The research team, led by Lauren R. Pacek of the Rutgers Institute for Nicotine and Tobacco Studies, drew on three years of data from the National Survey on Drug Use and Health, spanning 2021 through 2023 and encompassing 139,524 adult respondents. The survey employs a 50-state multistage area probability design, with sampling weights adjusted to match US Census Bureau population estimates, making it one of the most statistically robust windows into American substance use behavior available. The investigators focused on exclusive users of five tobacco categories: cigarettes, cigars, smokeless tobacco, e-cigarettes, and multiple tobacco products, defined as use of two or more products during the past year and past month.

The headline numbers are stark. Among past-year cigarette smokers who attended at least one medical appointment, 78.9 percent reported being asked about their tobacco use by a doctor or other health professional. That figure dropped to 74.3 percent for cigar users, 72.5 percent for smokeless tobacco users, and 73.2 percent for e-cigarette users—differences that reached statistical significance. In logistic regression models adjusting for demographics, healthcare visit frequency, insurance status, and mental and physical health comorbidities, exclusive users of cigars, smokeless tobacco, e-cigarettes, and multiple products all had lower adjusted odds of being asked about tobacco use compared with cigarette smokers.

The gap widens precipitously at the advising stage. Among cigarette smokers who were asked about their tobacco use, 77.1 percent reported receiving advice to quit. For cigar users, that figure collapsed to 25.4 percent. Smokeless tobacco users fared somewhat better at 46.0 percent, while users of multiple tobacco products reached 65.4 percent. The most extreme disparity belonged to e-cigarette users: just 0.5 percent of those asked about tobacco use reported being advised to quit vaping. In adjusted models, e-cigarette users had roughly 0.2 percent of the odds of receiving cessation advice compared with cigarette smokers—an adjusted odds ratio of 0.002, with cigar users at 0.11 and smokeless tobacco users at 0.24.

These disparities matter because the assumption that non-cigarette products are benign is increasingly untenable. Epidemiological research has linked cigar and pipe use with elevated mortality risk, and recent cohort analyses have associated cigar, pipe, and smokeless tobacco use with adverse cardiovascular outcomes. Smokeless tobacco carries established carcinogenic risks, and e-cigarettes expose users to nicotine along with a cocktail of aerosolized chemicals whose long-term effects remain under investigation. Meanwhile, the popularity of these products is substantial: the 2023–2024 National Health Interview Survey found that 7.0 percent of adults report using e-cigarettes and 3.7 percent report using cigars. Interest in quitting is also high—68.2 percent of established e-cigarette users in the Population Assessment of Tobacco and Health study reported plans to quit vaping.

Why are providers falling silent? The study’s authors point to a tangle of plausible mechanisms. Clinical guidelines for non-cigarette tobacco products are notably more ambiguous than those for cigarettes, leaving providers without clear directives. Surveys of physicians and oral health practitioners consistently reveal limited knowledge about e-cigarettes and other emerging products, alongside perceptions that these products are less harmful than cigarettes. Some clinicians view e-cigarettes as harm reduction tools for smokers who switch, which may suppress the impulse to advise complete cessation. Provider-reported lack of training and confidence in treating tobacco dependence remains a persistent barrier, and time-limited encounters crowded with competing priorities—acute illness, chronic disease management—often push tobacco discussions aside. Qualitative research suggests some providers believe other specialties or settings should shoulder the responsibility, or that patients are simply not interested in quitting, despite epidemiological evidence indicating that most tobacco users want to quit.

The correlates uncovered by the regression analyses add a troubling socioeconomic dimension. Respondents with greater educational attainment and higher annual income were more likely to be asked about their tobacco use across several product categories. Among exclusive cigarette smokers, having at least some college education raised the adjusted odds of being asked by 43 percent, and incomes of 40,000 to 74,999 dollars or at least 75,000 dollars raised those odds by 76 to 84 percent compared with incomes below 20,000 dollars. Non-Hispanic Black e-cigarette users were less likely than non-Hispanic White users to be asked about their vaping, and among users of multiple products, non-Hispanic Black and Hispanic respondents were less likely to be advised to quit. These patterns echo prior findings of racial disparities in provider-delivered cessation advice and are especially concerning given the disproportionate burden of tobacco use borne by lower-income communities.

Not every correlate points toward neglect. Attending six or more healthcare appointments in the past year raised the adjusted odds of both being asked about tobacco use and receiving advice to quit by roughly 50 percent overall. Having a lifetime chronic health condition—cancer, heart disease, diabetes, COPD, or similar diagnoses—increased the adjusted odds of being asked by 71 percent, and older age, at 50 years or above, more than tripled the adjusted odds of receiving cessation advice. Notably, the chronic condition effect persisted even after controlling for visit frequency, suggesting that providers may be more vigilant about tobacco when patients present with conditions plausibly linked to it. Among cigarette smokers, a past-year major depressive episode raised the adjusted odds of being asked by 91 percent, while using the product on more days per month modestly increased the likelihood of both being asked and being advised to quit.

The study is not without limitations, which the authors acknowledge candidly. The National Survey on Drug Use and Health is a cross-sectional, self-report instrument, precluding causal inference and introducing potential recall bias. It captures only a subset of tobacco products, omitting heated tobacco products and nicotine pouches, and does not differentiate among cigar types such as large cigars, cigarillos, and little filtered cigars—categories that may elicit different provider responses. The analysis was also conditioned on attending a healthcare appointment, so the estimates describe tobacco users in contact with the healthcare system rather than the entire adult population. Data collection occurred during the COVID-19 pandemic, though methodological changes to the survey prevent statistical comparison with prior years.

Even so, this represents the most current national assessment of the Ask and Advise components of tobacco cessation care, and the first to treat cigars, smokeless tobacco, and e-cigarettes individually rather than lumping them into a single non-cigarette category. The implications for clinical policy are direct. The authors call for expanded tobacco treatment training integrated into medical education, which trials show increases provider-delivered cessation care across specialties. They also urge education on the diversifying tobacco marketplace and the continuum of relative harm across products—along with the persistent misperception, documented among US physicians, that nicotine itself is the primary cause of tobacco-related disease, when in fact it is the combustion products and other toxicants that drive morbidity and mortality. Embedding dedicated tobacco treatment specialists in clinics and deploying medical assistants to assess tobacco use could relieve the burden on time-pressed physicians. Until such changes take hold, millions of Americans who vape, dip, or smoke cigars will continue to visit their doctors without ever being asked the question that could start their journey to quitting.

Subject of Research: Healthcare Providers are Less Likely to Ask About and Advise Cessation for Non-Cigarette Tobacco Products: NSDUH 2021–2023

Article Title: Healthcare Providers are Less Likely to Ask About and Advise Cessation for Non-Cigarette Tobacco Products: NSDUH 2021–2023

Article References: Pacek, L. R., Yang, M.-J., Mercincavage, M., Gilles, M. J., Jordan-Casarona, K., Garthe, N. E., Delnevo, C. D., & Steinberg, M. B. (2026). Healthcare Providers are Less Likely to Ask About and Advise Cessation for Non-Cigarette Tobacco Products: NSDUH 2021–2023. Journal of General Internal Medicine. https://doi.org/10.1007/s11606-026-10925-2

Image Credits: AI Generated

DOI: 10.1007/s11606-026-10925-2

Keywords: Healthcare, Providers, Less, Likely, Advise, Cessation, Non-Cigarette, Tobacco, Products, NSDUH, scientific research