{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,1]],"date-time":"2026-07-01T15:52:49Z","timestamp":1782921169210,"version":"3.54.5"},"reference-count":16,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,7,1]],"date-time":"2026-07-01T00:00:00Z","timestamp":1782864000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Oncol."],"abstract":"<jats:sec>\n                    <jats:title>Introduction<\/jats:title>\n                    <jats:p>Tobacco exposure is a major determinant of risk and clinical outcomes in head and neck squamous cell carcinoma (HNSCC). Although pack-years have long represented the standard metric for quantifying smoking exposure, increasing evidence suggests that this approach incompletely captures the biological and clinical heterogeneity of tobacco-related risk.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Discussion<\/jats:title>\n                    <jats:p>Recent epidemiological and clinical studies demonstrate that smoking duration rather than its intensity or cumulative pack-years measures is a stronger predictor of HNSCC risk and overall survival, particularly among long-term smokers. Regarding cumulative metrics, metrics like log cigarette-years have shown a better prognostic role when compared with pack-years. Beyond cumulative or duration-based models, smoking cessation and the use of alternative tobacco products substantially influence HNSCC risk and clinical outcomes. While smoking cessation is associated with a progressive reduction in risk and improved survival, active smoking at diagnosis is consistently associated with inferior treatment response. In parallel, non-cigarette tobacco products\u2014including cigars, pipes, and smokeless tobacco\u2014have been shown to independently increase HNSCC risk, are rarely incorporated into exposure models. The growing use of alternative nicotine-containing products, often in combination with cigarette smoking, further complicates risk assessment, as their long-term carcinogenic and immunomodulatory effects remain incompletely characterized.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>Pack-years\u2013based models alone are insufficient for accurate risk stratification in HNSCC and realize integrated models including smoking duration assessment may improve prognostic and predictive accuracy, supporting more personalized treatment strategies.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.3389\/fonc.2026.1887251","type":"journal-article","created":{"date-parts":[[2026,7,1]],"date-time":"2026-07-01T15:32:08Z","timestamp":1782919928000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["Rethinking smoking assessment in head and neck squamous cell carcinoma: are we missing something?"],"prefix":"10.3389","volume":"16","author":[{"given":"Riccardo","family":"Gili","sequence":"first","affiliation":[{"name":"Medical Oncology and Hematology Unit, IRCCS Humanitas Research Hospital","place":["Milan, Italy"]},{"name":"Medical Oncology, Department of Internal Medicine and Medical Specialties, University of Genova","place":["Genoa, Italy"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Luigi","family":"Lorini","sequence":"additional","affiliation":[{"name":"Medical Oncology and Hematology Unit, IRCCS Humanitas Research Hospital","place":["Milan, Italy"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Davide","family":"Smussi","sequence":"additional","affiliation":[{"name":"Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia; Unit of Medical Oncology, Azienda Socio Sanitaria Territoriale (ASST) Spedali Civili","place":["Brescia, Italy"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Armando","family":"Di Bello","sequence":"additional","affiliation":[{"name":"Oncologia Medica, Fondazione Policlinico Universitario Agostino Gemelli Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS)","place":["Roma, Italy"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Paolo","family":"Bossi","sequence":"additional","affiliation":[{"name":"Medical Oncology and Hematology Unit, IRCCS Humanitas Research Hospital","place":["Milan, Italy"]},{"name":"Department of Biomedical Sciences, Humanitas University","place":["Milan, Italy"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Carlo","family":"Resteghini","sequence":"additional","affiliation":[{"name":"Medical Oncology and Hematology Unit, IRCCS Humanitas Research Hospital","place":["Milan, Italy"]},{"name":"Department of Biomedical Sciences, Humanitas University","place":["Milan, 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