{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,23]],"date-time":"2026-10-23T17:40:48Z","timestamp":1792777248214,"version":"4.5.0"},"reference-count":95,"publisher":"Public Library of Science (PLoS)","issue":"10","license":[{"start":{"date-parts":[[2026,10,23]],"date-time":"2026-10-23T00:00:00Z","timestamp":1792713600000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS One"],"abstract":"<jats:p>Smoking is a well-documented risk factor for chronic diseases, including arthritis. Vaping, often marketed as a safer alternative, has risen sharply, yet its implications for musculoskeletal health remain unclear. We examine the associations of vaping and smoking with arthritis using Double Machine Learning (DML), and present illustrative economic scenarios projecting the potential cost implications of arthritis cases associated with these behaviors. Data from the Behavioral Risk Factor Surveillance System (BRFSS) of the Centers for Disease Control and Prevention (CDC), collected in the United States, for adults aged 18\u201364 years (N\u2009=\u200936,768) is used. Arthritis is the outcome variable; vaping and smoking are the exposure variables, with estimates conditioned on twenty-seven demographic, behavioral, and health-related covariates (See Table 1). Results show that vaping is associated with a 2.12 percentage point higher prevalence of arthritis than among non-vapers, while smoking is associated with a 2.22 percentage points increase compared with non-smokers. When accounting for concurrent nicotine behaviors, the estimated associations remain largely stable, with smoking exhibiting a slightly larger estimate of 2.14 percentage points while vaping attenuated to 1.91 percentage points. Vaping was estimated to be associated with approximately 190,581\u2013254,109 arthritis cases annually, corresponding to a potential economic cost projection of $133.4--$177.9 million. Smoking was statistically associated with approximately 518,886\u2013687,413 cases, corresponding to $363.2 \u2013$481.2 million. Combined, the projected economic burden associated with vaping and smoking was approximately $496.6\u2013$659.1 million annually under conservative assumptions. Relative to published estimates of the total U.S. arthritis burden, these projections represent approximately 0.09%\u20130.22% of arthritis-related expenditures under direct healthcare cost assumptions and up to 9.23% when broader indirect and societal costs are considered. Our findings suggest that vaping is associated with musculoskeletal risk comparable to, or potentially exceeding, that of smoking, and do not support the perception of vaping as a risk-free alternative. The illustrative projections may inform policy discussions on vaping and smoking in relation to the broader arthritis-related health and economic burden.<\/jats:p>","DOI":"10.1371\/journal.pone.0360863","type":"journal-article","created":{"date-parts":[[2026,10,23]],"date-time":"2026-10-23T17:23:51Z","timestamp":1792776231000},"page":"e0360863","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":0,"title":["Vaping and smoking as risk factors for arthritis: Evidence from double machine learning"],"prefix":"10.1371","volume":"21","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-3167-4713","authenticated-orcid":true,"given":"Onyedikachi Emmanuel","family":"Chike","sequence":"first","affiliation":[{"name":"Palm Beach Atlantic University","place":["West Palm Beach, Florida, United States of America"],"department":["The Rinker College of Business"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6808-5563","authenticated-orcid":true,"given":"Syed","family":"Badruddoza","sequence":"additional","affiliation":[{"name":"Texas Tech University","place":["Lubbock, Texas, Lubbock, United States of America"],"department":["Department of Agricultural and Applied Economics"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Conrad","family":"Lyford","sequence":"additional","affiliation":[{"name":"Texas Tech University","place":["Lubbock, Texas, Lubbock, United States of America"],"department":["Department of Agricultural and Applied Economics"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2026,10,23]]},"reference":[{"issue":"5","key":"pone.0360863.ref001","doi-asserted-by":"crossref","first-page":"1557","DOI":"10.1378\/chest.06-2179","article-title":"Systemic effects of smoking","volume":"131","author":"DG Yanbaeva","year":"2007","journal-title":"Chest"},{"issue":"5","key":"pone.0360863.ref002","doi-asserted-by":"crossref","first-page":"409","DOI":"10.1007\/s00011-011-0308-7","article-title":"Impact of smoking on inflammation: Overview of molecular mechanisms","volume":"60","author":"RB Gon\u00e7alves","year":"2011","journal-title":"Inflamm Res"},{"issue":"8","key":"pone.0360863.ref003","doi-asserted-by":"crossref","first-page":"1018","DOI":"10.1080\/08870446.2017.1325890","article-title":"Tobacco smoking: Health impact, prevalence, correlates and interventions","volume":"32","author":"R West","year":"2017","journal-title":"Psychol Health"},{"issue":"1","key":"pone.0360863.ref004","doi-asserted-by":"crossref","first-page":"580","DOI":"10.3390\/cancers6010580","article-title":"Impact of neuro-psychological factors on smoking-associated lung cancer","volume":"6","author":"HM Schuller","year":"2014","journal-title":"Cancers (Basel)"},{"issue":"10","key":"pone.0360863.ref005","doi-asserted-by":"crossref","first-page":"1980","DOI":"10.1253\/circj.CJ-19-0323","article-title":"Effects of tobacco smoking on cardiovascular disease","volume":"83","author":"T Kondo","year":"2019","journal-title":"Circ J"},{"issue":"7","key":"pone.0360863.ref006","doi-asserted-by":"crossref","first-page":"642","DOI":"10.1001\/jama.2019.10298","article-title":"Association of smoking cessation with subsequent risk of cardiovascular disease","volume":"322","author":"MS Duncan","year":"2019","journal-title":"JAMA"},{"issue":"1","key":"pone.0360863.ref007","doi-asserted-by":"crossref","first-page":"193","DOI":"10.1186\/s12872-024-03838-7","article-title":"Investigating the interplay of smoking, cardiovascular risk factors, and overall cardiovascular disease risk: NHANES analysis 2011-2018","volume":"24","author":"A Mambo","year":"2024","journal-title":"BMC Cardiovasc Disord"},{"issue":"1","key":"pone.0360863.ref008","doi-asserted-by":"crossref","first-page":"193","DOI":"10.1186\/s12933-023-01930-4","article-title":"Smoking behavior change and risk of cardiovascular disease incidence and mortality in patients with type 2 diabetes mellitus","volume":"22","author":"S-M Jeong","year":"2023","journal-title":"Cardiovasc Diabetol"},{"issue":"1","key":"pone.0360863.ref009","doi-asserted-by":"crossref","first-page":"128","DOI":"10.1186\/s12916-019-1351-4","article-title":"Tobacco smoking and risk of 36 cardiovascular disease subtypes: fatal and non-fatal outcomes in a large prospective Australian study","volume":"17","author":"E Banks","year":"2019","journal-title":"BMC Med"},{"key":"pone.0360863.ref010","doi-asserted-by":"crossref","first-page":"1685","DOI":"10.1002\/(SICI)1097-0258(20000615\/30)19:11\/12<1685::AID-SIM454>3.0.CO;2-#","article-title":"Does an interaction between smoking and drinking influence the risk of Alzheimer\u2019s disease? 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