREC ~6 watts) and PG:VG ratios (e.g., JUUL ~30:70 vs. NJOY/SREC ~50:50), they performed consistently across these configurations, supporting the robustness of these models. Finally, the models only estimate acute nicotine delivery after 12 hours of abstinence and, therefore, do not capture longitudinal or chronic exposure. Still, the acute model can be very fitting for the initial assessment of nicotine delivery of new products for regulatory purposes. Additionally, plasma nicotine was assessed as a nicotine boost, reflecting nicotine uptake during the vaping session rather than the complete nicotine concentration-time pharmacokinetic profile. The interval between the final puff and blood collection may have varied across participants; however, all post-session blood samples were collected within 10 minutes of session completion, likely reducing the influence of this variability. Future research can adopt and test these models across larger, more diverse populations, incorporating a broader range of device and e- liquid formulations.

  Predicting nicotine emissions and plasma nicotine boost in E-cigarette users using machine learning · 2026 · DOI

• Several limitations of this study should be acknowledged. First, the cross-sectional design precludes causal inference regarding the observed associations between tobacco product use and asthma. Second, both asthma status and tobacco use were assessed using self-reported measures, which may be subject to misclassification bias due to recall error or social desirability, potentially leading to non-differential misclassification. Third, although we adjusted for a wide range of sociodemographic, behavioral, and environmental factors, residual confounding by unmeasured variables – such as intensity and duration of tobacco use, nicotine dependence, or prior combustible cigarette use – cannot be excluded. In addition, the findings may not be fully generalizable to adolescents who are not enrolled in school or to settings with different cultural and regulatory contexts. Finally, reverse causality cannot be ruled out with this cross-sectional design. Despite these limitations, the present study provides large-scale, nationally representative evidence of an association between emerging tobacco product use and asthma prevalence among adolescents, underscoring Tob. Induc. Dis. 2026;24(May):70 https://doi.org/10.18332/tid/217962 7 Tobacco Induced Diseases Research Paper the importance of continued surveillance and youthfocused tobacco control and prevention efforts.

  Association between the use of e-cigarettes and heated tobacco products and asthma prevalence in adolescents: A secondary dataset analysis of the Korea Youth Risk Behavior Survey 2022–2024 · 2026 · DOI

• This study has several strengths. Compared to other studies of youth attempting to quit nicotine products, this study included a relatively large sample size. Also, no study has to our knowledge shed light on the differences in reasons to quit across nicotine product types. In addition, including smokeless nicotine was a significant strength, given that the use is highly prevalent in Denmark1,37 and thus the need for knowledge about helping youth to quit is much needed. This study also has some limitations. First, because of the cross-sectional design, it was not possible to indicate any causal direction between reason to quit and quit success. Second, the overall response rate was low. However, data were weighted to account for non-response, which diminishes selection bias arising from uneven response rates across age and gender. Selection bias due to other factors, i.e. socioeconomic status, could, however, be present. Third, few respondents did not report reasons to quit (n=71). However, as these responders are equally distributed across products, results were not affected. Fourth, youth who attempted to quit e-cigarettes reported ‘Do not remember’ more frequently. This may introduce information bias, due to differential misclassification of the outcome, dependent on the exposure, as an underestimation of the predefined reasons among those using e-cigarettes, may cause an overestimation of the differences in reported reasons between those using e-cigarettes and those using other products. Lastly, analyses were unadjusted, enhancing the risk of biased estimates, due to confounding factors, i.e. age and gender. However, age at the time of quit attempt was not measured, and adjusting for age at data collection would not be informative. Also, as causality was not the aim of this study, adjusting for potential confounding factors was not deemed relevant. It should further be noted that the findings may only apply in a Danish context, or contexts similar to this, although we found several agreements in findings with studies from other countries.

  Reasons to quit cigarettes, e-cigarettes, and smokeless nicotine products: A cross-sectional study among Danish people aged 15–29 years · 2026 · DOI

• To effectively address the high prevalence of tobacco, use among out-of-school youth in Tella, community outreach must be prioritized. Mobile health education units can serve as dynamic platforms for reaching informal youth gatherings, such as street corners, markets, and recreational spots where traditional health services rarely penetrate. These units should be staffed with trained educators who use interactive tools—such as visual aids, storytelling, and peer-led discussions—to engage youth in meaningful conversations about the risks of smoking. By meeting young people where they are, outreach efforts can overcome barriers of access and trust, making health education more relatable and impactful. Peer mentorship programs offer another powerful avenue for intervention. Training former smokers to serve as mentors not only provides relatable role models but also fosters a sense of community and accountability. These mentors can share personal stories of quitting, offer emotional support, and guide others through the challenges of behavior change. Such Volume 3, Issue 2, 2026 231 Isaac John Umaru, Solomon O. Asare, Tyem Lawal Danjuma, Inemesit Samuel Essien, Ingwu Joseph Akem, Genevieve A. Yeboah, Julius Ishaya Salman, Kwabena Owusu Amoah, Precious Chioma Jack, Hauwa A.

  Smoking Behaviors and Perceived Health Risks Among Out-of-School Youth in Tella, Taraba State · 2026 · DOI

• Further investigations into the thermo-oxidative reactions that happen during EC aerosol generation are necessary, as the harmful substances detected are distinct from those in cigarettes and have unique chemistry behind their generation.

  Vaping with a Mass Spectrometer — On the Road to Profile all Chemicals in E-Cigarette Puffs in Minutes · 2026 · DOI

• Short study period and limited number of participating departments are among the limitations of our study. We believe that future studies with larger participation, which will examine other factors that may influence smoking cessation, will contribute to the development of smoking cessation programs.

  Smoking cessation behaviors of patients who refer to smoking cessation clinics affiliated to family medicine departments · 2026 · DOI

• The relationship between tobacco use and CVDs is complex, and that between cigarette smoking and echocardiographic measurements of right ventricular (RV) and left ventricular (LV) structure and function has been poorly studied.

  Impact of smoking on left and right ventricular systolic function and left ventricular mass in young healthy males: A two- and three-dimensional echocardiographic study · 2025 · DOI

• Future research could explore the role of other individual differences in shaping counterarguing responses, the long-term effects of exposure to different types of anti-smoking messages on smoking behavior, and using more advanced neuroimaging techniques to investigate the neural processes that underlie counterarguing responses to anti-smoking messages for better flow.

  Maximizing the Effectiveness of Anti-Smoking Campaigns With Targeted Framing Strategies: Evidence From Behavioral and Neurological Studies · 2024 · DOI

• We identified 107 predictors and grouped them into "probable," "possible," "insufficient evidence," "probably unrelated," and "inconsistent direction" categories.

  A Systematic Review of Predictors of Vaping Cessation Among Young People · 2024 · DOI

Most-cited papers in Smoking Behavior and Cessation

• Smoking and Mental Illness · JAMA · 2000 · 2,009 citations
• Spatial, temporal, and demographic patterns in prevalence of smoking tobacco use and attributable disease burden in 204 countries and territories, 1990–2019: a systematic analysis from the Global Burden of Disease Study 2019 · The Lancet · 2021 · 1,404 citations
• Socioeconomic status and smoking: a review · Annals of the New York Academy of Sciences · 2011 · 1,298 citations
• Smoking Prevalence and Cigarette Consumption in 187 Countries, 1980-2012 · JAMA · 2014 · 1,284 citations
• Tobacco Product Use Among Adults — United States, 2019 · MMWR Morbidity and Mortality Weekly Report · 2020 · 809 citations
• Tobacco Product Use Among Adults – United States, 2021 · MMWR Morbidity and Mortality Weekly Report · 2023 · 689 citations
• Tobacco Product Use Among Adults — United States, 2020 · MMWR Morbidity and Mortality Weekly Report · 2022 · 577 citations
• Reasons for Electronic Cigarette Experimentation and Discontinuation Among Adolescents and Young Adults · Nicotine & Tobacco Research · 2014 · 538 citations
• Tobacco Use Among Middle and High School Students — United States, 2011–2015 · MMWR Morbidity and Mortality Weekly Report · 2016 · 497 citations
• E-cigarette Use Among Middle and High School Students — United States, 2020 · MMWR Morbidity and Mortality Weekly Report · 2020 · 438 citations

Most recent work

• Comparison of e-Cigarette and Cigarette Use and Dual Use Associations With Disease: Updated Systematic Review and Meta-Analysis · Public Health Reports · 2026
• Electronic cigarette use after smoking cessation and lung cancer risk · Nature Medicine · 2026
• Factors associated with intention to quit smoking in Indonesia: findings from a cross-sectional Global Adult Tobacco Survey · Korean Journal of Family Medicine · 2026
• Oral nicotine pouch use motives and dependence among individuals who use both cigarettes and e-cigarettes · Drug and Alcohol Dependence · 2026
• E-Cigarette, Nicotine Pouch, and Other Oral Nicotine Product Concept Flavor Use Descriptives and Associations with Demographics and Product Use Characteristics · Substance Use & Misuse · 2026
• The lure of 'Healthier Smoke': Comparative physical, chemical, and oxidative potential characterization of emissions from herbal and tobacco cigarettes · Journal of Hazardous Materials · 2026
• Vaping with a Mass Spectrometer — On the Road to Profile all Chemicals in E-Cigarette Puffs in Minutes · CHIMIA International Journal for Chemistry · 2026
• Electronic cigarettes smoking by teenagers in Russia during the 2019—2020 and 2023—2024 yrs · Russian Journal of Preventive Medicine · 2026
• Smoking cessation behaviors of patients who refer to smoking cessation clinics affiliated to family medicine departments · Turkish Journal of Family Practice · 2026
• Determinants of Smoking Relapse Among Indonesian Children: A National Cross-sectional Analysis Using Global Youth Tobacco Surveillance Data · Journal of Preventive Medicine and Public Health · 2026

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