The World Health Organization (WHO) estimates that there are 1.3 billion tobacco consumers globally, with Europe having the highest prevalence of tobacco use among adults (1). The health consequences of tobacco use are widely known. It is one of the leading preventable causes of premature death worldwide (2). Tobacco increases the risk of cardiovascular diseases (3), and it is a major cause of certain types of cancers such as lung and esophageal cancer (4). Additionally, it leads to lung diseases like COPD (Chronic Obstructive Pulmonary Disease) or chronic bronchitis (5).

The perception of tobacco in society has undergone a significant change in the last few decades. While tobacco was socially accepted and even idealized some years ago, currently, its consumption is widely regarded as harmful to health and carries a great social stigma (6). This change in tobacco perception has been driven by various factors, such as public health initiatives to raise awareness about the risks associated with tobacco use (7), scientific evidence linking smoking to numerous diseases (8), and the adoption of policies and regulations to restrict tobacco access and reduce consumption. The implementation of legislation to control tobacco consumption has had a significant impact on reducing tobacco use in many parts of the world (9). Various studies show that the implementation of anti-tobacco policies, such as smoking bans in public places, has led to a significant reduction in the number of smokers (10). Other measures promoted in 2005 by the WHO, in the Framework Convention on Tobacco Control, included the implementation of warning labels on tobacco packages (11). In this regard, some studies have been conducted, demonstrating their effectiveness, especially among non-smokers, and their ability to evoke emotions of aversion toward tobacco (12). One study measured the impact of various measures implemented for tobacco control, and found that among the most effective were the implementation of smoke-free public spaces (13). For example, in Spain, after implementing various measures to control tobacco consumption, tobacco sales decreased by 51% between 2005 and 2019 (14).

Traditional research methods such as surveys, interviews, cohort studies or naturalistic approaches have been the main and most used methods to investigate patients' and healthcare providers' experiences. However, these methods have several limitations. For example, they are subject to social desirability and recall bias or the inability to gather information in real-time (15–17).

As an alternative and innovative approach, social media platforms are increasingly being used by researchers for public health surveillance (18), as they provide a useful tool to capture more candid and natural opinions from users (19), which may not be obtained in more formal settings like medical consultations (20). Furthermore, this new research methodology allows health care professionals to listen to those patients who might be reluctant to participate in surveys and questionnaires through traditional methods (21).

Platforms like X (previously known as Twitter) host real-time, spontaneous discussions, offering an authentic window into the nuances of patient attitudes toward a certain topic, which are often missed by time-lagged traditional research methods. In a systematic review conducted to analyze the advantages and disadvantages of using Twitter in public health research, it was found that it is a valuable tool for identifying social concerns and information needs on a specific topic, but as a source of information, greater involvement of healthcare professionals is needed to improve the quality and accuracy of the messages (22).

Indeed, Twitter has proven to be a useful platform for evaluating public health topics related to tobacco legislation (23), population health behaviors (24), and tobacco consumption (25).

However, despite efforts to control tobacco use, the consumption of tobacco-related products remains high, and policies aimed at eradicating tobacco use continue to generate significant controversy.

In this study, we have formulated two hypotheses. Firstly, we hypothesize that the societal consideration of tobacco regarding personal experiences and health consequences has changed among the population due to anti-tobacco policies implemented in recent decades. Secondly, we assume that it is possible to identify geographical differences in opinions and concerns regarding tobacco consumption, which provide insights into user attitudes in different parts of the world.

Therefore, this article aims to examine whether there has been a shift in society's perception of tobacco and what prevailing opinions exist regarding anti-tobacco policies. To achieve this, we have collected tweets published on the topic between January 1, 2018, and April 30, 2022, analyzing the content, the type of user posting on Twitter about the topic under study, perceptions of its health effects, and personal experiences with consumption, taking into account the geolocation of the tweets to explore differences among different continents.

In this work, we have found that there are six times more tweets about the harmful effects of tobacco on health than about its benefits, which is a very encouraging finding concerning the social awareness of users. This trend aligns with previous studies showing an increasing focus on the health risks of tobacco consumption, which could suggest that the implemented policies in recent years have been effective. In Europe, the proportion of smokers continues to decrease, with the majority of countries experiencing a decline from 32% to 26% since 2006 (41). Additionally, the most prevalent emotion in the tweets is fear, accounting for 40.4% of the posts, which is a positive result as this emotional response can prompt individuals to quit smoking (42). This emotional reaction is often associated with the population's knowledge about the physical health risks of tobacco consumption (43).

It is concerning that there is still a 9.2% of users who consider smoking to be beneficial. New forms of tobacco, such as e-cigarettes and vaping, may play a crucial role in this aspect, as they are sometimes perceived as less harmful by some individuals (44). Twitter conversations often promote the use of e-cigarettes and vaping as socially acceptable practices, discrediting scientific evidence of health risks, and advocating for minimal regulation of these products (45). This poses a new challenge in debunking the misconception that these new forms of tobacco are harmless and reducing their consumption. Some measures have already been implemented to tackle this new epidemic (46). For example, in the United States, the Federal T21 Law was passed in late 2019, raising the minimum age for the sale of tobacco products to 21 years (47, 48).

Interestingly, tweets regarding the supposed health benefits of smoking have achieved the same level of engagement as tweets about the health harms of smoking. Looking at the engagement generated by different types of users, it is surprising that undetermined users, despite being a minority, have clearly generated more engagement than the rest, which is contrary to what has been reported in previous studies that used a similar methodology to study other health issues. For example, in a study that examined common opinions and beliefs about electroconvulsive therapy, the users who generated the most engagement were healthcare professionals (37). In another study focusing on opioid-related posts on Twitter, it was also found that healthcare professionals and institutions were the users who generated the most engagement (49). Similarly, a recent study on societal views regarding cocaine also found that tweets published by healthcare professionals generated the most engagement (50). Therefore, the fact that in our study both tweets discussing the supposed benefits of smoking and those discussing the health harms of smoking have achieved very similar levels of engagement may be due to the presence of a few accounts classified as undetermined, which have many followers and are promoting the supposed benefits of tobacco. This assumption cannot be dismissed since previous studies have demonstrated that the tobacco industry uses social media to position itself and promote its sales (51, 52). Furthermore, it is well known that in other sectors, industries promote their products through social media. Indeed, food, beverage, and snack companies promote their brands on social media platforms, and use posts to advertise unhealthy products (53, 54). In the case of tobacco, this is particularly dangerous because exposure to such content on social media increases the likelihood that a young person will start smoking (40, 55).

The significant presence of healthcare professionals on Twitter, with 50.1% of the posts coming from this group, is a very positive finding. The use of social media by healthcare professionals facilitates the dissemination of health-related information and fosters bidirectional communication with users (56). Due to the higher number of tweets published by healthcare professionals, it is logical that the most recurring theme is general information about tobacco, scientific topics, health effects, and preventive measures. In light of these results, Twitter could be a useful platform for disseminating messages by healthcare professionals and institutions for tobacco prevention.

Regarding frequent tobacco consumption, only 11% of the analyzed tweets discuss this aspect. This finding does not align with more traditional data collection methods; according to the World Health Organization (WHO), 22.3% of the global population were smokers in 2020 (1). The discrepancy between official surveys and this study's analysis may be attributed to the exclusion of the keyword “vaping,” as the population might not consider vaping the same as tobacco consumption. Twitter discourse tends to view vaping as not posing health risks (43, 57), and the population is exposed to advertising related to e-cigarettes as a smoking cessation aid (58). The dissemination of preventive campaigns against the minimization of the risk of new tobacco products would be interesting. Social media could be a useful tool, as they are more cost-effective and currently have a larger audience than traditional media outlets (television, press) (59).

Another important group of tobacco influencers on Twitter are celebrities, accounting for 30.2% of the sample. We should not overlook this data as they often hold prominent positions on social media and have a large number of followers, which means their opinions reach a significant audience. A study on opinion leaders and general users on Twitter and their behavior and attitude toward tobacco products found that opinion leaders reported the highest prevalence of consumption. Therefore, they may be negatively influencing the rest of the population, especially the youth (60). Also, in another study, it was found that social influence on Twitter was primarily related to popularity (61). Messages shared by celebrities can influence public opinion and online discourse of other users (62).

A novel aspect of our work is the geolocation of tweets. It is notable that America is the continent with the highest number of geolocated tweets, representing more than a third of the total. This high proportion may reflect both the prevalence of Twitter usage in America, with the United States being the country with the most Twitter users (63), this data makes sense. Additionally, it is evident that there is interest and concern about this issue, and that in this country 1 out of every 5 deaths is a consequence of smoking tobacco (64).

The second continent with the highest number of tweets is Europe. Among the posts, a higher frequency of content related to frequent tobacco consumption is observed, which may indicate a concern for tobacco consumption patterns in the region. This result may be due to the fact that, according to the WHO global report, Europe is the second continent with the highest prevalence of smokers (65).

However, it is noteworthy that the African continent has the lowest percentage of tweets regarding the harm of tobacco use to health (41.6%), when compared to the rest of the continents. For example, in America, 53.1% of tweets mention the harms of tobacco to health; in Europe, 60.6%; in Asia, 74.2%; and in Oceania, 52.5%. This could be due to greater laxity in tobacco control policies (66, 67), with lower taxes and a stronger presence of the tobacco industry in this region (68).

Overall, these findings highlight the importance of considering geographical and cultural differences when designing strategies for tobacco prevention and control on a global scale.

Public health surveillance of behaviors, opinions, and attitudes on relevant health topics on social media has proven to be of great value for healthcare professionals. It allows us to focus on what our users truly think and thus develop more appropriate approaches to their needs and create efficient interventions to prevent future health issues (21).

This study has some limitations. Firstly, the social, economic, and demographic characteristics of Twitter users do not fully reflect society as a whole. Secondly, the design of the codebook and the analysis of tweets involve some subjectivity, as is common in qualitative studies. However, this methodology is consistent with previous medical research studies using Twitter. Additionally, to address this issue, our study included several countermeasures, such as an initial review, codebook design, and agreement among coders. Third, another limitation to note is that the use of the keyword tobacco probably limited the sample of tweets, since the people who use the products probably use the name of the product or hashtags such as vaping, juuling or smoking. So, because of the nature of the word tobacco it is likely that the sample was more of health professionals or other people who use the more formal term “tobacco” and it probably increased the likelihood that the tweets were about the harms of tobacco. Finally, it should be noted that the least represented continent has been Africa, probably because we have only collected tweets published in Spanish or English. In future work, consideration should be given to including languages that are more widely spoken on this continent.

In conclusion, our study sheds light on several important aspects of tobacco discourse on Twitter and its implications for public health. Firstly, we found a notable emphasis on tweets discussing the harmful effects of tobacco, indicating a positive trend toward increased awareness among users.

Furthermore, our analysis reveals unexpected patterns of engagement, with tweets discussing both the benefits and harms of smoking garnering similar levels of interaction. This suggests the presence of influential accounts promoting tobacco-related content, potentially aligned with industry interests. The substantial presence of healthcare professionals on Twitter presents an opportunity for disseminating accurate information and preventive measures.

Geographically, America emerges as the predominant region for tobacco-related discourse on Twitter, followed by Europe. These findings underscore the need to tailor tobacco prevention strategies to regional differences and cultural contexts.

Overall, our study underscores the value of social media surveillance for understanding public attitudes toward tobacco and informing targeted interventions. By leveraging platforms like Twitter, healthcare professionals and institutions can amplify their efforts in combating tobacco use and promoting public health.

As future lines of research, we aim to include other keywords, such as vaping or electronic cigarettes, which would allow us to analyze discourse on Twitter regarding new forms of tobacco products. Additionally, we believe it would be interesting to expand the search to more languages to have greater representation in other geographical areas, which were minority in our study.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

The studies involving humans were approved by Comité de Ética de la Investigación y de Experimentación Animal de la Universidad de Alcalá. The studies were conducted in accordance with the local legislation and institutional requirements. Written informed consent for participation was not required from the participants or the participants' legal guardians/next of kin in accordance with the national legislation and institutional requirements.

CC-T: Conceptualization, Investigation, Methodology, Project administration, Writing – original draft. CF-L: Formal analysis, Methodology, Writing – review & editing. FL-A: Data curation, Formal analysis, Software, Writing – review & editing. RM-R: Visualization, Writing – review & editing. MO: Visualization, Writing – review & editing. FM: Visualization, Writing – review & editing. MA-M: Supervision, Writing – review & editing. JQ: Visualization, Writing – review & editing. MAA-M: Project administration, Supervision, Writing – review & editing.