Smoking-dependent circulating non-coding biomarkers in lung cancer

Smoking is the most significant preventable cause of lung cancer, influencing both tumor progression and the circulating nucleic acid milieu. Consequently, the interpretation of liquid biopsy signals requires a specific approach. The literature search was conducted in the PubMed and Scopus databases from 2010 to 2025. Circulating non-coding RNAs (ncRNAs), including microRNAs and long non-coding RNAs in plasma or extracellular vesicles (e.g., miRNAs, lncRNAs), have been associated in initial studies with early detection, specific histologic differentiation, prognostic stratification based on survival outcomes, and dynamic alterations during treatment and relapse. This review integrates findings from existing evidence and the current review to examine the patterns of smoking dependence across various lung cancer subtypes. This is achieved by correlating exposure measures and smoking-related comorbidities with variations in circulating RNA profiles, thereby elucidating the circumstances under which biomarkers are likely to be informative in the context of lung cancer. The novelty of this work is the laboratory implementation perspective to work with biological plausibility and practical requirements in terms of standardized pre-analytics, hemolysis and platelet controls, robust normalization, platform selection, and transparent risk score reporting. In addition, we discuss the analytical and clinical trade-offs between cell-free and extracellular vesicle (EV)-associated ncRNAs, including differences in stability, background signal, workflow complexity, and the circumstances in which EV analysis provides incremental clinical value. We correlated candidate markers with specific applications, including the triage of indeterminate nodules, support of subtypes without tissue destruction, and monitoring of chemotherapy, targeted therapy, and immunotherapy. We underscore the necessity of multicenter validation, commutable reference materials, external quality assessments, and decision-impact studies, all of which are crucial for clinical application.