Tobacco use is a significant risk factor for several health conditions, such as cancer, cardiovascular disorders, chronic obstructive pulmonary diseases, and oral diseases (1–3). Commercial tobacco can be smoked as cigarettes, e-cigarettes, cigars, cigarillos, little filtered cigars, pipes, hookahs, etc.; consumed smokeless as snuff, loose leaf chewing tobacco, lozenges, etc. (4); or can be used in combination (poly use) (5–7). Despite its public health impact, tobacco use remains a serious health concern. In 2021, it was estimated that nearly 1 in 5 US adults (18.7%) were using any commercial tobacco product (5). Although the prevalence of cigarette smoking (which has been the primary target of most smoking cessation interventions so far) has decreased in the last decade in the US [from 18.0% in 2012 (8) to 11.5% in 2021 (5)], the use of other tobacco products (electronic cigarettes, cigars, cigarillos, little filtered cigars, pipes, and smokeless tobacco) has increased [from 7.3% in 2012 (8) to 11.0% in 2021 (5)].

In 2020, over half (53.9%) of US adults who smoked attempted to quit smoking, and only 8.5% were successful (9). Evidence suggests that advice from healthcare professionals (HCPs) increased the likelihood of quit attempts and successful quitting of tobacco use. Kastaun and colleagues found that patients who received advice from HCPs to quit smoking had 2-fold higher odds of quit attempts and also reported 2.22-fold higher odds of point prevalence abstinence at 26 weeks follow-up than those who did not receive such advice (10). In a systematic review of 42 trials, Stead and colleagues found that even brief advice from HCPs would likely increase quit smoking rates (11). In addition to doctors and other health professionals, tobacco cessation in oral health settings is effective and feasible (3). Yadav and colleagues found that individuals who received smoking cessation advice from a dental care professional reported 18% more quit attempts (12). In a systematic review, Holliday and colleagues found that brief advice from dental professionals increased quit rates for all tobacco use (13). Therefore, to increase tobacco use cessation rate, the United States Public Health Service (USPHS) clinical practice guidelines recommended that HCPs should use the 5A’s model (ask, advise, assess, assist, and arrange) to ask for tobacco use at every visit; advise to quit; assess willingness to quit; assist patients who are willing to make a quit attempt with counseling and pharmacotherapy; and arrange follow-up within the first week after the quit date (14). In the US, more than 80% of adults reported visiting an HCP, and more than 60% reported visiting a dentist at least once a year (15), which represents a unique opportunity for HCPs and dentists to ask about tobacco use and advise them to quit its use.

Previous studies have reported a 57.2% prevalence of medical advice to quit cigarette smoking, and sociodemographic characteristics such as Hispanic, younger age, male, and uninsured were found to be associated with a lower likelihood of receiving medical advice to quit smoking (10, 11, 16, 17). Furthermore, immigrants constitute 13.9% (18) of the US population and often experience challenges in receiving healthcare services due to cultural, social, and economic barriers (19–22). There is limited information on the prevalence of the receipt of medical advice to quit tobacco among immigrants in the US.

Although cigarette use has gradually decreased (5, 23), the emergence of a diverse landscape of combustible and noncombustible tobacco products and the observed increase in the consumption of these products (5, 8) may counterbalance the health, social, and economic benefits expected from the reduction of cigarette smoking. Therefore, it is essential to have a holistic approach in rendering medical advice to quit tobacco use. However, previous reports (10, 11, 16, 17, 24) have focused only on receiving advice to quit cigarette smoking, but not all forms of tobacco products. Furthermore, none of the previous reports included dentists as a source of medical advice to quit tobacco use (10, 11, 16, 17, 24).

To address these gaps, our study aimed to (1) investigate the prevalence of receiving advice to quit any form of tobacco products (cigarettes, e-cigarettes, cigars, cigarillos, little filtered cigars, pipes, and smokeless tobacco) from HCPs and dentists, and (2) examine disparities associated with receiving such advice among US adult tobacco users.

The NHIS 2022 dataset included 27,651 adult individuals, 91% of whom visited an HCP in the last 12 months. After screening for HCP visits and tobacco use in the past 12 months, the study sample included 4,424 individuals (Figure 1).

In this nationally representative sample of the US adult population who used tobacco and visited an HCP in the last 12 months, 38.4% received medical advice to quit. Although medical advice to quit tobacco use is an effective intervention for tobacco use cessation (1, 10, 11, 31), our study suggests that almost two-thirds of adult tobacco users missed clinical opportunities to quit and remain at risk of tobacco-use-related diseases. The current literature on medical advice to quit tobacco use is mainly focused on cigarette smoking. However, in practice, cigarettes and other tobacco products such as e-cigarettes, cigars, pipes, and smokeless tobacco are used solo or in combination (32). With the growing consumption of other tobacco products (33) and the rising popularity of polysubstance use (34) in the US, it is of utmost importance that every tobacco user, regardless of the type of tobacco product used, receive advice and education from their HCPs on the harms associated with tobacco use.

In our study, race and ethnicity, sex, place of birth, age, and level of educational attainment were the major sociodemographic factors found to be significantly associated with the receipt of HCPs’ advice to quit all tobacco use. We found that Hispanics were less likely to receive medical advice to quit tobacco use, which is consistent with the existing literature on tobacco smoking (19, 24, 35, 36). Among other factors, the language barrier was found contributing to the lower odds of receipt of medical advice to quit tobacco use among Hispanics (20). Therefore, culturally competent interventions should be made available to HCPs to provide advice to Hispanics to quit tobacco use (19, 37, 38).

We also found that male tobacco users were less likely to receive medical advice to quit, corroborating the existing literature (17, 35). Females are more likely to receive medical advice because they tend to seek medical assistance to quit smoking and use recommended cessation resources more frequently than males (39). Since the prevalence of tobacco use is higher among males (40), lower odds of receiving medical advice to quit in males is alarming and calls for increased efforts to encourage men to seek medical assistance to quit tobacco use.

Interestingly, foreign-born US residents were less likely to receive medical advice to quit tobacco use compared to US-born individuals. Lower odds of receiving medical advice to quit tobacco use among foreign-born could be due to physicians’ limited access to culturally competent smoking cessation interventions and patient’s lack of access to care (19, 20). Moreover, studies have reported that foreign-born individuals have lower healthcare utilization and are less likely to use preventative care (21, 22). HCPs give priority to the patient’s primary complaint and usually do not focus on smoking cessation unless they present with a smoking-related disease (41). Since foreign-born individuals are more likely to visit an HCP only when they have a health complaint, and if the complaint is not associated with any smoking-related condition, it is less likely that they will receive any quit smoking advice from the HCP (41).

We found that individuals younger than 45 years were less likely to receive medical advice to quit tobacco use, which is congruent with other studies (17, 35). According to Frank and colleagues, a physician might not find advising healthy younger patients time-efficient due to lower perceived health risk; hence, physicians focus more on older patients as they present more frequently with smoking-related diseases (42). Moreover, El-Shahawy and colleagues found that physicians are inconsistent in advising users of newer tobacco products commonly used among the youth, such as e-cigarettes, because information on the potential harms and benefits are lacking or non-consensual, and there were beliefs supporting e-cigarette use as a safer alternative to combustible products and has benefits in smoking cessation (43, 44). The 2020 Surgeon General’s report indicates that the efficacy of e-cigarettes as a smoking cessation aid is inconclusive (1), and there are health risks associated with e-cigarette use, such as nicotine dependence, cancer, respiratory infections, and oral and gastrointestinal disorders (45, 46). Under such circumstances, the lower rate of HCP advice or inconsistent advice to quit all tobacco use among younger adults reflects a missed opportunity to prevent adverse tobacco-related health issues in the future.

We also found that individuals with tertiary education (bachelor’s degree or higher) were less likely to receive advice to quit tobacco use from HCPs. The existing literature has conflicting findings on this topic. While some studies supported our findings (24, 35, 36, 47), other studies suggested that individuals with a tertiary level of education were more likely to receive medical advice to quit smoking (48–50). After adjusting for education, we found that individuals living in households above the poverty level were less likely to receive medical advice to quit tobacco use. Like education, the relationship between poverty and medical advice to quit smoking was also inconsistent in the literature. While some reports state that high-income individuals are more likely to receive medical advice (48, 50), others found no significant association between income or poverty ratio (17, 49) and medical advice. Therefore, the role of patients’ education and income on medical advice to quit tobacco use needs further investigation. A plausible explanation of our finding is that individuals from middle or high socioeconomic status (here proxied by education and poverty ratio) have a low prevalence of tobacco use (5) and have lower comorbidities (51), high literacy (52), and better living conditions, which leads to HCPs having a low perceived threat of smoking-related diseases for these patients.

Despite recommendations from the Surgeon General and other professional medical associations, medical advice to quit tobacco use remains low in the US (1). Considering the critical role of HCPs in their patient’s decision to abstain from tobacco use, the suboptimal prevalence of medical advice indicates a missed clinical opportunity to promote quitting tobacco use. This is especially concerning because, in our data, about 91% of the US adult population had a clinical encounter(s) with a healthcare professional (HCP) or a dentist in the past 12 months, indicating a missed clinical opportunity to ask for tobacco use and advice to quit to a significant proportion of the US adult population. Individual and organization-level barriers may be accountable for suboptimal medical advice to quit tobacco. At the individual level, lower odds of medical advice to quit smoking could be driven by the HCPs’ lack of perceived health risks to patients (e.g., the patient has good health), a fear of damaging patient-provider relationship (41, 42), the lack of perceived effectiveness of counseling, perceived low patient motivation, and the lack of training in tobacco use cessation and effective counseling communication (53, 54).

At the organizational level, poor reimbursement, lack of tobacco use cessation resources, limited time for patient-provider communication, and lack of support services needed for smoking cessation could account for the low receipt of medical advice to stop tobacco use (36, 55). Therefore, training HCPs on quitting tobacco use and counseling skills and developing an integrated system of HCPs advice and a tiered system of support to quit tobacco use will help improve quitting (56).

To the best of our knowledge, this is the first study that included all tobacco products (and not just cigarettes) as the primary outcome and assessed disparities in receiving medical advice to quit all tobacco use. Holistic medical advice to quit any form of tobacco is especially important now, considering the rising use of other tobacco products, such as electronic cigarettes (57) and poly use (34). Considering the established effectiveness of tobacco use cessation by oral healthcare professionals (3, 12, 13), another novelty of this study is that in addition to HCP visits, we also accounted for dental visits as a criterion for the study population, unlike previous reports (16, 19). Additionally, we included foreign-born as a predictor, which was not included in the previous studies. Finding that foreign-born individuals are less likely to receive medical advice to quit smoking gives a new insight into healthcare disparities experienced by US immigrants and should be further investigated in greater depth. Moreover, our finding on disparate medical advice to individuals with tertiary education was unique and calls for further analysis to assess intersectionality for other factors such as race and sex. Another key strength of our study is that it uses the most updated (released June 2023) nationally representative large sample of the US population.

The study had some limitations. Given the cross-sectional design, the study could not establish a causal relationship between identified factors and advice to quit tobacco use. Therefore, longitudinal studies are needed to establish the causal relationship. The data was based on self-report; hence, recall bias could have affected participants’ responses. Further, because NHIS is limited to non-institutionalized US civilian populations, results are not generalizable to institutionalized populations or persons in the military.

The prevalence of receiving HCP advice to quit tobacco use in the US adult population remains suboptimal and disparate among sociodemographic groups. Our findings call for strategic implementation of USPHS’s guidelines through policy enforcement and resource allocation to improve the receipt of medical advice to quit tobacco use among Hispanics, males, foreign-born, young individuals, and those who are highly educated. Policies should be implemented to increase training on cessation for all forms of tobacco products in medical and dental schools, as well as practitioner licensing renewal curriculums, especially for primary care physicians and dentists. More resources should be allocated to equip the HCPs with culturally adapted counseling competencies. The other targeted systemic level changes could include increasing resources and funding towards college campus health clinics and community health clinics (especially in areas with a high presence of ethnic minorities and foreign-born) to improve quit smoking.