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• Volume 14, Issue 5
• The most important and influential papers in tobacco control: results of an online poll
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• Correspondence to:
 Professor Simon Chapman
 School of Public Health, Edward Ford building A27, University of Sydney, NSW 2006, Australia; simonchapmanhealth.usyd.edu.au

https://doi.org/10.1136/tc.2005.013177

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In a recent issue, we published a list of the 100 most cited authors who have published work relevant to tobacco control. 1 We also listed the 50 most cited papers in our field. That exercise produced lists of authors and papers dominated by “big epi” work: papers mainly establishing the contribution of tobacco use to disease. Such papers are often published in high impact factor journals and tend to be cited in the introductory sections of other papers.

Throughout my own career, I have often noted papers that struck me as in some way seminal or as having made a research contribution that changed the ways in which our field thought about strategy and what needed to be done. I thought a parallel exercise where we invited people to vote for what they considered, simply, are the most important and influential papers in tobacco control might produce an interesting list.

Over one month, all corresponding authors on papers published in Tobacco Control since 2001, as well as the members of the journal’s editorial advisory board and its senior editors, were invited to go to a closed website to nominate up to five papers in each of 12 broad subject categories which they regarded as the “most important and influential papers” on tobacco control. Fifteen author’s emails were returned as non-functional, leaving 202 who were invited to nominate. The software associated with the nomination process allowed the PubMed database to be searched and the unique identifying number of each nominated paper to be extracted to a database. Nominators could not see papers nominated by other nominators.

The 12 lists of papers thus obtained were then placed on a public website and thrown open for public voting for four weeks. Publicity about the voting was placed on the Tobacco Control homepage, on my own website, 2 and via the Globalink and Society for Research on Nicotine and Tobacco membership list servers. The software limited each person’s voting to five votes per category. Voters were unable to see the progressive voting totals as they voted. Papers nominated in more than one category were allowed to attract votes in each of their nominated categories.

The nomination phase saw 49 people nominate 658 different papers; 49 (19.8%) made at least one nomination (range 1–60, mean 22.1). The voting phase saw 179 people vote 2966 times for these 658 papers. Papers listed by the nominators were included in the total votes. The 12 lists (tables 1–12) are shown below in order of the number of votes received for the 10 top papers in each category (in two categories there were 11 papers because of tied votes), as well as their citations as shown on the Institute of Scientific Information’s Web of Science site as of June 2005.

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 Secondhand smoke: 378 votes for 85 nominations. Top 10 received 48.6% of votes

 Epidemiology of tobacco caused disease: 340 votes for 45 nominations. Top 10 received 50.3% of votes

 Cessation: 305 votes for 64 nominations. Top 10 received 44.9% of votes

 Youth: 254 votes for 60 nominations. Top 10 received 46.5% of votes

 Epidemiology of tobacco use, knowledge, beliefs and attitudes: 251 votes for 45 nominations. Top 10 received 54.2% of votes

 Tobacco industry conduct: 243 votes for 68 nominations. Top 10 received 58% of votes

 Economics: 239 votes for 58 nominations. Top10 received 54.8% of votes

 Policy analysis, advocacy, legislation and litigation: 238 votes for 57 nominations. Top 10 received 47.9% of votes

 Tobacco advertising, promotion, PR and packaging: 236 votes for 55 nominations. Top 10 received 47.0% of votes

 Mass media campaigns: 176 votes for 35 nominations. Top 10 received 64.8% of votes

 Pharmacology: 172 votes for 34 nominations. Top 10 received 58.7% of votes

 Other: 134 votes for 22 nominations. Top 10 received 78.4% of votes

Over three quarters of the leading papers were published in five journals: Tobacco Control (40), JAMA (20), BMJ (17), American Journal of Public Health (10), and New England Journal of Medicine (6).

Self nominations in the nomination phase were common although, with a few exceptions, by no means dominated any individual’s list. It is possible that some authors may have urged their colleagues to vote for their papers, but if this occurred, it did not appear to be obvious in the pattern of voting. Voters had no way of knowing how many votes would have been needed to get them “over the line” into the top 10 in any category.

The average number of years since publication of papers in all categories was 8.5 years. In some categories (industry conduct, mass media, and “other”) recent papers dominated the lists, suggesting a recent recall bias may have been operating or, in the case of industry conduct, the avalanche of recent work engendered by the availability of internal industry documents. It may have been that some considered “influence and importance” to mean importance to today’s policy environment.

The lists of papers may be useful to teachers wishing to point students to a range of reading that those working in the field regard as important. Journals sometimes ask a prominent researcher to list important papers they would advise all newcomers to a field to read. This exercise has advanced the spirit of those sorts of lists further by engaging far more in the voting process.

• ↵ Byrne F , Chapman S. The most cited authors and papers in tobacco control. Tobacco Control 2005 ; 14 : 155 –60. OpenUrl FREE Full Text
• ↵ Tobacco Control Supersite . http://tobacco.health.usyd.edu.au/ .

Competing interests: none declared

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• Published: 24 March 2022

Tobacco and nicotine use

• Bernard Le Foll 1 , 2 ,
• Megan E. Piper 3 , 4 ,
• Christie D. Fowler 5 ,
• Serena Tonstad 6 ,
• Laura Bierut 7 ,
• Lin Lu   ORCID: orcid.org/0000-0003-0742-9072 8 , 9 ,
• Prabhat Jha 10 &
• Wayne D. Hall 11 , 12  

Nature Reviews Disease Primers volume  8 , Article number:  19 ( 2022 ) Cite this article

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• Disease genetics
• Experimental models of disease
• Preventive medicine

Tobacco smoking is a major determinant of preventable morbidity and mortality worldwide. More than a billion people smoke, and without major increases in cessation, at least half will die prematurely from tobacco-related complications. In addition, people who smoke have a significant reduction in their quality of life. Neurobiological findings have identified the mechanisms by which nicotine in tobacco affects the brain reward system and causes addiction. These brain changes contribute to the maintenance of nicotine or tobacco use despite knowledge of its negative consequences, a hallmark of addiction. Effective approaches to screen, prevent and treat tobacco use can be widely implemented to limit tobacco’s effect on individuals and society. The effectiveness of psychosocial and pharmacological interventions in helping people quit smoking has been demonstrated. As the majority of people who smoke ultimately relapse, it is important to enhance the reach of available interventions and to continue to develop novel interventions. These efforts associated with innovative policy regulations (aimed at reducing nicotine content or eliminating tobacco products) have the potential to reduce the prevalence of tobacco and nicotine use and their enormous adverse impact on population health.

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Introduction.

Tobacco is the second most commonly used psychoactive substance worldwide, with more than one billion smokers globally 1 . Although smoking prevalence has reduced in many high-income countries (HICs), tobacco use is still very prevalent in low-income and middle-income countries (LMICs). The majority of smokers are addicted to nicotine delivered by cigarettes (defined as tobacco dependence in the International Classification of Diseases, Tenth Revision (ICD-10) or tobacco use disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)). As a result of the neuro-adaptations and psychological mechanisms caused by repeated exposure to nicotine delivered rapidly by cigarettes, cessation can also lead to a well-characterized withdrawal syndrome, typically manifesting as irritability, anxiety, low mood, difficulty concentrating, increased appetite, insomnia and restlessness, that contributes to the difficulty in quitting tobacco use 2 , 3 , 4 .

Historically, tobacco was used in some cultures as part of traditional ceremonies, but its use was infrequent and not widely disseminated in the population. However, since the early twentieth century, the use of commercial cigarettes has increased dramatically 5 because of automated manufacturing practices that enable large-scale production of inexpensive products that are heavily promoted by media and advertising. Tobacco use became highly prevalent in the past century and was followed by substantial increases in the prevalence of tobacco-induced diseases decades later 5 . It took decades to establish the relationship between tobacco use and associated health effects 6 , 7 and to discover the addictive role of nicotine in maintaining tobacco smoking 8 , 9 , and also to educate people about these effects. It should be noted that the tobacco industry disputed this evidence to allow continuing tobacco sales 10 . The expansion of public health campaigns to reduce smoking has gradually decreased the use of tobacco in HICs, with marked increases in adult cessation, but less progress has been achieved in LMICs 1 .

Nicotine is the addictive compound in tobacco and is responsible for continued use of tobacco despite harms and a desire to quit, but nicotine is not directly responsible for the harmful effects of using tobacco products (Box  1 ). Other components in tobacco may modulate the addictive potential of tobacco (for example, flavours and non-nicotine compounds) 11 . The major harms related to tobacco use, which are well covered elsewhere 5 , are linked to a multitude of compounds present in tobacco smoke (such as carcinogens, toxicants, particulate matter and carbon monoxide). In adults, adverse health outcomes of tobacco use include cancer in virtually all peripheral organs exposed to tobacco smoke and chronic diseases such as eye disease, periodontal disease, cardiovascular diseases, chronic obstructive pulmonary disease, stroke, diabetes mellitus, rheumatoid arthritis and disorders affecting immune function 5 . Moreover, smoking during pregnancy can increase the risk of adverse reproductive effects, such as ectopic pregnancy, low birthweight and preterm birth 5 . Exposure to secondhand cigarette smoke in children has been linked to sudden infant death syndrome, impaired lung function and respiratory illnesses, in addition to cognitive and behavioural impairments 5 . The long-term developmental effects of nicotine are probably due to structural and functional changes in the brain during this early developmental period 12 , 13 .

Nicotine administered alone in various nicotine replacement formulations (such as patches, gum and lozenges) is safe and effective as an evidence-based smoking cessation aid. Novel forms of nicotine delivery systems have also emerged (called electronic nicotine delivery systems (ENDS) or e-cigarettes), which can potentially reduce the harmful effects of tobacco smoking for those who switch completely from combustible to e-cigarettes 14 , 15 .

This Primer focuses on the determinants of nicotine and tobacco use, and reviews the neurobiology of nicotine effects on the brain reward circuitry and the functioning of brain networks in ways that contribute to the difficulty in stopping smoking. This Primer also discusses how to prevent tobacco use, screen for smoking, and offer people who smoke tobacco psychosocial and pharmacological interventions to assist in quitting. Moreover, this Primer presents emerging pharmacological and novel brain interventions that could improve rates of successful smoking cessation, in addition to public health approaches that could be beneficial.

Box 1 Tobacco products

Conventional tobacco products include combustible products that produce inhaled smoke (most commonly cigarettes, bidis (small domestically manufactured cigarettes used in South Asia) or cigars) and those that deliver nicotine without using combustion (chewing or dipping tobacco and snuff). Newer alternative products that do not involve combustion include nicotine-containing e-cigarettes and heat-not-burn tobacco devices. Although non-combustion and alternative products may constitute a lesser risk than burned ones 14 , 15 , 194 , no form of tobacco is entirely risk-free.

Epidemiology

Prevalence and burden of disease.

The Global Burden of Disease Project (GBDP) estimated that around 1.14 billion people smoked in 2019, worldwide, increasing from just under a billion in 1990 (ref. 1 ). Of note, the prevalence of smoking decreased significantly between 1990 and 2019, but increases in the adult population meant that the total number of global smokers increased. One smoking-associated death occurs for approximately every 0.8–1.1 million cigarettes smoked 16 , suggesting that the estimated worldwide consumption of about 7.4 trillion cigarettes in 2019 has led to around 7 million deaths 1 .

In most populations, smoking prevalence is much higher among groups with lower levels of education or income 17 and among those with mental health disorders and other co-addictions 18 , 19 . Smoking is also more frequent among men than women (Figs  1 – 3 ). Sexual and/or gender minority individuals have disproportionately high rates of smoking and other addictions 17 , 20 . In addition, the prevalence of smoking varies substantially between regions and ethnicities; smoking rates are high in some regions of Asia, such as China and India, but are lower in North America and Australia. Of note, the prevalence of mental health disorders and other co-addictions is higher in individuals who smoke compared with non-smokers 18 , 19 , 21 . For example, the odds of smoking in people with any substance use disorder is more than five times higher than the odds in people without a substance use disorder 19 . Similarly, the odds of smoking in people with any psychiatric disorder is more than three times higher than the odds of smoking in those without a psychiatric diagnosis 22 . In a study in the USA, compared with a population of smokers with no psychiatric diagnosis, subjects with anxiety, depression and phobia showed an approximately twofold higher prevalence of smoking, and subjects with agoraphobia, mania or hypomania, psychosis and antisocial personality or conduct disorders showed at least a threefold higher prevalence of smoking 22 . Comorbid disorders are also associated with higher rates of smoking 22 , 23 .

a | Number of current male smokers aged 15 years or older per country expressed in millions. b | Former male smokers aged 45–59 years per country expressed in millions. c | Former male smokers aged 45–59 years per country expressed as the percentage of smokers who stopped. The data shown are for male smokers for the period 2015–2019 from countries with direct smoking surveys. The prevalence of smoking among males is less variable than among females. Data from ref. 1 .

a | Number of current female smokers aged 15 years or older per country expressed in millions. b | Former female smokers aged 45–59 years per country expressed in millions. c | Former female smokers aged 45–59 years per country expressed as the percentage of smokers who stopped. The data shown are for female smokers for the period 2015–2019 from countries with direct smoking surveys. The prevalence of smoking among females is much lower in East and South Asia than in Latin America or Eastern Europe. Data from ref. 1 .

a | Number of current male and female smokers aged 15 years or older per country expressed in millions. b | Former male and female smokers aged 45–59 years per country expressed in millions. c | Former male and female smokers aged 45–59 years per country expressed as the percentage of smokers who stopped. The data shown are for the period 2015–2019 from countries with direct smoking surveys. Cessation rates are higher in high-income countries, but also notably high in Brazil. Cessation is far less common in South and East Asia and Russia and other Eastern European countries, and also low in South Africa. Data from ref. 1 .

Age at onset

Most smokers start smoking during adolescence, with almost 90% of smokers beginning between 15 and 25 years of age 24 . The prevalence of tobacco smoking among youths substantially declined in multiple HICs between 1990 and 2019 (ref. 25 ). More recently, the widespread uptake of ENDS in some regions such as Canada and the USA has raised concerns about the long-term effects of prolonged nicotine use among adolescents, including the possible notion that ENDS will increase the use of combustible smoking products 25 , 26 (although some studies have not found much aggregate effect at the population level) 27 .

Smoking that commences in early adolescence or young adulthood and persists throughout life has a more severe effect on health than smoking that starts later in life and/or that is not persistent 16 , 28 , 29 . Over 640 million adults under 30 years of age smoke in 22 jurisdictions alone (including 27 countries in the European Union where central efforts to reduce tobacco dependence might be possible) 30 . In those younger than 30 years of age, at least 320 million smoking-related deaths will occur unless they quit smoking 31 . The actual number of smoking-related deaths might be greater than one in two, and perhaps as high as two in three, long-term smokers 5 , 16 , 29 , 32 , 33 . At least half of these deaths are likely to occur in middle age (30–69 years) 16 , 29 , leading to a loss of two or more decades of life. People who smoke can expect to lose an average of at least a decade of life versus otherwise similar non-smokers 16 , 28 , 29 .

Direct epidemiological studies in several countries paired with model-based estimates have estimated that smoking tobacco accounted for 7.7 million deaths globally in 2020, of which 80% were in men and 87% were current smokers 1 . In HICs, the major causes of tobacco deaths are lung cancer, emphysema, heart attack, stroke, cancer of the upper aerodigestive areas and bladder cancer 28 , 29 . In some lower income countries, tuberculosis is an additional important cause of tobacco-related death 29 , 34 , which could be related to, for example, increased prevalence of infection, more severe tuberculosis/mortality and higher prevalence of treatment-resistant tuberculosis in smokers than in non-smokers in low-income countries 35 , 36 .

Despite substantial reductions in the prevalence of smoking, there were 34 million smokers in the USA, 7 million in the UK and 5 million in Canada in 2017 (ref. 16 ), and cigarette smoking remains the largest cause of premature death before 70 years of age in much of Europe and North America 1 , 16 , 28 , 29 . Smoking-associated diseases accounted for around 41 million deaths in the USA, UK and Canada from 1960 to 2020 (ref. 16 ). Moreover, as smoking-associated diseases are more prevalent among groups with lower levels of education and income, smoking accounts for at least half of the difference in overall mortality between these social groups 37 . Any reduction in smoking prevalence reduces the absolute mortality gap between these groups 38 .

Smoking cessation has become common in HICs with good tobacco control interventions. For example, in France, the number of ex-smokers is four times the number of current smokers among those aged 50 years or more 30 . By contrast, smoking cessation in LMICs remains uncommon before smokers develop tobacco-related diseases 39 . Smoking cessation greatly reduces the risks of smoking-related diseases. Indeed, smokers who quit smoking before 40 years of age avoid nearly all the increased mortality risks 31 , 33 . Moreover, individuals who quit smoking by 50 years of age reduce the risk of death from lung cancer by about two-thirds 40 . More modest hazards persist for deaths from lung cancer and emphysema 16 , 28 ; however, the risks among former smokers are an order of magnitude lower than among those who continue to smoke 33 .

Mechanisms/pathophysiology

Nicotine is the main psychoactive agent in tobacco and e-cigarettes. Nicotine acts as an agonist at nicotinic acetylcholine receptors (nAChRs), which are localized throughout the brain and peripheral nervous system 41 . nAChRs are pentameric ion channels that consist of varying combinations of α 2 –α 7 and β 2 –β 4 subunits, and for which acetylcholine (ACh) is the endogenous ligand 42 , 43 , 44 . When activated by nicotine binding, nAChR undergoes a conformational change that opens the internal pore, allowing an influx of sodium and calcium ions 45 . At postsynaptic membranes, nAChR activation can lead to action potential firing and downstream modulation of gene expression through calcium-mediated second messenger systems 46 . nAChRs are also localized to presynaptic membranes, where they modulate neurotransmitter release 47 . nAChRs become desensitized after activation, during which ligand binding will not open the channel 45 .

nAChRs with varying combinations of α-subunits and β-subunits have differences in nicotine binding affinity, efficacy and desensitization rate, and have differential expression depending on the brain region and cell type 48 , 49 , 50 . For instance, at nicotine concentrations found in human smokers, β 2 -containing nAChRs desensitize relatively quickly after activation, whereas α 7 -containing nAChRs have a slower desensitization profile 48 . Chronic nicotine exposure in experimental animal models or in humans induces an increase in cortical expression of α 4 β 2 -containing nAChRs 51 , 52 , 53 , 54 , 55 , but also increases the expression of β 3 and β 4 nAChR subunits in the medial habenula (MHb)–interpeduncular nucleus (IPN) pathway 56 , 57 . It is clear that both the brain localization and the type of nAChR are critical elements in mediating the various effects of nicotine, but other factors such as rate of nicotine delivery may also modulate addictive effects of nicotine 58 .

Neurocircuitry of nicotine addiction

Nicotine has both rewarding effects (such as a ‘buzz’ or ‘high’) and aversive effects (such as nausea and dizziness), with the net outcome dependent on dose and others factors such as interindividual sensitivity and presence of tolerance 59 . Thus, the addictive properties of nicotine involve integration of contrasting signals from multiple brain regions that process reward and aversion (Fig.  4 ).

During initial use, nicotine exerts both reinforcing and aversive effects, which together determine the likelihood of continued use. As the individual transitions to more frequent patterns of chronic use, nicotine induces pharmacodynamic changes in brain circuits, which is thought to lead to a reduction in sensitivity to the aversive properties of the drug. Nicotine is also a powerful reinforcer that leads to the conditioning of secondary cues associated with the drug-taking experience (such as cigarette pack, sensory properties of cigarette smoke and feel of the cigarette in the hand or mouth), which serves to enhance the incentive salience of these environmental factors and drive further drug intake. When the individual enters into states of abstinence (such as daily during sleep at night or during quit attempts), withdrawal symptomology is experienced, which may include irritability, restlessness, learning or memory deficits, difficulty concentrating, anxiety and hunger. These negative affective and cognitive symptoms lead to an intensification of the individual’s preoccupation to obtain and use the tobacco/nicotine product, and subsequently such intense craving can lead to relapse.

The rewarding actions of nicotine have largely been attributed to the mesolimbic pathway, which consists of dopaminergic neurons in the ventral tegmental area (VTA) that project to the nucleus accumbens and prefrontal cortex 60 , 61 , 62 (Fig.  5 ). VTA integrating circuits and projection regions express several nAChR subtypes on dopaminergic, GABAergic, and glutamatergic neurons 63 , 64 . Ultimately, administration of nicotine increases dopamine levels through increased dopaminergic neuron firing in striatal and extrastriatal areas (such as the ventral pallidum) 65 (Fig.  6 ). This effect is involved in reward and is believed to be primarily mediated by the action of nicotine on α 4 -containing and β 2 -containing nAChRs in the VTA 66 , 67 .

Multiple lines of research have demonstrated that nicotine reinforcement is mainly controlled by two brain pathways, which relay predominantly reward-related or aversion-related signals. The rewarding properties of nicotine that promote drug intake involve the mesolimbic dopamine projection from the ventral tegmental area (VTA) to the nucleus accumbens (NAc). By contrast, the aversive properties of nicotine that limit drug intake and mitigate withdrawal symptoms involve the fasciculus retroflexus projection from the medial habenula (MHb) to the interpeduncular nucleus (IPN). Additional brain regions have also been implicated in various aspects of nicotine dependence, such as the prefrontal cortex (PFC), ventral pallidum (VP), nucleus tractus solitarius (NTS) and insula (not shown here for clarity). All of these brain regions are directly or indirectly interconnected as integrative circuits to drive drug-seeking and drug-taking behaviours.

Smokers received brain PET scans with [ 11 C]PHNO, a dopamine D 2/3 PET tracer that has high sensitivity in detecting fluctuations of dopamine. PET scans were performed during abstinence or after smoking a cigarette. Reduced binding potential (BP ND ) was observed after smoking, indicating increased dopamine levels in the ventral striatum and in the area that corresponds to the ventral pallidum. The images show clusters with statistically significant decreases of [ 11 C]PHNO BP ND after smoking a cigarette versus abstinence condition. Those clusters have been superimposed on structural T1 MRI images of the brain. Reprinted from ref. 65 , Springer Nature Limited.

The aversive properties of nicotine are mediated by neurons in the MHb, which project to the IPN. Studies in rodents using genetic knockdown and knockout strategies demonstrated that the α 5 -containing, α 3 -containing and β 4 -containing nAChRs in the MHb–IPN pathway mediate the aversive properties of nicotine that limit drug intake, especially when animals are given the opportunity to consume higher nicotine doses 68 , 69 , 70 , 71 , 72 . In addition to nAChRs, other signalling factors acting on the MHb terminals in the IPN also regulate the actions of nicotine. For instance, under conditions of chronic nicotine exposure or with optogenetic activation of IPN neurons, a subtype of IPN neurons co-expressing Chrna5 (encoding the α 5 nAChR subunit) and Amigo1 (encoding adhesion molecule with immunoglobulin-like domain 1) release nitric oxide from the cell body that retrogradely inhibits MHb axon terminals 70 . In addition, nicotine activates α 5 -containing nAChR-expressing neurons that project from the nucleus tractus solitarius to the IPN, leading to release of glucagon-like peptide-1 that binds to GLP receptors on habenular axon terminals, which subsequently increases IPN neuron activation and decreases nicotine self-administration 73 . Taken together, these findings suggest a dynamic signalling process at MHb axonal terminals in the IPN, which regulates the addictive properties of nicotine and determines the amount of nicotine that is self-administered.

Nicotine withdrawal in animal models can be assessed by examining somatic signs (such as shaking, scratching, head nods and chewing) and affective signs (such as increased anxiety-related behaviours and conditioned place aversion). Interestingly, few nicotine withdrawal somatic signs are found in mice with genetic knockout of the α 2 , α 5 or β 4 nAChR subunits 74 , 75 . By contrast, β 2 nAChR-knockout mice have fewer anxiety-related behaviours during nicotine withdrawal, with no differences in somatic symptoms compared with wild-type mice 74 , 76 .

In addition to the VTA (mediating reward) and the MHb–IPN pathway (mediating aversion), other brain areas are involved in nicotine addiction (Fig.  5 ). In animals, the insular cortex controls nicotine taking and nicotine seeking 77 . Moreover, humans with lesions of the insular cortex can quit smoking easily without relapse 78 . This finding led to the development of a novel therapeutic intervention modulating insula function (see Management, below) 79 , 80 . Various brain areas (shell of nucleus accumbens, basolateral amygdala and prelimbic cortex) expressing cannabinoid CB 1 receptors are also critical in controlling rewarding effects and relapse 81 , 82 . The α 1 -adrenergic receptor expressed in the cortex also control these effects, probably through glutamatergic afferents to the nucleus accumbens 83 .

Individual differences in nicotine addiction risk

Vulnerability to nicotine dependence varies between individuals, and the reasons for these differences are multidimensional. Many social factors (such as education level and income) play a role 84 . Broad psychological and social factors also modulate this risk. For example, peer smoking status, knowledge on effect of tobacco, expectation on social acceptance, exposure to passive smoking modulate the risk of initiating tobacco use 85 , 86 .

Genetic factors have a role in smoking initiation, the development of nicotine addiction and the likelihood of smoking cessation. Indeed, heritability has been estimated to contribute to approximatively half of the variability in nicotine dependence 87 , 88 , 89 , 90 . Important advances in our understanding of such genetic contributions have evolved with large-scale genome-wide association studies of smokers and non-smokers. One of the most striking findings has been that allelic variation in the CHRNA5 – CHRNA3 – CHRNB4 gene cluster, which encodes α 5 , α 3 and β 4 nAChR subunits, correlates with an increased vulnerability for nicotine addiction, indicated by a higher likelihood of becoming dependent on nicotine and smoking a greater number of cigarettes per day 91 , 92 , 93 , 94 , 95 . The most significant effect has been found for a single-nucleotide polymorphism in CHRNA5 (rs16969968), which results in an amino acid change and reduced function of α 5 -containing nAChRs 92 .

Allelic variation in CYP2A6 (encoding the CYP2A6 enzyme, which metabolizes nicotine) has also been associated with differential vulnerability to nicotine dependence 96 , 97 , 98 . CYP2A6 is highly polymorphic, resulting in variable enzymatic activity 96 , 99 , 100 . Individuals with allelic variation that results in slow nicotine metabolism consume less nicotine per day, experience less-severe withdrawal symptoms and are more successful at quitting smoking than individuals with normal or fast metabolism 101 , 102 , 103 , 104 . Moreover, individuals with slow nicotine metabolism have lower dopaminergic receptor expression in the dopamine D2 regions of the associative striatum and sensorimotor striatum in PET studies 105 and take fewer puffs of nicotine-containing cigarettes (compared with de-nicotinized cigarettes) in a forced choice task 106 . Slower nicotine metabolism is thought to increase the duration of action of nicotine, allowing nicotine levels to accumulate over time, therefore enabling lower levels of intake to sustain activation of nAChRs 107 .

Large-scale genetic studies have identified hundreds of other genetic loci that influence smoking initiation, age of smoking initiation, cigarettes smoked per day and successful smoking cessation 108 . The strongest genetic contributions to smoking through the nicotinic receptors and nicotine metabolism are among the strongest genetic contributors to lung cancer 109 . Other genetic variations (such as those related to cannabinoid, dopamine receptors or other neurotransmitters) may affect certain phenotypes related to smoking (such as nicotine preference and cue-reactivity) 110 , 111 , 112 , 113 , 114 , 115 .

Diagnosis, screening and prevention

Screening for cigarette smoking.

Screening for cigarette smoking should happen at every doctor’s visit 116 . In this regard, a simple and direct question about a person’s tobacco use can provide an opportunity to offer information about its potential risks and treatments to assist in quitting. All smokers should be offered assistance in quitting because even low levels of smoking present a significant health risk 33 , 117 , 118 . Smoking status can be assessed by self-categorization or self-reported assessment of smoking behaviour (Table  1 ). In people who smoke, smoking frequency can be assessed 119 and a combined quantity frequency measure such as pack-year history (that is, average number of cigarettes smoked per day multiplied by the number of years, divided by 20), can be used to estimate cumulative risk of adverse health outcomes. The Association for the Treatment of Tobacco Use and Dependence recommends that all electronic health records should document smoking status using the self-report categories listed in Table  1 .

Owing to the advent of e-cigarettes and heat-not-burn products, and the popularity of little cigars in the US that mimic combustible cigarettes, people who use tobacco may use multiple products concurrently 120 , 121 . Thus, screening for other nicotine and tobacco product use is important in clinical practice. The self-categorization approach can also be used to describe the use of these other products.

Traditionally tobacco use has been classified according to whether the smoker meets criteria for nicotine dependence in one of the two main diagnostic classifications: the DSM 122 (tobacco use disorder) and the ICD (tobacco dependence) 123 . The diagnosis of tobacco use disorder according to DSM-5 criteria requires the presence of at least 2 of 11 symptoms that have produced marked clinical impairment or distress within a 12-month period (Box  2 ). Of note, these symptoms are similar for all substance use disorder diagnoses and may not all be relevant to tobacco use disorder (such as failure to complete life roles). In the ICD-10, codes allow the identification of specific tobacco products used (cigarettes, chewing tobacco and other tobacco products).

Dependence can also be assessed as a continuous construct associated with higher levels of use, greater withdrawal and reduced likelihood of quitting. The level of dependence can be assessed with the Fagerström Test for Nicotine Dependence, a short questionnaire comprising six questions 124 (Box  2 ). A score of ≥4 indicates moderate to high dependence. As very limited time may be available in clinical consultations, the Heaviness of Smoking Index (HSI) was developed, which comprises two questions on the number of cigarettes smoked per day and how soon after waking the first cigarette is smoked 125 . The HSI can guide dosing for nicotine replacement therapy (NRT).

Other measures of cigarette dependence have been developed but are not used in the clinical setting, such as the Cigarette Dependence Scale 126 , Hooked on Nicotine Checklist 127 , Nicotine Dependence Syndrome Scale 128 , the Wisconsin Inventory of Smoking Dependence Motives (Brief) 129 and the Penn State Cigarette Dependence Index 130 . However, in practice, these are not often used, as the most important aspect is to screen for smoking and encourage all smokers to quit smoking regardless of their dependence status.

Box 2 DSM-5 criteria for tobacco use disorder and items of the Fagerström Test for nicotine dependence

DSM-5 (ref. 122 )

Taxonomic and diagnostic tool for tobacco use disorder published by the American Psychiatric Association.

A problematic pattern of tobacco use leading to clinically significant impairment or distress as manifested by at least two of the following, occurring within a 12-month period.

Tobacco often used in larger amounts or over a longer period of time than intended

A persistent desire or unsuccessful efforts to reduce or control tobacco use

A great deal of time spent in activities necessary to obtain or use tobacco

Craving, or a strong desire or urge to use tobacco

Recurrent tobacco use resulting in a failure to fulfil major role obligations at work, school or home

Continued tobacco use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of tobacco (for example, arguments with others about tobacco use)

Important social, occupational or recreational activities given up or reduced because of tobacco use

Recurrent tobacco use in hazardous situations (such as smoking in bed)

Tobacco use continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by tobacco use

Tolerance, defined by either of the following.

A need for markedly increased amounts of tobacco to achieve the desired effect

A markedly diminished effect with continued use of the same amount of tobacco

Withdrawal, manifesting as either of the following.

Withdrawal syndrome for tobacco

Tobacco (or a closely related substance, such as nicotine) taken to relieve or avoid withdrawal symptoms

Fagerström Test for Nicotine Dependence 124

A standard instrument for assessing the intensity of physical addiction to nicotine.

How soon after you wake up do you smoke your first cigarette?

Within 5 min (scores 3 points)

5 to 30 min (scores 2 points)

31 to 60 min (scores 1 point)

After 60 min (scores 0 points)

Do you find it difficult not to smoke in places where you should not, such as in church or school, in a movie, at the library, on a bus, in court or in a hospital?

Yes (scores 1 point)

No (scores 0 points)

Which cigarette would you most hate to give up; which cigarette do you treasure the most?

The first one in the morning (scores 1 point)

Any other one (scores 0 points)

How many cigarettes do you smoke each day?

10 or fewer (scores 0 points)

11 to 20 (scores 1 point)

21 to 30 (scores 2 points)

31 or more (scores 3 points)

Do you smoke more during the first few hours after waking up than during the rest of the day?

Do you still smoke if you are so sick that you are in bed most of the day or if you have a cold or the flu and have trouble breathing?

A score of 7–10 points is classified as highly dependent; 4–6 points is classified as moderately dependent; <4 points is classified as minimally dependent.

DSM-5, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.

Young people who do not start smoking cigarettes between 15 and 25 years of age have a very low risk of ever smoking 24 , 131 , 132 . This age group provides a critical opportunity to prevent cigarette smoking using effective, evidence-based strategies to prevent smoking initiation and reduce escalation from experimentation to regular use 131 , 132 , 133 , 134 , 135 .

Effective prevention of cigarette uptake requires a comprehensive package of cost-effective policies 134 , 136 , 137 to synergistically reduce the population prevalence of cigarette smoking 131 , 135 . These policies include high rates of tobacco taxation 30 , 134 , 137 , 138 , widespread and rigorously enforced smoke-free policies 139 , bans on tobacco advertising and promotions 140 , use of plain packaging and graphic warnings about the health risks of smoking 135 , 141 , mass media and peer-based education programmes to discourage smoking, and enforcement of laws against the sale of cigarettes to young people below the minimum legal purchase age 131 , 135 . These policies make cigarettes less available and affordable to young people. Moreover, these policies make it more difficult for young people to purchase cigarettes and make smoking a much less socially acceptable practice. Of note, these policies are typically mostly enacted in HICs, which may be related to the declining prevalence of smoking in these countries, compared with the prevalence in LMICs.

Pharmacotherapy

Three evidence-based classes of pharmacotherapy are available for smoking cessation: NRT (using nicotine-based patches, gum, lozenges, mini-lozenges, nasal sprays and inhalers), varenicline (a nAChR partial agonist), and bupropion (a noradrenaline/dopamine reuptake inhibitor that also inhibits nAChR function and is also used as an antidepressant). These FDA-approved and EMA-approved pharmacotherapies are cost-effective smoking cessation treatments that double or triple successful abstinence rates compared with no treatment or placebo controls 116 , 142 .

Combinations of pharmacotherapies are also effective for smoking cessation 116 , 142 . For example, combining NRTs (such as the steady-state nicotine patch and as-needed NRT such as gum or mini-lozenge) is more effective than a single form of NRT 116 , 142 , 143 . Combining NRT and varenicline is the most effective smoking cessation pharmacotherapy 116 , 142 , 143 . Combining FDA-approved pharmacotherapy with behavioural counselling further increases the likelihood of successful cessation 142 . Second-line pharmacotherapies (for example, nortriptyline) have some potential for smoking cessation, but their use is limited due to their tolerability profile.

All smokers should receive pharmacotherapy to help them quit smoking, except those in whom pharmacotherapy has insufficient evidence of effectiveness (among adolescents, smokeless tobacco users, pregnant women or light smokers) or those in whom pharmacotherapy is medically contraindicated 144 . Table  2 provides specific information regarding dosing and duration for each FDA-approved pharmacotherapy. Extended use of pharmacotherapy beyond the standard 12-week regimen after cessation is effective and should be considered 116 . Moreover, preloading pharmacotherapy (that is, initiating cessation medication in advance of a quit attempt), especially with the nicotine patch, is a promising treatment, although further studies are required to confirm efficacy.

Cytisine has been used for smoking cessation in Eastern Europe for a long time and is available in some countries (such as Canada) without prescription 145 . Cytisine is a partial agonist of nAChRs and its structure was the precursor for the development of varenicline 145 . Cytisine is at least as effective as some approved pharmacotherapies for smoking cessation, such as NRT 146 , 147 , 148 , and the role of cytisine in smoking cessation is likely to expand in the future, notably owing to its much lower cost than traditional pharmacotherapies. E-cigarettes also have the potential to be useful as smoking cessation devices 149 , 150 . The 2020 US Surgeon General’s Report concluded that there was insufficient evidence to promote cytisine or e-cigarettes as effective smoking cessation treatments, but in the UK its use is recommended for smoking cessation (see ref. 15 for regularly updated review).

Counselling and behavioural treatments

Psychosocial counselling significantly increases the likelihood of successful cessation, especially when combined with pharmacotherapy. Even a counselling session lasting only 3 minutes can help smokers quit 116 , although the 2008 US Public Health Service guidelines and the Preventive Services Task Force 151 each concluded that more intensive counselling (≥20 min per session) is more effective than less intensive counselling (<20 min per session). Higher smoking cessation rates are obtained by using behavioural change techniques that target associative and self-regulatory processes 152 . In addition, behavioural change techniques that will favour commitment, social reward and identity associated with changed behaviour seems associated with higher success rates 152 . Evidence-based counselling focuses on providing social support during treatment, building skills to cope with withdrawal and cessation, and problem-solving in challenging situations 116 , 153 . Effective counselling can be delivered by diverse providers (such as physicians, nurses, pharmacists, social workers, psychologists and certified tobacco treatment specialists) 116 .

Counselling can be delivered in a variety of modalities. In-person individual and group counselling are effective, as is telephone counselling (quit lines) 142 . Internet and text-based intervention seem to be effective in smoking cessation, especially when they are interactive and tailored to a smoker’s specific circumstances 142 . Over the past several years, the number of smoking cessation smartphone apps has increased, but there the evidence that the use of these apps significantly increases smoking cessation rates is not sufficient.

Contingency management (providing financial incentives for abstinence or engagement in treatment) has shown promising results 154 , 155 but its effects are not sustained once the contingencies are removed 155 , 156 . Other treatments such as hypnosis, acupuncture and laser treatment have not been shown to improve smoking cessation rates compared with placebo treatments 116 . Moreover, no solid evidence supports the use of conventional transcranial magnetic stimulation (TMS) for long-term smoking cessation 157 , 158 .

Although a variety of empirically supported smoking cessation interventions are available, more than two-thirds of adult smokers who made quit attempts in the USA during the past year did not use an evidence-based treatment and the rate is likely to be lower in many other countries 142 . This speaks to the need to increase awareness of, and access to, effective cessation aids among all smokers.

Brain stimulation

The insula (part of the frontal cortex) is a critical brain structure involved in cigarette craving and relapse 78 , 79 . The activity of the insula can be modulated using an innovative approach called deep insula/prefrontal cortex TMS (deep TMS), which is effective in helping people quit smoking 80 , 159 . This approach has now been approved by the FDA as an effective smoking cessation intervention 80 . However, although this intervention was developed and is effective for smoking cessation, the number of people with access to it is limited owing to the limited number of sites equipped and with trained personnel, and the cost of this intervention.

Quality of life

Generic instruments (such as the Short-Form (SF-36) Health Survey) can be used to evaluate quality of life (QOL) in smokers. People who smoke rate their QOL lower than people who do not smoke both before and after they become smokers 160 , 161 . QOL improves when smokers quit 162 . Mental health may also improve on quitting smoking 163 . Moreover, QOL is much poorer in smokers with tobacco-related diseases, such as chronic respiratory diseases and cancers, than in individuals without tobacco-related diseases 161 , 164 . The dimensions of QOL that show the largest decrements in people who smoke are those related to physical health, day-to-day activities and mental health such as depression 160 . Smoking also increases the risk of diabetes mellitus 165 , 166 , which is a major determinant of poor QOL for a wide range of conditions.

The high toll of premature death from cigarette smoking can obscure the fact that many of the diseases that cause these deaths also produce substantial disability in the years before death 1 . Indeed, death in smokers is typically preceded by several years of living with the serious disability and impairment of everyday activities caused by chronic respiratory disease, heart disease and cancer 2 . Smokers’ QOL in these years may also be adversely affected by the adverse effects of the medical treatments that they receive for these smoking-related diseases (such as major surgery and radiotherapy).

Expanding cessation worldwide

The major global challenge is to consider individual and population-based strategies that could increase the substantially low rates of adult cessation in most LMICs and indeed strategies to ensure that even in HICs, cessation continues to increase. In general, the most effective tools recommended by WHO to expand cessation are the same tools that can prevent smoking initiation, notably higher tobacco taxes, bans on advertising and promotion, prominent warning labels or plain packaging, bans on public smoking, and mass media and educational efforts 29 , 167 . The effective use of these policies, particularly taxation, lags behind in most LMICs compared with most HICs, with important exceptions such as Brazil 167 . Access to effective pharmacotherapies and counselling as well as support for co-existing mental health conditions would also be required to accelerate cessation in LMICs. This is particularly important as smokers living in LMICs often have no access to the full range of effective treatment options.

Regulating access to e-cigarettes

How e-cigarettes should be used is debated within the tobacco control field. In some countries (for example, the UK), the use of e-cigarettes as a cigarette smoking cessation aid and as a harm reduction strategy is supported, based on the idea that e-cigarette use will lead to much less exposure to toxic compounds than tobacco use, therefore reducing global harm. In other countries (for example, the USA), there is more concern with preventing the increased use of e-cigarettes by youths that may subsequently lead to smoking 25 , 26 . Regulating e-cigarettes in nuanced ways that enable smokers to access those products whilst preventing their uptake among youths is critical.

Regulating nicotine content in tobacco products

Reducing the nicotine content of cigarettes could potentially produce less addictive products that would allow a gradual reduction in the population prevalence of smoking. Some clinical studies have found no compensatory increase in smoking whilst providing access to low nicotine tobacco 168 . Future regulation may be implemented to gradually decrease the nicotine content of combustible tobacco and other nicotine products 169 , 170 , 171 .

Tobacco end games

Some individuals have proposed getting rid of commercial tobacco products this century or using the major economic disruption arising from the COVID-19 pandemic to accelerate the demise of the tobacco industry 172 , 173 . Some tobacco producers have even proposed this strategy as an internal goal, with the idea of switching to nicotine delivery systems that are less harmful ( Philip Morris International ). Some countries are moving towards such an objective; for example, in New Zealand, the goal that fewer than 5% of New Zealanders will be smokers in 2025 has been set (ref. 174 ). The tobacco end-game approach would overall be the best approach to reduce the burden of tobacco use on society, but it would require coordination of multiple countries and strong public and private consensus on the strategy to avoid a major expansion of the existing illicit market in tobacco products in some countries.

Innovative interventions

The COVID-19 pandemic has shown that large-scale investment in research can lead to rapid development of successful therapeutic interventions. By contrast, smoking cessation has been underfunded compared with the contribution that it makes to the global burden of disease. In addition, there is limited coordination between research teams and most studies are small-scale and often underpowered 79 . It is time to fund an ambitious, coordinated programme of research to test the most promising therapies based on an increased understanding of the neurobiological basis of smoking and nicotine addiction (Table  3 ). Many of those ideas have not yet been tested properly and this could be carried out by a coordinated programme of research at the international level.

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Acknowledgements

B.Le F. is supported by a clinician-scientist award from the Department of Family and Community Medicine at the University of Toronto and the Addiction Psychiatry Chair from the University of Toronto. The funding bodies had no role in the study design, collection, analysis or interpretation of the data, writing the manuscript, or the decision to submit the paper for publication. The authors thank H. Fu (University of Toronto) for assistance with Figs 1–3.

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Translational Addiction Research Laboratory, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, University of Toronto, Toronto, Ontario, Canada

Bernard Le Foll

Departments of Family and Community Medicine, Psychiatry, Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada

Department of Medicine, University of Wisconsin, Madison, WI, USA

Megan E. Piper

University of Wisconsin Center for Tobacco Research and Intervention, Madison, WI, USA

Department of Neurobiology and Behaviour, University of California Irvine, Irvine, CA, USA

Christie D. Fowler

Section for Preventive Cardiology, Department of Endocrinology, Morbid Obesity and Preventive Medicine, Oslo University Hospital, Oslo, Norway

Serena Tonstad

Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA

Laura Bierut

Institute of Mental Health, Peking University Sixth Hospital, Peking University, Beijing, China

National Institute on Drug Dependence, Peking University Health Science Center, Beijing, China

Centre for Global Health Research, Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada

• Prabhat Jha

National Centre for Youth Substance Use Research, The University of Queensland, St Lucia, Queensland, Australia

Wayne D. Hall

Queensland Alliance for Environmental Health Sciences, The University of Queensland, Woolloongabba, Queensland, Australia

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Contributions

Introduction (B.Le F.); Epidemiology (P.J. and W.D.H.); Mechanisms/pathophysiology (C.D.F., L.B., L.L. and B.Le F.); Diagnosis, screening and prevention (P.J., M.E.P., S.T. and B.Le F.); Management (M.E.P., S.T., W.D.H., L.L. and B.Le F.); Quality of life (P.J. and W.D.H.); Outlook (all); Conclusions (all). All authors contributed substantially to the review and editing of the manuscript.

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Correspondence to Bernard Le Foll .

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Competing interests.

B.Le F. has obtained funding from Pfizer (GRAND Awards, including salary support) for investigator-initiated projects. B.Le F. has received some in-kind donations of cannabis product from Aurora and medication donation from Pfizer and Bioprojet and was provided a coil for TMS study from Brainsway. B.Le F. has obtained industry funding from Canopy (through research grants handled by CAMH or the University of Toronto), Bioprojet, ACS, Indivior and Alkermes. B.Le F. has received in-kind donations of nabiximols from GW Pharma for past studies funded by CIHR and NIH. B.Le F. has been an advisor to Shinoghi. S.T. has received honoraria from Pfizer the manufacturer of varenicline for lectures and advice. All other authors declare no competing interests.

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• Published: 06 February 2024

Technology-based interventions for tobacco smoking prevention and treatment: a 20-year bibliometric analysis (2003–2022)

• Waleed M. Sweileh 1  

Substance Abuse Treatment, Prevention, and Policy volume  19 , Article number:  13 ( 2024 ) Cite this article

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Substance abuse, particularly tobacco smoking, is a significant global public health concern. Efforts have been made to reduce smoking prevalence and promote cessation, but challenges, such as nicotine addiction, marketing tactics by tobacco industry, and cultural acceptability hinder progress. Technology has emerged as a potential tool to address these challenges by providing innovative scalable interventions. The objective of the study was to analyze and map scientific literature on technology-based intervention for tobacco prevention and treatment.

A bibliometric methodology was conducted. Scopus database was used to retrieve relevant research articles published between 2003 and 2022. The analysis included publication trends, key contributors, research hotspots, research themes, the most impactful articles, and emerging research topics.

A total of 639 articles were found, with a slow and fluctuating growth pattern observed after 2011. The Journal of Medical Internet Research was the most prominent journal in the field. The United States was the leading country in the field, followed up by the United Kingdom, and the Netherlands. Research hotspots included smoking cessation, randomized controlled trials, and technology-based methods such as internet, mHealth, smartphone apps, text messages, and social media. Four primary research themes were identified: development of smartphone applications, efficacy of text messaging interventions, acceptance and effectiveness of smartphone applications, and interventions targeting young adults and students using mobile phone and social media platforms. The top 10 cited articles demonstrated effectiveness of digital interventions in promoting smoking cessation rates and reducing relapse rates. Emerging research topics included the use of virtual reality interventions, interventions for specific populations through personalized tools, and technology-based interventions in non-Western countries.

Conclusions

The findings of the current study highlight the potential of technology to address the challenges associated with tobacco smoking. Further future research in this area is warranted to continue advancing the field and developing effective and evidence-based interventions to combat tobacco smoking.

Substance abuse, particularly tobacco smoking, continues to be a significant public health concern worldwide [ 1 ]. Over the past three decades, tremendous governmental and non-governmental efforts have been implemented to curb smoking prevalence, aiming to decrease tobacco smoking, prevent initiation among youth, and promote smoking cessation among current smokers [ 1 ]. However, smoking is a highly addictive behavior due to the presence of nicotine, a potent stimulant and psychoactive substance [ 2 , 3 ]. Furthermore, the tobacco industry has employed various marketing tactics to promote smoking. Such tactics include extensive advertising, attractive packaging, and innovative products with different flavors have attracted different target populations [ 4 , 5 ]. The wide spread use of tobacco has also been attributed to the cultural and societal acceptability of smoking [ 6 , 7 ]. The addictive properties of nicotine, the marketing tactics by tobacco industry, and cultural acceptability of smoking are the main challenges facing individuals who want to quit smoking. In addition, the addictive properties of nicotine is the main cause of the persistently higher prevalence rates of tobacco use [ 8 , 9 ]. Nicotine stimulates the release of dopamine in the brain, creating a rewarding sensation and reinforcing the habit-forming cycle. Over time, regular smoking leads to nicotine dependence, making it difficult for individuals to quit without nicotine compensation [ 2 , 10 ]. Despite all these difficulties, a wide range of important initiatives and preventive policies have been implemented nationally or internationally to tackle the challenges of smoking [ 11 ]. One important example of an international initiative to curb smoking is the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC), which stands as the first global treaty negotiated under the auspices of the WHO [ 1 ].

As societal behaviors and communication patterns have evolved, technology has emerged as a powerful tool with the potential to revolutionize the substance abuse prevention and treatment [ 12 , 13 ]. Traditionally, substance abuse prevention and treatment methods have relied on conventional methods such as face-to-face counseling, group therapy, and printed educational materials [ 14 , 15 ]. While these conventional methods have demonstrated some efficacy, they often face limitations in reach, accessibility, and engagement. However, with the rapid advancement of technology, new avenues have emerged, providing innovative ways to address substance abuse [ 16 , 17 ]. For example, technology-based interventions can reach a wider audience by leveraging the pervasive nature of digital technologies. Technology can overcome geographical barriers and reach individuals living in remote and underserved areas provided that they have adequate digital literacy. Technology provides real-time monitoring and assessment, enabling personalized interventions tailored to an individual’s specific needs, with high degree of privacy reducing stigma and fear of judgment [ 18 , 19 , 20 ]. Furthermore, the interactive and immersive nature of technology allows for engaging and interactive interventions that can increase motivation and promote behavioral change. Therefore, technology can be more cost-effective and scalable compared to conventional methods [ 21 , 22 , 23 ]. Social media platforms are another important aspect of digital technology that offer a unique opportunity to reach and engage with large number of populations. Social media enables for the formation of online communities and support networks, allowing for peer and social support. It could be argued that social media could be used to encourage and promote smoking, especially among young generations through the portrayal of smoking in movies and tobacco industry advertisements. However, the platform used for the promotion of tobacco smoking are usually not the same platforms used to help smokers quit smoking and usually don’t use the same networks.

Research is considered a key element in building evidence-based preventive policies and strategies to curb persistent smoking rates. The WHO emphasizes the importance of research to address global health challenges [ 24 ]. Similarly, the US CDC supports research on health promotion and preventive strategies [ 25 ]. The National Institutes of Health (NIH) provide funding and resources for research on combating health challenges. Recognizing the addictive nature of tobacco smoking, advantages of digital technology, and the recommendations by international health organizations to research major global health challenges, research efforts have focused on implementing technology to reduce tobacco smoking rates through preventive and treatment interventions. Based on all the above-mentioned information, it is imperative to do a comprehensive analysis of research on prevention and treatment of tobacco smoking using digital technologies. Therefore, the current study aims to analyze and map scientific literature on technology-based interventions for the prevention and treatment of tobacco smoking. The study aims to achieve the following objectives: (1) identify research volume, growth pattern, and key contributors to the field; (2) identify the main research hotspots and research themes in the field; (3) analyze the content of the top 10 cited articles in the field; and (4) identify the emerging research topics in the field.

To analyze and map the research landscape, a comprehensive methodology was developed and implemented in Scopus database. The Scopus ( www.scopus.com ) has several advantages regarding the number and type of indexed journals as well as features related to handling and export of data for analysis and mapping.

The study focused on retrieving relevant research articles from the Scopus database using a set of specific keywords related to digital technologies including social media platforms in addition to keywords related to tobacco smoking. All keywords were used in the title search to minimize false-positive results. Supplement 1 shows the keywords used and the inclusion and exclusion criteria.

Inclusion and exclusion criteria

The followings were used as inclusion criteria: (1) research articles published between 2003 and 2022; (2) English language articles; and (3) Quantitative, qualitative, and mixed-methods studies. The followings were used as the exclusion criteria: (1) review articles, editorials, commentaries, and letters to the editor; (2) studies that do not specifically focus on traditional tobacco smoking such as e-cigarettes, electronic cigarettes, and e-cig.

The retrieved articles underwent a rigorous validation process to ensure their relevance and accuracy. A validation sample comprising 100 retrieved articles was carefully examined by two knowledgeable colleagues in the field of medicine. Based on their expertise, it was strongly recommended to include two additional specific terms, namely opioids and e-cig in the exclusion step. This crucial addition was deemed necessary to mitigate the risk of false-negative results and enhance the overall validity of the study. The number of documents retrieved in each step in the search strategy is shown in Fig.  1 .

Flow chart for the search strategy on technology-based interventions for tobacco smoking prevention and treatment

Data analysis and visualization

The retrieved articles were analyzed quantitatively to gain insights into the research landscape. Key metrics such as publication trends, journal, country, and author distributions were examined to understand the research output. VOSviewer [ 26 , 27 ], a widely used free online program, was used to create maps for the identification of most frequent author keywords (research hotspots) and research clusters (research themes).

Interpretation of VOSviewer maps

We undertook a rigorous mapping analysis of the retrieved dataset using VOSviewer. In VOSviewer maps, each term or keyword in the dataset is represented as a point on the map, denoted by a circle or node. These nodes vary in size and color, and they are interconnected by lines of differing thickness. The size of a node serves as an indicator of the term’s significance or prevalence within the dataset. Larger nodes signify that a specific term is frequently discussed or holds a central role in the body of research, while smaller nodes denote less commonly mentioned concepts. The colors assigned to these nodes facilitate the grouping of terms into thematic clusters, with terms of the same color typically belonging to the same cluster or sharing a common thematic thread. The spatial proximity of nodes on the map reflects their similarity in meaning or concept. Nodes positioned closely together share a robust semantic or contextual connection and are likely to be co-mentioned in research articles or share a similar thematic focus. Conversely, nodes placed farther apart suggest a lower degree of commonality in terms of their usage in the literature. The lines that link these nodes represent the relationships between terms. The thickness of these lines provides insights into the strength and frequency of these connections. Thick lines indicate that the linked terms are frequently discussed together or exhibit a robust thematic association, while thinner lines imply weaker or less frequent connections. In essence, VOSviewer maps offer a visual narrative of the underlying structure and relationships within your dataset. By examining node size and color, we can identify pivotal terms and thematic clusters. Simultaneously, analyzing the distance between nodes and line thickness unveils the semantic closeness and strength of associations between terms. These visual insights are invaluable for researchers seeking to unearth key concepts, identify research clusters, and track emerging trends within their field of study.

Emerging research topics

To uncover the current trends in research within the field, we conducted an analysis of 65 articles published in 2022. Through the use of VOSviewer, we created a visualization and interpretation of the articles, allowing us to deduce the prominent research topics and emerging areas of interest.

Volume, growth pattern, and key contributors

The search strategy yielded 639 pertinent articles spanning from 2003 to 2022. The annual growth of publications revealed a slow and upward fluctuating growth after 2011 (Fig.  2 ). The Journal Of Medical Internet Research ranked first ( n  = 73; 11.4%), followed by the Nicotine and Tobacco Research journal ( n  = 53; 8.3%), and JMIR Mhealth and Uhealth ( n  = 37; 5.8%), and BMC Public Health journal ( n  = 23; 3.6%). The results indicated a significant contribution from the United States (US) ( n  = 359; 56.2%), followed by the United Kingdom, the Netherlands, Australia, Canada, and Germany. It is noteworthy that China ranked seventh and India ranked eleventh. Scholars from 51 different countries have made contributions to the field of technology-based smoking prevention and treatment. However, of these 51 countries, only 13 made a significant contribution of 10 articles or more each. Contribution of countries in the Middle East, Africa, Latin America, East Europe, and certain areas in Asia was relatively low. Upon analyzing the research activity, it was found that certain institutions have made notable contributions to the topic. Leading the pack is the Universiteit Maastricht (the Netherlands) ( n  = 36; 5.6%), followed by the University of California, San Francisco (United States), Brown University (United States), and Fred Hutchinson Cancer Research Center (United States). The National Cancer Institute ( n  = 141; 21.7%) of the US NIH ranked first as a funding sponsor for the retrieved articles. A total of 3709 authors collaborated in publishing the 639 research articles that were found. On average, each article had 5.8 authors. There were 15 (2.3%) articles with a single author, 41 (6.4%) with two authors, 62 (9.7%) with three authors, and 102 (16.0%) with four authors each. The remaining 419 (65.6%) articles were multi-authored (≥ 5). The most prolific author was Graham, (A) L. ( n  = 30; 4.7%), followed by De Vries, H ( n  = 28; 4.4%), and Bricker, J. (B) ( n  = 20; 3.1%).

Annual growth of publications on technology-based interventions for tobacco smoking prevention and treatment

Research hotspots and research themes

When visualizing author keywords that appeared at least 10 times, a map consisting of 33 keywords were generated (Fig.  3 ). The “smoking cessation” keyword had the largest node size suggesting that the majority of the retrieved literature focused on smoking cessation research efforts [ 26 , 27 ]. The map included smaller nodes for the keywords “randomized controlled trial”, adolescence, young adults, and pregnancy. The map included different technology-based methods used in the context of prevention and treatment of smoking, with “internet”, “mHealth”, “smartphone app.”, “text message”, and ‘social media” being the most frequently mentioned.

Mapping frequent author keywords to identify research hotspots on technology-based interventions for tobacco smoking prevention and treatment

The visualization map derived from the frequent terms in titles and abstracts of the retrieved articles revealed four primary research themes represented as four clusters with different distinct colors (Fig.  4 ). The red cluster signifies a prominent research focus on the development and content of smartphone applications designed for smoking cessation purposes [ 28 , 29 ]. The green cluster represents research predominantly centered around Randomized Clinical Trials (RCTs) aimed at assessing the efficacy of text messaging interventions for smoking cessation therapy [ 30 , 31 ]. The yellow cluster denotes research investigations pertaining to the acceptance and the effectiveness of smartphone applications in supporting smoking cessation efforts [ 32 , 33 , 34 , 35 ]. Lastly, the fourth cluster encompasses research-related to technology-based interventions utilizing mobile phones and social media platforms targeting smoking cessation among young adults and students [ 36 , 37 , 38 ].

Mapping frequent terms in titles and abstracts to identify research themes on technology-based interventions for tobacco smoking prevention and treatment

The most impactful articles

In the present study the top ten cited articles in the field were analyzed. These highly influential studies have played a pivotal role in substantiating the efficacy of digital interventions in augmenting smoking cessation rates and ameliorating relapse rates. Each of these articles has contributed valuable insights into the field, and their findings collectively provide a strong foundation for the effectiveness of digital approaches in addressing smoking cessation and relapse prevention. Their findings offer invaluable insights for healthcare professionals, policymakers, and researchers, and their consistent trends affirm the efficacy and potential of digital approaches in smoking cessation and relapse prevention.

The criteria employed to evaluate the efficacy of these digital interventions have been diverse, reflecting a comprehensive assessment of their impact. Some common criteria include the measurement of smoking cessation rates, often assessed through 7-day point prevalence abstinence or continuous abstinence, and, in some cases, employing biochemical verification to confirm participants’ smoking status [ 39 , 40 ]. Long-term abstinence, often measured at 6 months or 12 months post-cessation, has been a key indicator of sustained efficacy [ 40 , 41 , 42 ]. User engagement with digital interventions has also been evaluated, with studies showing that higher engagement often correlates with better outcomes [ 43 , 44 , 45 ]. Comparative studies have examined the advantages of digital approaches in contrast to traditional methods such as counseling or pharmacotherapy [ 42 , 46 , 47 ]. Cost-effectiveness has been assessed, shedding light on the economic benefits of these interventions [ 48 , 49 , 50 ].

Table  1 shows the top 10 articles that received the highest number of citations [ 44 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 ]. In summary, the articles demonstrated the effectiveness of digital interventions such as mobile phone text messaging, smartphone applications, web-based programs, and social media-based interventions in promoting smoking cessation rates and reducing relapse rates. The interventions have shown higher quit rates and increased continuous abstinence rates compared to control groups. Participants reported high satisfaction and perceived the interventions helpful in their quit attempts. The article that received the highest number of citations ( n  = 576) was a RCTs called “txt2stop” and used mobile phone text messaging [ 57 ]. The trial showed significant successful smoking cessation rates and the author suggested inclusion of the method in smoking cessation services. The second highly cited article “Do u smoke after txt” showed similar effectiveness in smoking quit rates [ 59 ]. The third highly cited articles was a web-based computer tailored smoking cessation program as a supplement to nicotine patch therapy [ 52 ]. The trial showed a significantly higher abstinence rates in the interventional group compared to control group. The fourth cited article was about the development of a program designed to deliver text messages to help college students quit smoking [ 56 ]. The program was tested in a small number of college students and showed promising results that support the use of wireless messages in smoking cessation services. In a study that aimed to evaluate popular smartphone apps designed to help people quit smoking, authors revealed that these apps had limited adherence to clinical guidelines. This underscores the need for improving app content and design to better align with evidence-based practices [ 29 ]. Another study explored how user engagement affected the effectiveness of a web-based smoking cessation program [ 60 ]. The results indicated that greater user engagement, as measured by the number of web sections opened, was associated with a higher likelihood of quitting smoking. However, certain demographic factors, like age, gender, and education level, were linked to lower engagement, especially when program sections were presented sequentially. Another study provided an early assessment of QuitNet, a widely accessible online smoking cessation website [ 61 ]. Researchers revealed a 7% point prevalence abstinence rate among QuitNet users, which increased to 30% when considering only those who responded to the survey. The study shed light on the potential impact of web-based behavior change programs for smoking cessation. It underscored the critical role of user engagement and support in achieving positive outcomes.

The screening process involved analyzing articles published in 2022 to uncover emerging research topics concerning the technology-based prevention and treatment of tobacco smoking. While some of the identified research topics were extensions of ongoing investigations that began a decade ago, there were also a few novel areas of exploration. To identify the emerging research topics on technology-based interventions for prevention and treatment of tobacco smoking, articles published in 2022 were screened. Research topics identified in the articles published in 2022 ( n  = 65) were presented in Table  2 . The following research topics are considered emerging research topics:

Employing virtual reality interventions for smoking cessation [ 62 , 63 ].

Implementing telemedicine/telehealth interventions for smoking cessation [ 64 , 65 ].

Developing personalized/tailored interventions for smoking cessation [ 66 , 67 ].

Addressing smoking cessation interventions for specific populations such as socioeconomically disadvantaged young adults, people living with HIV, cancer survivors, and veterans [ 68 , 69 ].

Use of technology-based interventions in countries that are not in North America or Western Europe, such as Thailand, South Africa, Brazil, and Japan [ 70 , 71 ].

The use of digital technology in the prevention and treatment of tobacco smoking has gained significant attention in recent years as indicated by the increase in the number of publications after 2011. The period after 2011 has witnessed a widespread adoption of smartphones, mobile applications, and wearable devices [ 72 ]. In the past two decades, there have been an increasing recognition of the importance of smoking as a risk factor for several fatal NCDs [ 73 ]. This have prompted researchers and funding bodies to search for an acceptable, effective, and relatively inexpensive method to curb smoking prevalence by promoting smoking cessation [ 74 ]. The fact that scholars from the US contributed to more than half of the retrieved articles, does not necessarily mean that the US had the highest prevalence of tobacco smoking. The research activity of any particular country depends on several factors that include governmental initiatives, research infrastructure, research environment, funding availability, and the prevalence or importance of the topic to national and global health [ 75 , 76 ]. It is possible that the research output and country rank are linked to the extent of advancement and use of technology in that particular country. Countries with higher rates of technology adoption among their populations may be more open and willing to use technology-based intervention to manage tobacco smoking. The observation that China ranked seventh and India ranked eleventh holds profound significance. These rankings underscore the global impact of tobacco smoking, particularly in two of the most populous countries worldwide [ 77 ]. It implies the need for tailored and culturally sensitive technology-based strategies to address the unique challenges in these countries. Additionally, understanding these rankings provides valuable insights into the cultural and regional factors influencing smoking habits, enabling the development of contextually relevant interventions. These rankings allows for comparative analyses of China and India’s approaches to tobacco smoking prevention and treatment, offering lessons and best practices for global sharing. It also emphasizes the significance of research and investments in technology-based solutions to combat tobacco smoking challenges in these countries. Furthermore, policymakers can use this information to inform public health policies, taxation, and regulatory measures related to tobacco control. Lastly, tracking these rankings over time can reveal trends in tobacco use and the effectiveness of prevention and treatment strategies, facilitating ongoing assessments of various interventions’ impact. This explanation remains speculative and further investigations are needed to determine the factors affecting the research output in technology-based interventions in the general discipline of health.

The findings in the current study indicated that the vast majority of research activity was directed toward tobacco smoking treatment, specifically smoking cessation, while relatively limited research was published on technology-based prevention. The emphasis of technology-based research on smoking cessation rather than preventive strategies could be attributed to several factors. Quitting smoking is challenging to smokers and the use of technology offers a new avenue to support smoking cessation [ 78 , 79 , 80 , 81 ]. Research funding agencies prioritize research on smoking cessation interventions that produce immediate effects. Preventive strategies including awareness and educational campaigns could be achieved by non-traditional methods and their effects are seen on the long term rather than on the short term. A second reason for the greater emphasis on smoking cessation research is related to the relatively easier method to measure the outcome of smoking cessation using technology tools, which is not the case in measuring the outcome of prevention through policies and awareness campaigns. Tobacco smoking policies such as smoking-free places needs long times to show effects on smoking prevalence. The same applies to awareness campaigns that require years to show positive effects in contrast to smoking cessation.

Mapping of frequent terms showed the presence of a research theme related to smoking cessation among students, adolescents, and young adults. Adolescents are considered vulnerable when it comes to smoking initiation and addiction. Research has shown that the majority of adult smokers start smoking during their teenage years or yearly adulthood [ 82 , 83 ]. Secondly, the familiarity of technology among young adults makes it easier to carry out research utilizing modern technology [ 84 ]. Finally, technology-based interventions have demonstrated promising results regarding effectiveness and reach among young populations. Technology-based interventions can offer personalized support, deliver tailored messages, provide interactive tools, and leverage social support networks, which are all factors that may be appealing and effective in engaging young individuals in quitting smoking [ 85 , 86 , 87 ].

Another important feature revealed by mapping frequent author keywords was the limited used of social media in the context of tobacco smoking and prevention. Several factors could explain this. Despite the very wide spread use of social media, there is limited evidence-based about the effectiveness of social media in smoking cessation. This makes research on social media-based tobacco smoking prevention and treatment limited compared to smartphone or internet-based methodology. A second possible reason for the limited research activity using social media is the regulations imposed by social media that restrict tobacco– related content material. This might limit the utilization of social media in tobacco-related research.

Analysis showed that the use of text messaging to help in smoking cessation constituted a research theme and articles on text messaging received relatively high number of citations. The use of text messaging as a tool for smoking cessation represents a relatively new and innovative approach in the field. The integration of text messaging as an intervention strategy offered a fresh perspective and attracted significant attention from both researchers and policy makers. Text messaging is currently a widely used means of communication among different groups of populations including smokers. The use of text misaligning tool capitalize on the prevalence and convenience of mobile phones, making it easier to reach and engage with smokers. The text messaging has the advantage of scalability, which makes it appealing for researchers and public health practitioners who aim to implement and measure the efficacy of cessation program on a large scale. The research findings consistently demonstrated positive results and effectiveness as measured by increasing smoking abstinence rates, acceptability, and feedback from users. These advantages of text messaging tools increased the interest of researchers in this technology-based tool. Finally, the majority of RCTs on smoking cessation showed promising and successful results of the text messaging tool, which adds to the credibility, scientific rigor, and reliability of the tool within the scientific committee [ 88 , 89 , 90 , 91 ]. Based on all the above, health policy makers should promote the use and monitoring of text messaging method in smoking cessation tool in primary healthcare services. It is expected that future research will witness greater research activity on the use of virtual reality and telemedicine in smoking cessation programs [ 62 , 64 , 65 , 92 ]. Furthermore, personalized and tailored interventions in special population groups, such as cancer survivors, will witness greater research activity [ 66 , 67 ].Future research activity using technology for tobacco smoking will not be limited to high-income countries. It is expected that research activity using technology-based tools in smoking cessation will be worldwide [ 37 , 70 , 93 ].

Research gaps and future research directions

The research landscape analysis of technology-based tobacco smoking prevention and control gave an overall insight of has been published in this field. However, the research landscape also shows certain gaps and limitations in scientific research in this field. For example, most of the highly cited articles that had a positive impact on the field were limited by short follow up. Most of the articles had a follow up for several weeks to several months and there is a noticeable lack of long-term follow up investigations. Longer follow up times are needed to confirm sustainable effectiveness of the methods. Future research should focus on extended follow up assessments to confirm efficacy and relapse rates. Secondly, most studies, especially those with the high citations, included participants from high-income countries. This limits the generalizability of the conclusions of the studies. Future studies should have a diverse group of participants with different socioeconomic background, ethnic groups, gender, religious groups, and geographical distribution. The majority of studies testing the efficacy of the RCTs using technology-based tools have variable components, which makes comparison difficult. Therefore, it is recommended that future standardized method should be used to make comparison between various articles credible and reliable. Articles that reported benefit of technology-based tool in smoking cessation relied on self-reported abstinence, which is subject to recall bias and error [ 94 , 95 ]. Therefore, future research should focus on biochemical measures to confirm abstinence. Future research should also focus on two major areas related to future implementation of technology in smoking cessation activities. Potential adverse health effects of technology methods and cost-effectiveness should be investigated and reported.

Limitations

The current research landscape study was limited by the use of single database and by the possible presence of false-positive and false-negative results. In research landscape analysis, such limitations are common but does not affect the overall analysis and identification of research hotspots, research themes, research gaps, and potential future research focus. In our study, we primarily focused on the bibliometric analysis of research articles related to technology-based interventions for smoking cessation. While our analysis provides a comprehensive overview of the research landscape, it is essential to acknowledge that assessing real-world technology adoption and utilization falls outside the scope of a bibliometric analysis. However, we recognize the significance of this aspect and its potential relevance to the field. In practice, the diffusion of technology-based interventions for tobacco smoking prevention and treatment is influenced by various factors, including accessibility, acceptance, and adoption rates among users. We did not directly collect data on real-world utilization in this study. Nevertheless, the widespread availability of such interventions and their increasing integration into healthcare systems and public health campaigns suggest a growing interest in their real-world use. Future research endeavors may explore the adoption rates, user experiences, and effectiveness of these interventions, providing insights into their diffusion and practical impact on smoking cessation efforts.

In this extensive bibliometric analysis spanning two decades (2003–2022), our study provides a comprehensive overview of the research landscape in the domain of technology-based interventions for tobacco smoking prevention and treatment. The findings and insights obtained from this analysis offer a wealth of information that holds significant implications for the advancement of smoking cessation strategies and the future of public health. Several key takeaways emerge from this research landscape analysis. The exponential growth in research publications following 2011 corresponds with the widespread adoption of smartphones, mobile applications, and wearable devices. The emergence of these technologies has created unprecedented opportunities for innovative interventions in the field of tobacco smoking prevention and treatment. The leading role of the United States in contributing to more than half of the retrieved articles emphasizes the significance of technological advancement and its impact on research activity. It is essential to note that high research output does not necessarily reflect high smoking prevalence but rather indicates the extent of technological integration and investment in the research domain. The remarkable rankings of China and India as the seventh and eleventh countries, respectively, highlight the global reach and consequences of tobacco smoking, particularly in two of the most populous nations worldwide. This underscores the need for culturally tailored, context-specific technology-based solutions to address the distinct challenges these countries face. The overwhelming emphasis on smoking cessation research rather than prevention could be attributed to the immediate and measurable outcomes of cessation interventions. Moreover, the application of technology in smoking cessation provides a novel and effective avenue for supporting smokers in their quit attempts. The research landscape further reveals the critical role of text messaging as a promising tool for smoking cessation. The scalability, reach, and effectiveness of text messaging make it a compelling choice for researchers and policymakers alike. The presence of limited research on social media in the context of tobacco smoking prevention may be attributed to the limited evidence-based knowledge regarding the effectiveness of social media in this area, as well as the regulations imposed by social media platforms on tobacco-related content. To bridge existing research gaps, future studies should include long-term follow-up assessments to confirm the sustainability of intervention efficacy and expand participant diversity to improve the generalizability of findings. Standardized methods and biochemical measures to confirm abstinence should be incorporated in future research. Additionally, the investigation of potential adverse health effects and cost-effectiveness of technology-based methods in smoking cessation activities will be essential for comprehensive insights. This research landscape analysis serves as a valuable resource for researchers, healthcare professionals, policymakers, and public health advocates. The identified research hotspots, research themes, and emerging topics can guide the development of evidence-based interventions in technology-based tobacco smoking prevention and treatment. By continually monitoring the research landscape, stakeholders can track the evolving trends, assess the effectiveness of various interventions, and adapt strategies to combat the global tobacco smoking epidemic more effectively. In conclusion, technology-based interventions have shown great promise in supporting smoking cessation and reducing relapse rates. As technology continues to advance and integrate further into our lives, it is evident that these interventions will play a pivotal role in tobacco control efforts. This comprehensive analysis underscores the critical importance of technology in public health strategies and highlights the vast potential for innovative, evidence-based approaches to mitigate the adverse health effects of tobacco smoking worldwide. Future research, innovation, and collaboration will drive the continued evolution of technology-based interventions and pave the way for a smoke-free future.

Data availability

The datasets generated and/or analyzed during the current study are available in the Scopus repository, ( www.scopus.com ).

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Sweileh, W.M. Technology-based interventions for tobacco smoking prevention and treatment: a 20-year bibliometric analysis (2003–2022). Subst Abuse Treat Prev Policy 19 , 13 (2024). https://doi.org/10.1186/s13011-024-00595-w

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235 Smoking Essay Topics & Examples

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Lung cancer is the foremost issue in the public mind because of the general worry associated with the condition and its often incurable nature, but smoking can lead to other severe illnesses.

Heart conditions remain a prominent consideration due to their lethal effects, and strokes or asthma deserve significant consideration, as well. Overall, smoking has few to no beneficial health effects but puts the user at risk of a variety of concerns.

As such, people should eventually quit once their health declines, but their refusal to do so deserves a separate investigation and can provide many interesting smoking essay titles.

One of the most prominent reasons why a person would continue smoking despite all the evidence of its dangers and the informational campaigns carried out to inform consumers is nicotine addiction.

The substance is capable of causing dependency, a trait that has led to numerous discussions of the lawfulness of the current state of cigarettes.

It is also among the most dangerous aspects of smoking, a fact you should mention.

Lastly, you can discuss the topics of alternatives to smoking in your smoking essay bodies, such as e-cigarettes, hookahs, and vapes, all of which still contain nicotine and can, therefore, lead to considerable harm. You may also want to discuss safe cigarette avoidance options and their issues.

Here are some additional tips for your essay:

• Dependency is not the sole factor in cigarette consumption, and many make the choice that you should respect consciously.
• Cite the latest medical research titles, as some past claims have been debunked and are no longer valid.
• Mortality is not the sole indicator of the issues associated with smoking, and you should take chronic conditions into consideration.

Find smoking essay samples and other useful paper samples on IvyPanda, where we have a collection of professionally written materials!

• Conclusion of Smoking Should Be Banned on College Campuses Essay However, it is hard to impose such a ban in some colleges because of the mixed reactions that are held by different stakeholders about the issue of smoking, and the existing campus policies which give […]
• Should Smoking Be Banned in Public Places? Besides, smoking is an environmental hazard as much of the content in the cigarette contains chemicals and hydrocarbons that are considered to be dangerous to both life and environment.
• Smoking: Problems and Solutions To solve the problem, I would impose laws that restrict adults from smoking in the presence of children. In recognition of the problems that tobacco causes in the country, The Canadian government has taken steps […]
• How Smoking Is Harmful to Your Health The primary purpose of the present speech is to inform the audience about the detrimental effects of smoking. The first system of the human body that suffers from cigarettes is the cardiovascular system.
• Causes and Effects of Smoking Some people continue smoking as a result of the psychological addiction that is associated with nicotine that is present in cigarettes.
• Smoking Cigarette Should Be Banned Ban on tobacco smoking has resulted to a decline in the number of smokers as the world is sensitized on the consequences incurred on 31st May.
• On Why One Should Stop Smoking Thesis and preview: today I am privileged to have your audience and I intend to talk to you about the effects of smoking, and also I propose to give a talk on how to solve […]
• Smoking: Effects, Reasons and Solutions This presentation provides harmful health effects of smoking, reasons for smoking, and solutions to smoking. Combination therapy that engages the drug Zyban, the concurrent using of NRT and counseling of smokers under smoking cessation program […]
• Advertisements on the Effect of Smoking Do not Smoke” the campaign was meant to discourage the act of smoking among the youngsters, and to encourage them to think beyond and see the repercussions of smoking.
• Smoking and Its Negative Effects on Human Beings Therefore, people need to be made aware of dental and other health problems they are likely to experience as a result of smoking.
• Smoking Cessation Programs Through the Wheel of Community Organizing The first step of the wheel is to listen to the community’s members and trying to understand their needs. After the organizer and the person receiving treatment make the connection, they need to understand how […]
• Smoking Among Teenagers as Highlighted in Articles The use of tobacco through smoking is a trend among adolescents and teenagers with the number of young people who involve themselves in smoking is growing each day.
• Causes and Effects of Smoking in Public The research has further indicated that the carcinogens are in higher concentrations in the second hand smoke rather than in the mainstream smoke which makes it more harmful for people to smoke publicly.
• “Thank You For Smoking” by Jason Reitman Film Analysis Despite the fact that by the end of the film the character changes his job, his nature remains the same: he believes himself to be born to talk and convince people.
• Health Promotion Plan: Smokers in Mississippi The main strategies of the training session are to reduce the number of smokers in Mississippi, conduct a training program on the dangers of smoking and work with tobacco producers.
• Public Health Education: Anti-smoking Project The workshop initiative aimed to achieve the following objectives: To assess the issues related to smoking and tobacco use. To enhance the health advantages of clean air spaces.
• Summary of “Smokers Get a Raw Deal” by Stanley Scott Lafayette explains that people who make laws and influence other people to exercise these laws are obviously at the top of the ladder and should be able to understand the difference between the harm sugar […]
• Smoking and Youth Culture in Germany The report also assailed the Federal Government for siding the interest of the cigarette industry instead of the health of the citizens.
• Introducing Smoking Cessation Program: 5 A’s Intervention Plan The second problem arises in an attempt to solve the issue of the lack of counseling in the unit by referring patients to the outpatient counseling center post-hospital discharge to continue the cessation program.
• Teenage Smoking and Solution to This Problem Overall, the attempts made by anti-smoking campaigners hardly yield any results, because they mostly focus on harmfulness of tobacco smoking and the publics’ awareness of the problem, itself, but they do not eradicate the underlying […]
• Smoking and Its Effects on Human Body The investigators explain the effects of smoking on the breath as follows: the rapid pulse rate of smokers decreases the stroke volume during rest since the venous return is not affected and the ventricles lose […]
• Tobacco Debates in “Thank You for Smoking” The advantage of Nick’s strategy is that it offers the consumer a role model to follow: if smoking is considered to be ‘cool’, more people, especially young ones, will try to become ‘cool’ using cigarettes.
• Smoking Habit, Its Causes and Effects Smoking is one of the factors that are considered the leading causes of several health problems in the current society. Smoking is a habit that may be easy to start, but getting out of this […]
• Ban Smoking in Cars Out of this need, several regulations have been put in place to ensure children’s safety in vehicles is guaranteed; thus, protection from second-hand smoke is an obvious measure that is directed towards the overall safety […]
• Aspects of Anti-Smoking Advertising Thus, it is safe to say that the authors’ main and intended audience is the creators of anti-smoking public health advertisements.
• Smoking Qualitative Research: Critical Analysis Qualitative research allows researchers to explore a wide array of dimensions of the social world, including the texture and weave of everyday life, the understandings, experiences and imaginings of our research participants, the way that […]
• The Change of my Smoking Behavior With the above understanding of my social class and peer friends, I was able to create a plan to avoid them in the instances that they were smoking.
• Hookah Smoking and Its Risks The third component of a hookah is the hose. This is located at the bottom of the hookah and acts as a base.
• Health Promotion for Smokers The purpose of this paper is to show the negative health complications that stem from tobacco use, more specifically coronary heart disease, and how the health belief model can help healthcare professionals emphasize the importance […]
• Gender-Based Assessment of Cigarette Smoking Harm Thus, the following hypothesis is tested: Women are more likely than men to believe that smoking is more harmful to health.
• Hazards of Smoking and Benefits of Cessation Prabhat Jha is the author of the article “The Hazards of Smoking and the Benefits of Cessation,” published in a not-for-profit scientific journal, eLife, in 2020.
• The Impact of Warning Labels on Cigarette Smoking The regulations requiring tobacco companies to include warning labels are founded on the need to reduce nicotine intake, limit cigarette dependence, and mitigate the adverse effects associated with addiction to smoking.
• Psilocybin as a Smoking Addiction Remedy Additionally, the biotech company hopes to seek approval from FDA for psilocybin-based therapy treatment as a cigarette smoking addiction long-term remedy.
• Tobacco Smoking: The Health Outcomes Tobacco smoke passing through the upper respiratory tract irritates the membrane of the nasopharynx, and other organism parts, generating copious separation of mucus and saliva.
• Investing Savings from Quitting Smoking: A Financial Analysis The progression of interest is approximately $50 per year, and if we assume n equal to 45 using the formula of the first n-terms of the arithmetic progression, then it comes out to about 105 […]
• Smoking as a Community Issue: The Influence of Smoking A review of the literature shows the use of tobacco declined between 1980 and 2012, but the number of people using tobacco in the world is increasing because of the rise in the global population.
• Smoking Public Education Campaign Assessment The major influence of the real cost campaign was to prevent the initiation of smoking among the youth and prevent the prevalence of lifelong smokers.
• Smoking Cessation Therapy: Effectiveness of Electronic Cigarettes Based on the practical experiments, the changes in the patients’ vascular health using nicotine and electronic cigarettes are improved within one-month time period. The usage only of electronic cigarettes is efficient compared to when people […]
• Quitting Smoking and Related Health Benefits The regeneration of the lungs will begin: the process will touch the cells called acini, from which the mucous membrane is built. Therefore, quitting the habit of smoking a person can radically change his life […]
• Smoking and Stress Among Veterans The topic is significant to explore because of the misconception that smoking can alleviate the emotional burden of stress and anxiety when in reality, it has an exacerbating effect on emotional stress.
• Smoking as a Predictor of Underachievement By comparing two groups smoking and non-smoking adolescents through a parametric t-test, it is possible to examine this assumption and draw conclusions based on the resulting p-value.
• Smoking and the Pandemic in West Virginia In this case, the use of the income variable is an additional facet of the hypothesis described, allowing us to evaluate whether there is any divergence in trends between the rich and the poor.
• Anti-Smoking Policy in Australia and the US The anti-smoking policy is to discourage people from smoking through various means and promotion of a healthy lifestyle, as well as to prevent the spread of the desire to smoke.
• Smoking Prevalence in Bankstown, Australia The secondary objective of the project was to gather and analyze a sufficient amount of auxiliary scholarly sources on smoking cessation initiatives and smoking prevalence in Australia.
• Drug Addiction in Teenagers: Smoking and Other Lifestyles In the first part of this assignment, the health problem of drug addiction was considered among teens and the most vulnerable group was established.
• Anti-Smoking Communication Campaign’s Analysis Defining the target audience for an anti-smoking campaign is complicated by the different layers of adherence to the issue of the general audience of young adults.
• Smoking as a Risk Factor for Lung Cancer Lung cancer is one of the most frequent types of the condition, and with the low recovery rates. If the problem is detected early and the malignant cells are contained to a small region, surgery […]
• Smoking Cessation Project Implementation In addition, the review will include the strengths and weaknesses of the evidence presented in the literature while identifying gaps and limitations.
• Smoking Cessation and Health Promotion Plan Patients addicted to tobacco are one of the major concerns of up-to-date medicine as constant nicotine intake leads to various disorders and worsens the health state and life quality of the users.
• Maternal and Infant Health: Smoking Prevention Strategies It is known that many women know the dangers of smoking when pregnant and they always try to quit smoking to protect the lives of themselves and the child.
• A Peer Intervention Program to Reduce Smoking Rates Among LGBTQ Therefore, the presumed results of the project are its introduction into the health care system, which will promote a healthy lifestyle and diminish the level of smoking among LGBTQ people in the SESLHD.
• Tackling Teenage Smoking in Community The study of the problem should be comprehensive and should not be limited by the medical aspect of the issue. The study of the psychological factor is aimed at identifying the behavioral characteristics of smoking […]
• Peer Pressure and Smoking Influence on Teenagers The study results indicate that teenagers understand the health and social implications of smoking, but peer pressure contributes to the activity’s uptake.
• Smoking: Benefits or Harms? Hundreds of smokers every day are looking for a way to get rid of the noose, which is a yoke around the neck, a cigarette.
• The Culture of Smoking Changed in Poland In the 1980-90s, Poland faced the challenge of being a country with the highest rates of smoking, associated lung cancer, and premature mortality in the world.
• The Stop Smoking Movement Analysis The paper discusses the ideology, objective, characteristics, context, special techniques, organization culture, target audience, media strategies, audience reaction, counter-propaganda and the effectiveness of the “Stop Smoking” Movement.”The Stop Smoking” campaign is a prevalent example of […]
• Smoking Health Problem Assessment The effects of smoking correlate starkly with the symptoms and diseases in the nursing practice, working as evidence of the smoking’s impact on human health.
• Integration of Smoking Cessation Into Daily Nursing Practice Generally, smoking cessation refers to a process structured to help a person to discontinue inhaling smoked substances. It can also be referred to as quitting smoking.
• E-Cigarettes and Smoking Cessation Many people argue that e-cigarettes do not produce secondhand smoke. They believe that the e-fluids contained in such cigarettes produce vapor and not smoke.
• Outdoor Smoking Ban in Public Areas of the Community These statistics have contributed to the widespread efforts to educate the public regarding the need to quit smoking. However, most of the chronic smokers ignore the ramifications of the habit despite the deterioration of their […]
• Nicotine Replacement Therapy for Adult Smokers With a Psychiatric Disorder The qualitative research methodology underlines the issue of the lack of relevant findings in the field of nicotine replacement therapy in people and the necessity of treatment, especially in the early stages of implementation.
• Smoking and Drinking: Age Factor in the US As smoking and drinking behavior were both strongly related to age, it could be the case that the observed relationship is due to the fact that older pupils were more likely to smoke and drink […]
• Poland’s Smoking Culture From Nursing Perspective Per Kinder, the nation’s status as one of Europe’s largest tobacco producers and the overall increase in smoking across the developing nations of Central and Eastern Europe caused its massive tobacco consumption issues.
• Smoking Cessation Clinic Analysis The main aim of this project is to establish a smoking cessation clinic that will guide smoker through the process of quitting smoking.
• Cigarette Smoking Among Teenagers in the Baltimore Community, Maryland The paper uses the Baltimore community in Maryland as the area to focus the event of creating awareness of cigarette smoking among the teens of this community.
• Advocating for Smoking Cessation: Health Professional Role Health professionals can contribute significantly to tobacco control in Australia and the health of the community by providing opportunities for smoking patients to quit smoking.
• Lifestyle Management While Quitting Smoking Realistically, not all of the set goals can be achieved; this is due to laxity in implementing them and the associated difficulty in letting go of the past lifestyle.
• Smoking in the Actuality The current use of aggressive marketing and advertising strategies has continued to support the smoking of e-cigarettes. The study has also indicated that “the use of such e-cigarettes may contribute to the normalization of smoking”.
• Analysis of the Family Smoking Prevention and Tobacco Control Act The law ensures that the FDA has the power to tackle issues of interest to the public such as the use of tobacco by minors.
• “50-Year Trends in Smoking-Related Mortality in the United States” by Thun et al. Thun is affiliated with the American Cancer Society, but his research interests cover several areas. Carter is affiliated with the American Cancer Society, Epidemiology Research Program.
• Pulmonology: Emphysema Caused by Smoking The further development of emphysema in CH can lead to such complications caused by described pathological processes as pneumothorax that is associated with the air surrounding the lungs.
• Smoking and Lung Cancer Among African Americans Primarily, the research paper provides insight on the significance of the issue to the African Americans and the community health nurses.
• Health Promotion and Smoking Cessation I will also complete a wide range of activities in an attempt to support the agency’s goals. As well, new studies will be conducted in order to support the proposed programs.
• Maternal Mental Health and Prenatal Smoking It was important to determine the variables that may lead to postpartum relapse or a relapse during the period of pregnancy. It is important to note that the findings are also consistent with the popular […]
• Nursing Interventions for Smoking Cessation For instance, the authors are able to recognize the need to classify the level of intensity in respect to the intervention that is employed by nurses towards smoking cessation.
• Smoking and Cancer in the United States In this research study, data on tobacco smoking and cancer prevalence in the United States was used to determine whether cancer in the United States is related to tobacco smoking tobacco.
• Marketing Plan: Creating a Smoking Cessation Program for Newton Healthcare Center The fourth objective is to integrate a smoking cessation program that covers the diagnosis of smoking, counseling of smokers, and patient care system to help the smokers quit their smoking habits. The comprehensive healthcare needs […]
• Smoking Among the Youth Population Between 12-25 Years I will use the theory to strengthen the group’s beliefs and ideas about smoking. I will inform the group about the relationship between smoking and human health.
• Risks of Smoking Cigarettes Among Preteens Despite the good news that the number of preteen smokers has been significantly reducing since the 1990s, there is still much to be done as the effects of smoking are increasingly building an unhealthy population […]
• Healthy People Program: Smoking Issue in Wisconsin That is why to respond to the program’s effective realization, it is important to discuss the particular features of the target population in the definite community of Wisconsin; to focus on the community-based response to […]
• Health Campaign: Smoking in the USA and How to Reduce It That is why, the government is oriented to complete such objectives associated with the tobacco use within the nation as the reduction of tobacco use by adults and adolescents, reduction of initiation of tobacco use […]
• Smoking Differentials Across Social Classes The author inferred her affirmations from the participant’s words and therefore came to the right conclusion; that low income workers had the least justification for smoking and therefore took on a passive approach to their […]
• Cigarette Smoking Side Effects Nicotine is a highly venomous and addictive substance absorbed through the mucous membrane in the mouth as well as alveoli in the lungs.
• Long-Term Effects of Smoking The difference between passive smoking and active smoking lies in the fact that, the former involves the exposure of people to environmental tobacco smoke while the latter involves people who smoke directly.
• Smoking Cessation Program Evaluation in Dubai The most important program of this campaign is the Quit and Win campaign, which is a unique idea, launched by the DHCC and is in the form of an open contest.
• Preterm Birth and Maternal Smoking in Pregnancy The major finding of the discussed research is that both preterm birth and maternal smoking during pregnancy contribute, although independently, to the aortic narrowing of adolescents.
• Enforcement of Michigan’s Non-Smoking Law This paper is aimed at identifying a plan and strategy for the enforcement of the Michigan non-smoking law that has recently been signed by the governor of this state.
• Smoking Cessation for Patients With Cardio Disorders It highlights the key role of nurses in the success of such programs and the importance of their awareness and initiative in determining prognosis.
• Legalizing Electronic Vaping as the Means of Curbing the Rates of Smoking However, due to significantly less harmful effects that vaping produces on health and physical development, I can be considered a legitimate solution to reducing the levels of smoking, which is why it needs to be […]
• Drinking, Smoking, and Violence in Queer Community Consequently, the inequality and discrimination against LGBTQ + students in high school harm their mental, emotional, and physical health due to the high level of stress and abuse of various substances that it causes.
• Self-Efficacy and Smoking Urges in Homeless Individuals Pinsker et al.point out that the levels of self-efficacy and the severity of smoking urges change significantly during the smoking cessation treatment.
• “Cigarette Smoking: An Overview” by Ellen Bailey and Nancy Sprague The authors of the article mentioned above have presented a fair argument about the effects of cigarette smoking and debate on banning the production and use of tobacco in America.
• “The Smoking Plant” Project: Artist Statement It is the case when the art is used to pass the important message to the observer. The live cigarette may symbolize the smokers while the plant is used to denote those who do not […]
• Dangers of Smoking While Pregnant In this respect, T-test results show that mean birthweight of baby of the non-smoking mother is 3647 grams, while the birthweight of smoking mother is 3373 grams. Results show that gestation value and smoking habit […]
• The Cultural Differences of the Tobacco Smoking The Middle East culture is connected to the hookah, the Native American cultures use pipes, and the Canadian culture is linked to cigarettes.
• Ban on Smoking in Enclosed Public Places in Scotland The theory of externality explains the benefit or cost incurred by a third party who was not a party to the reasoning behind the benefit or cost. This will also lead to offer of a […]
• How Smoking Cigarettes Effects Your Health Cigarette smoking largely aggravates the condition of the heart and the lung. In addition, the presence of nicotine makes the blood to be sticky and thick leading to damage to the lining of the blood […]
• Alcohol and Smoking Abuse: Negative Physical and Mental Effects The following is a range of effects of heavy alcohol intake as shown by Lacoste, they include: Neuropsychiatric or neurological impairment, cardiovascular, disease, liver disease, and neoplasm that is malevolent.
• Smoking Prohibition: Local Issues, Personal Views This is due to the weakening of blood vessels in the penis. For example, death rate due to smoking is higher in Kentucky than in other parts of the country.
• Smoking During Pregnancy Issues Three things to be learned from the research are the impact of smoking on a woman, possible dangers and complications and the importance of smoking cessation interventions.
• The Smoking Problem: Mortality, Control, and Prevention The article presents smoking as one of the central problems for many countries throughout the world; the most shocking are the figures related to smoking rate among students. Summary: The article is dedicated to the […]
• Tobacco Smoking: Bootleggers and Baptists Legislation or Regulation The issue is based on the fact that tobacco smoking also reduces the quality of life and ruins the body in numerous ways.
• Smoking: Causes and Effects Considering the peculiarities of a habit and of a disease, smoking can be considered as a habit rather than a disease.
• Smoking Behavior Under Clinical Observation The physiological aspect that influences smokers and is perceived as the immediate effect of smoking can be summarized as follows: Within ten seconds of the first inhalation, nicotine, a potent alkaloid, passes into the bloodstream, […]
• Smoking and Its Effect on the Brain Since the output of the brain is behavior and thoughts, dysfunction of the brain may result in highly complex behavioral symptoms. The work of neurons is to transmit information and coordinate messengers in the brain […]
• Smoking Causes and Plausible Arguments In writing on the cause and effect of smoking we will examine the issue from the point of view of temporal precedence, covariation of the cause and effect and the explanations in regard to no […]
• Post Smoking Cessation Weight Gain The aim of this paper is to present, in brief, the correlation between smoking cessation and weigh gain from biological and psychological viewpoints.
• Marketing a Smoking Cessation Program In the case of the smoking cessation program, the target group is made up of smokers who can be further subdivided into segments such as heavy, medium, and light smokers.
• Smoking Cessation for Ages 15-30 The Encyclopedia of Surgery defines the term “Smoking Cessation” as an effort to “quit smoking” or “withdrawal from smoking”. I aim to discuss the importance of the issue by highlighting the most recent statistics as […]
• Motivational Interviewing as a Smoking Cessation Intervention for Patients With Cancer The dependent variable is the cessation of smoking in 3 months of the interventions. The study is based on the author’s belief that cessation of smoking influences cancer-treated patients by improving the efficacy of treatment.
• Factors Affecting the Success in Quitting Smoking of Smokers in West Perth, WA Australia Causing a wide array of diseases, health smoking is the second cause of death in the world. In Australia, the problem of smoking is extremely burning due to the high rates of diseases and deaths […]
• Media Effects on Teen Smoking But that is not how an adult human brain works, let alone the young and impressionable minds of teenagers, usually the ads targeted at the youth always play upon elements that are familiar and appealing […]
• “Passive Smoking Greater Health Hazard: Nimhans” by Stephen David The article focuses on analyzing the findings of the study and compares them to the reactions to the ban on public smoking.
• Partnership in Working About Smoking and Tobacco Use The study related to smoking and tobacco use, which is one of the problematic areas in terms of the health of the population.
• Cigar Smoking and Relation to Disease The article “Effect of cigar smoking on the risk of cardiovascular disease, chronic obstructive pulmonary disease and cancer in Men” by Iribarren et al.is a longitudinal study of cigar smokers and the impact of cigar […]
• Quitting Smoking: Motivation and Brain As these are some of the observed motivations for smoking, quitting smoking is actually very easy in the sense that you just have to set your mind on quitting smoking.
• Health Effects of Tobacco Smoking in Hispanic Men The Health Effects of Tobacco Smoking can be attributed to active tobacco smoking rather than inhalation of tobacco smoke from environment and passive smoking.
• Smoking in Adolescents: A New Threat to the Society Of the newer concerns about the risks of smoking and the increase in its prevalence, the most disturbing is the increase in the incidences of smoking among the adolescents around the world.
• The Importance of Nurses in Smoking-Cessation Programs When a patient is admitted to the hospital, the nursing staff has the best opportunity to assist them in quitting in part because of the inability to smoke in the hospital combined with the educational […]
• New Jersey Legislation on Smoking The advantages and disadvantages of the legislation were discussed in this case because of the complexity of the topic at hand as well as the potential effects of the solution on the sphere of public […]
• Environmental Health: Tabaco Smoking and an Increased Concentration of Carbon Monoxide The small size of the town, which is around 225000 people, is one of the reasons for high statistics in diseases of heart rate.
• Advanced Pharmacology: Birth Control for Smokers The rationale for IUD is the possibility to control birth without the partner’s participation and the necessity to visit a doctor just once for the device to be implanted.
• Legislation Reform of Public Smoking Therefore, the benefit of the bill is that the health hazard will be decreased using banning smoking in public parks and beaches.
• Female Smokers Study: Inferential Statistics Article The article “Differential Effects of a Body Image Exposure Session on Smoking Urge between Physically Active and Sedentary Female Smokers” deepens the behavioral mechanisms that correlate urge to smoke, body image, and physical activity among […]
• Smoking Bans: Protecting the Public and the Children of Smokers The purpose of the article is to show why smoking bans aim at protecting the public and the children of smokers.
• Clinical Effects of Cigarette Smoking Smoking is a practice that should be avoided or controlled rigorously since it is a risk factor for diseases such as cancer, affects the health outcomes of direct and passive cigarette users, children, and pregnant […]
• Public Health and Smoking Prevention Smoking among adults over 18 years old is a public health issue that requires intervention due to statistical evidence of its effects over the past decades.
• Smoking in the US: Statistics and Healthcare Costs According to the Centers for Disease Control and Prevention, tobacco smoking is the greatest preventable cause of death in the US.
• Smoking Should Be Banned Internationally The questions refer to the knowledge concerning the consequences of smoking and the opinions on smoking bans. 80 % of respondents agree that smoking is among the leading causes of death and 63, 3 % […]
• Microeconomics: Cigarette Taxes and Public Smoking Ban The problem of passive smoking will be minimized when the number of smokers decreases. It is agreeable that the meager incomes of such families will be used to purchase cigarettes.
• Alcohol and Smoking Impact on Cancer Risk The research question is to determine the quantity of the impact that different levels of alcohol ingestion combined with smoking behavioral patterns make on men and women in terms of the risks of cancer.
• Teenagers Motivated to Smoking While the rest of the factors also matter much in the process of shaping the habit of smoking, it is the necessity to mimic the company members, the leader, or any other authority that defines […]
• Indoor Smoking Restriction Effects at the Workplace Regrettably, they have neglected research on the effect of the legislation on the employees and employers. In this research, the target population will be the employees and employers of various companies.
• Hypnotherapy Session for Smoking Cessation When I reached the age of sixty, I realized that I no longer wanted to be a smoker who was unable to take control of one’s lifestyle.
• Stopping Tobacco Smoking: Lifestyle Management Plan In addition, to set objective goals, I have learned that undertaking my plan with reference to the modifying behaviour is essential for the achievement of the intended goals. The main intention of the plan is […]
• Smoking Epidemiology Among High School Students In this way, with the help of a cross-sectional study, professionals can minimalize the risk of students being afraid to reveal the fact that they smoke. In this way, the number of students who smoke […]
• Social Marketing: The Truth Anti-Smoking Campaign The agreement of November 1998 between 46 states, five territories of the United States, the District of Columbia, and representatives of the tobacco industry gave start to the introduction of the Truth campaign.
• Vancouver Coastal Health Smoking Cessation Program The present paper provides an evaluation of the Vancouver Coastal Health smoking cessation program from the viewpoint of the social cognitive theory and the theory of planned behavior.
• Smoking Experience and Hidden Dangers When my best college friend Jane started smoking, my eyes opened on the complex nature of the problem and on the multiple negative effects of smoking both on the smoker and on the surrounding society.
• South Illinois University’s Smoking Ban Benefits The purpose of this letter is to assess the possible benefits of the plan and provide an analysis of the costs and consequences of the smoking ban introduction.
• Smoking Cessation in Patients With COPD The strategy of assessing these papers to determine their usefulness in EBP should include these characteristics, the overall quality of the findings, and their applicability in a particular situation. The following article is a study […]
• Smoking Bans: Preventive Measures There have been several public smoking bans that have proved to be promising since the issue of smoking prohibits smoking in all public places. This means it is a way of reducing the exposure to […]
• Ban Smoking Near the Child: Issues of Morality The decision to ban smoking near the child on father’s request is one of the demonstrative examples. The father’s appeal to the Supreme Court of California with the requirement to prohibit his ex-wife from smoking […]
• The Smoking Ban: Arguments Comparison The first argument against banning smoking employs the idea that smoking in specially designated areas cannot do harm to the health of non-smokers as the latter are supposed to avoid these areas.
• Smoking Cessation and Patient Education in Nursing Pack-years are the concept that is used to determine the health risks of a smoking patient. The most important step in the management plan is to determine a date when the man should quit smoking.
• Philip Morris Company’s Smoking Prevention Activity Philip Morris admits the existence of scientific proof that smoking leads to lung cancer in addition to other severe illnesses even after years of disputing such findings from health professionals.
• Tobacco Smoking and Its Dangers Sufficient evidence also indicates that smoking is correlated with alcohol use and that it is capable of affecting one’s mental state to the point of heightening the risks of development of disorders.
• Virginia Slims’ Impact on Female Smokers’ Number Considering this, through the investigation of Philip Morris’ mission which it pursued during the launch of the Virginia Slims campaign in 1968-1970 and the main regulatory actions undertaken by the Congress during this period, the […]
• Cigarette Smoking and Parkinson’s Disease Risk Therefore, given the knowledge that cigarette smoking protects against the disease, it is necessary to determine the validity of these observations by finding the precise relationship between nicotine and PD.
• Tuberculosis Statistics Among Cigarette Smokers The proposal outlines the statistical applications of one-way ANOVA, the study participants, the variables, study methods, expected results and biases, and the practical significance of the expected results.
• Smoking Ban and UK’s Beer Industry However, there is an intricate type of relationship between the UK beer sector, the smoking ban, and the authorities that one can only understand by going through the study in detail The history of smoking […]
• Status of Smoking around the World Economic factors and level of education have contributed a lot to the shift of balance in the status of smoking in the world.
• Redwood Associates Company’s Smoking Ethical Issues Although employees are expected to know what morally they are supposed to undertake at their work place, it is the responsibility of the management and generally the Redwood’s hiring authority to give direction to its […]
• Smokers’ Campaign: Finding a Home for Ciggy Butts When carrying out the campaign, it is important to know what the situation on the ground is to be able to address the root cause of the problem facing the population.
• Mobile Applications to Quit Smoking A critical insight that can be gleaned from the said report is that one of the major factors linked to failure is the fact that smokers were unable to quit the habit on their own […]
• Behavior Modification Technique: Smoking Cessation Some of its advantages include: its mode of application is in a way similar to the act of smoking and it has very few side effects.
• Quitting Smoking: Strategies and Consequences Thus, for the world to realize a common positive improvement in population health, people must know the consequences of smoking not only for the smoker but also the society. The first step towards quitting smoking […]
• Effects of Thought Suppression on Smoking Behavior In the article under analysis called I suppress, Therefore I smoke: Effects of Thought Suppression on Smoking Behavior, the authors dedicate their study to the evaluation of human behavior as well as the influence of […]
• Suppressing Smoking Behavior and Its Effects The researchers observed that during the first and the second weeks of the suppressed behavior, the participants successfully managed to reduce their intake of cigarettes.
• Smoking Cessation Methods These methods are a part of NRT or nicotine replacement therapy, they work according to the principle of providing the smoker with small portions of nicotine to minimize the addiction gradually and at the same […]
• Understanding Advertising: Second-Hand Smoking
• People Should Quit Smoking
• Importance of Quitting Smoking
• Cigarette Smoking in Public Places
• Ban of Tobacco Smoking in Jamaica
• Anti-Smoking Campaign in Canada
• Electronic Cigarettes: Could They Help University Students Give Smoking Up?
• Psychosocial Smoking Rehabilitation
• The Program on Smoking Cessation for Employees
• Tips From Former Smokers (Campaign)
• Combating Smoking: Taxation Policies vs. Education Policies
• The Program to Quit Smoking
• Smoking Culture in Society
• Possible Smoking Policies in Florida
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IvyPanda. (2024, February 29). 235 Smoking Essay Topics & Examples. https://ivypanda.com/essays/topic/smoking-essay-examples/

"235 Smoking Essay Topics & Examples." IvyPanda , 29 Feb. 2024, ivypanda.com/essays/topic/smoking-essay-examples/.

IvyPanda . (2024) '235 Smoking Essay Topics & Examples'. 29 February.

IvyPanda . 2024. "235 Smoking Essay Topics & Examples." February 29, 2024. https://ivypanda.com/essays/topic/smoking-essay-examples/.

1. IvyPanda . "235 Smoking Essay Topics & Examples." February 29, 2024. https://ivypanda.com/essays/topic/smoking-essay-examples/.

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IvyPanda . "235 Smoking Essay Topics & Examples." February 29, 2024. https://ivypanda.com/essays/topic/smoking-essay-examples/.

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Declaration of interests, nicotine & tobacco qualitative research.

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Amy K Ferketich, Nicotine & Tobacco Qualitative Research, Nicotine & Tobacco Research , Volume 26, Issue 1, January 2024, Page 1, https://doi.org/10.1093/ntr/ntad200

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The January 2024 issue of Nicotine & Tobacco Research is somewhat unique, in that nearly half of the manuscripts feature qualitative research methods. Recognizing that not all readers may be familiar with these approaches, this editorial presents an overview of how qualitative research can advance the field of nicotine and tobacco research, using six papers in this issue to illustrate key points.

Qualitative research is often contrasted with quantitative research: whereas quantitative methods involve testing a hypothesis or describing an issue with numeric data, qualitative methods involve exploring themes that emerge through textual data. While there are multiple approaches to qualitative data collection (eg, ethnographic observation, document, or content analysis), the authors of the qualitative papers in this issue used focus group and semi-structured interviews to collect qualitative data, which were then analyzed by coding passages of text into major themes.

Qualitative research methods are used to advance nicotine and tobacco research in several ways. First, qualitative research is often a first step to understanding an issue when little has been published on the topic. Findings can then be used to inform the development of interventions, educational programs, or policies. Four of the papers in this issue fall into this category. Cooley and colleagues completed semi-structured interviews with American Indian adults to explore how a smoking cessation smartphone app could be aligned to meet the cultural needs of the population. The second paper, by Rasool and colleagues, reported findings from semi-structured interviews conducted with dental providers and patients to understand how to support smokeless tobacco cessation programs in dental practices in Pakistan. Guri-Scherman and colleagues conducted semi-structured interviews with expectant Israeli fathers who smoked to examine barriers and facilitators to refraining from smoking in the home or car. The fourth paper, by Sumodhee and colleagues, reported the results from semi-structured interviews conducted with tobacco treatment practitioners in the United Kingdom to explore how they address the dual use of tobacco and cannabis when assisting with cessation. Coincidentally, these latter three papers incorporated the Capability, Opportunity, and Motivation (COM-B) model to identify major themes. 1 This framework is useful for identifying barriers and enablers to behavior change. All four of these papers conclude with a discussion about the implications of the work, which will broadly inform interventions (for dental providers, expectant fathers, and smartphone apps) or training programs (for cessation counselors).

Second, qualitative research methods can be used to understand the results from complex or multicomponent behavior intervention studies. In this manner, qualitative research can help researchers move beyond addressing “what intervention components work?” to “for whom do intervention components work, how, and why?” and “how can intervention and interventions components be optimized or improved?.” The paper by Nadkarni and colleagues used semi-structured interviews as part of a process evaluation to examine the feasibility and acceptability of a tobacco cessation intervention in India. All participants who completed the text messaging cessation intervention were invited to follow-up interviews, which provided the investigators with detailed information about how to improve the effectiveness of the text messaging program. Such information is crucial for the widespread adoption of this type of program.

Third, qualitative research methods are used to understand consumer responses to tobacco public education or polity messages about tobacco products or policies. This was the goal of the study by Ntansah and colleagues, who examined how people who use little cigars and cigarillos responded to policy messages on FDA’s proposed rule to reduce nicotine content in cigarettes and other combusted tobacco products. Such studies can help researchers and policy makers understand cultural and behavioral factors that might be influencing consumers’ (lack of) support for a specific policy. They may also help identify message topics or themes that may be leveraged to increase consumer buy-in of tobacco public education or policy messages.

These six papers are excellent examples of how focus groups and semi-structured interviews are used to gather information on new topics, tailor existing interventions, and explore what worked and what needs to be refined to improve a program. Future issues will continue to feature papers that apply qualitative methods to answer important nicotine and tobacco research questions.

None declared.

Michie S , van Stralen MM , West R. The behaviour change wheel: a new method for characterising and designing behaviour change interventions . Implement Sci . 2011 ; 6 : 42 – 42 . doi: 10.1186/1748-5908-6-42 .

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If you plan to study tobacco products that do not have marketing authorization or that do not comply with an applicable tobacco product standard, you may submit your proposed protocol to FDA for review. FDA intends to evaluate specific uses of investigational tobacco products on a case-by-case basis according to potential human subject protection concerns or other impacts on public health.

Using Investigational Tobacco Products

Investigators who are designing a protocol involving administration of a tobacco product to humans should review the information below regarding the need for submitting their protocol to Food and Drug Administration (FDA) Center for Tobacco Products (CTP) for review.  

Investigators are encouraged to work with tobacco product manufacturers to ensure availability of products to complete planned studies. FDA evaluates the specific uses of investigational tobacco products (ITPs) on a case-by-case basis according to potential human subject protection concerns or other impacts on public health. Generally, submission of protocols by industry and academic researchers for FDA review is a voluntary process; however, FDA will review all protocols submitted. FDA recommends submission of proposed use of ITPs to FDA for review only if the study design is more likely to raise concerns about human subject protection, public health, or both. As discussed by FDA in its February 2019 guidance, Use of Investigational Tobacco Products , factors to consider would be studies that plan to enroll vulnerable populations, particularly those < 21 years old, studies that involve significant increases over the participants’ usual exposure to nicotine, studies that modify the tobacco product in a manner different from that described by the manufacturer or study of a novel product for which there is limited experience and knowledge.  

For all clinical studies involving use of ITPs, we recommend that you notify FDA, all participating clinical investigators, and any committee or group formally designated to oversee the study of any serious or unexpected adverse experience associated with the tobacco product you are investigating within a few weeks after initial notification, and that you supply FDA with a completed case report form for the adverse experience. We encourage the reporting of adverse experiences associated with a clinical investigation of an investigational tobacco product to FDA through the FDACTP Safety Reporting Portal for Researchers.

FDA is committed to furthering scientific research on tobacco products and has a major investment in regulatory science. If you plan to study tobacco products that do not have marketing authorization or that do not comply with an applicable tobacco product standard, you may submit your proposed protocol to FDA for review based on the criteria described above. FDA will review any protocols submitted and intends to evaluate specific uses of investigational tobacco products on a case-by-case basis according to potential human subject protection concerns or other impacts on public health. Generally, FDA does not recommend that investigators correspond with us about the use of investigational tobacco products in nonclinical studies as these are not ordinarily reviewed. You may refer to the draft guidance, Use of Investigational Tobacco Products , for more information regarding how to submit your proposed use of an investigational tobacco product and how FDA intends to make enforcement decisions regarding the use of investigational tobacco products.  

FDA understands that investigators may choose to obtain tobacco products directly from a tobacco product manufacturer with the sole intent to use the products for research investigations without commercializing the products. In such cases, FDA recommends that investigators add language to all product labels to indicate that these products are limited to investigational use, that study participants be instructed that the products may not be further distributed, and that study protocols include a plan to collect and account for all investigational tobacco products after the study has concluded. 

If there are additional questions, investigators should reach out to the FDA CTP at: [email protected]. 

The email should:

• Clearly and uniquely identify the product(s) you wish to study by brand and sub-brand—including the type or category of tobacco product (e.g., cigarette, smokeless tobacco, cigar, electronic nicotine delivery systems [ENDS], waterpipe tobacco) and subcategory (e.g., closed or open e-cigarette, closed or open e-liquid).
• Provide additional available information such as packaging type, package quantity, and/or characterizing flavor that may help answer the specific question(s)

Once the FDA CTP receives the email, they will make every effort to respond via email within 2weeks. 

Note that the FDA CTP intends to respond to investigators within 60 days of receipt of protocols for review. Investigators should receive acknowledgement of the submission with the name and contact information for the assigned Regulatory Health Project Manager (RHPM). If investigators do not receive a response within 60 days, they should contact the RHPM. Investigators may also contact their NIH Program Officer to discuss additional steps/actions.

If the marketed products will be used with investigator-manipulated modification(s), then the investigator should submit an ITP request. In addition to the protocol and other information described in the FDA Draft Guidance, the ITP request should also include: 

• A description of the planned modification(s).
• A rationale for how these modification(s) support the study design and do not increase risk to human participants.

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The global health and economic burden of tobacco use is enormous and is increasingly borne by low- and middle-income countries.” (Major Conclusion #1, Monograph 21)

The Tobacco Control Research Branch (TCRB) supports and conducts international tobacco control research on a variety of topics, such as understanding the use and characteristics of non-cigarette tobacco products, evaluating low-cost tobacco cessation interventions, and assessing the impact of tobacco control policies in distinct environments. TCRB also collaborates with a range of partners in building the evidence base needed to support global tobacco control and prevention.

Tobacco use is the leading preventable cause of cancer mortality worldwide, causing 25% of global cancer deaths and about 70% of global lung cancer deaths. WHO estimates that 20.2% of the world’s population aged ≥ 15 years were current smokers in 2015, and the prevalence of tobacco smoking has decreased steadily since the beginning of the twenty-first century. However, the burden of tobacco use is increasingly borne by low- and middle-income countries (LMICs), where over 80% of the world’s tobacco users reside.

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• Leadership Summit on Tobacco Control , virtual event from May 6-7, 2021, hosted by the World Conference on Tobacco or Health

Since 2000, NCI has supported tobacco control research grants in more than 50 countries around the world. Grants are awarded either to U.S. institutions collaborating with foreign partners or directly to a foreign institution.

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The following is a selected list of tobacco-related funding announcements open to foreign institutions. A complete list of current NCI Behavioral Research Program funding announcements can be found here .

Note : It is strongly recommended to speak with the Program Contact listed on the announcement to determine eligibility.

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Smokefree.gov (NCI) The Smokefree.gov Initiative offers free, evidence-based smoking cessation information and on-demand support to smokers who want to quit through web, social media, text-messaging programs and smartphone apps. The website Smokefree Español ( espanol.smokefree.gov ) is a Spanish-language resource for Hispanic Americans who want to quit smoking.

NCI Center for Global Health NCI established the Center for Global Health (CGH) in 2011 to help reduce the global burden of cancer by supporting cancer control capacity-building and planning, as well as cancer research and research networks in low- and middle-income countries (LMICs).

Institut National du Cancer (INCa) NCI has longstanding collaborations in cancer research and cancer control planning with the Institut National du Cancer of France (INCa). NCI and INCa are considering ways to identify opportunities for improved collaboration and coordination of tobacco control research between NCI and INCa and to encourage connections between US and French tobacco control researchers.

Fogarty International Center The Fogarty International Center is dedicated to advancing the mission of the National Institutes of Health (NIH) by supporting and facilitating global health research conducted by U.S. and international investigators, building partnerships between health research institutions in the U.S. and abroad, and training the next generation of scientists to address global health needs.

• Smokeless tobacco Olympics: the US Tobacco Company, the IOC and the 1980 Lake Placid Olympic Winter Games. Parascandola M. Tobacco Control, 2020. DOI: 10.1136/tobaccocontrol-2019-055333  
• What is Accounting for the Rapid Decline in Cigarette Sales in Japan? Cummings KM, Nahhas GJ, Sweanor DT. International Journal of Environmental Research and Public Health, 2020. DOI: 10.3390/ijerph17103570  
• Changes in Smoking and Vaping over 18 Months among Smokers and Recent Ex-Smokers: Longitudinal Findings from the 2016 and 2018 ITC Four Country Smoking and Vaping Surveys. Gravely S, Meng G, Cummings KM, Hyland A, Borland R, Hammond D, O'Connor RJ, Goniewicz ML, Kasza KA, McNeill A, Thompson ME, Hitchman SC, Levy DT, Thrasher JF, Quah ACK, Martin N, Ouimet J, Boudreau C, Fong GT. International Journal of Environmental Research and Public Health, 2020. DOI: 10.3390/ijerph17197084.  
• Economic burden of lung cancer attributable to smoking in China in 2015. Shi JF, Liu CC, Ren JS, Parascandola M, Zheng R, Tang W, Huang HY, Li F, Wang L, Su K, Li N, Zhang K, Chen WQ, Wu N, Zou XN, Liu GX, Dai M. Tobacco Control, 2020. DOI: 10.1136/tobaccocontrol-2018-054767.  
• Smoking and HIV in Sub-Saharan Africa: A 25-Country Analysis of the Demographic Health Surveys. Murphy JD, Liu B, Parascandola M. Nicotine & Tobacco Research. 2019. DOI: 10.1093/ntr/nty176.  
• JUUL from the USA to Indonesia: implications for expansion to LMICs. Orlan EN, Parascandola M, Grana R. Tobacco Control, 2019. DOI: 10.1136/tobaccocontrol-2019-054979.  
• Secondhand smoke exposure during pregnancy: a cross-sectional analysis of data from Demographic and Health Survey from 30 low-income and middle-income countries. Reece S, Morgan C, Parascandola M, Siddiqi K. Tobacco Control, 2019 Jul. DOI: 10.1136/tobaccocontrol-2018-054288.  
• Strengthening Policy-Relevant Tobacco Research Capacity in Low- and Middle-Income Countries: Challenges, Opportunities, and Lessons Learned. Berg CJ, Thrasher JF, Barnoya J, Cohen JE, Maziak W, Lando H, Drope J, Mejia R, Foley K, Nakkash R, Fong GT, Kupfer LE, Sturke R, Parascandola M. Nicotine & Tobacco Research, 2019. DOI: 10.1093/ntr/nty117.  
• IQOS point-of-sale marketing strategies in Israel: a pilot study. Bar-Zeev Y, Levine H, Rubinstein G, Khateb I, Berg CJ. Israel Journal of Health Policy Research, 2019. DOI: 10.1186/s13584-018-0277-1.  
• NCI Tobacco Control Monograph 21: The Economics of Tobacco and Tobacco Control
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• Medscape caves in on...

Medscape caves in on courses funded by tobacco giant Philip Morris, while medics fear global push into medical education

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Stop tobacco industry sponsorship of continuing medical education

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Clinic demonstrations, podcasts, and TV shows: Hristio Boytchev reveals how an ambitious deal between a leading medical education provider and the tobacco industry collapsed this week

The medical education provider Medscape has bowed to pressure and agreed to permanently remove a series of accredited medical education courses on smoking cessation funded by the tobacco industry giant Philip Morris International (PMI), The BMJ and The Examination have found. Medscape has acknowledged its “misjudgment” in a letter to complainants and says that it will not accept funding from any organisation affiliated with the tobacco industry in the future.

The move comes after a BMJ investigation revealed the PMI deal and widespread protests among doctors and academics in reaction to the partnership. Critics had said that the content tended to portray non-cigarette nicotine products as relatively harmless, therefore aligning with the commercial interests of PMI, which also sells e-cigarettes, nicotine pouches, and snus. 1

An internal Medscape document seen by The BMJ and The Examination also hints at the true scale of the multimillion dollar deal between PMI and Medscape. 2 Medscape had planned to deliver 13 programmes under the deal—called the PMI Curriculum, according to the internal document. It had also planned podcasts and a “TV-like series.”

Other PMI funded programmes with different continuing medical education (CME) providers have also emerged, including in Saudi Arabia and South Africa, where a former World Medical Association president featured as a speaker. This apparent global push by the tobacco giant into certified medical education has been met with alarm and calls for certification bodies to issue a ban.

In response to the criticism a spokesperson for PMI told The BMJ , “Health agencies around the world have recognised the beneficial role that smoke-free products can play to improve public health. We are concerned that known special interest groups are actively blocking medical education that the US Food and Drug Administration and medical community have determined are needed. These actions stand to prolong use and possibly increase consumption of combustible cigarettes—the most harmful form of nicotine use.”

But Tim McAfee, professor (adjunct) at the Department of Social and Behavioral Sciences at the University of California, San Francisco, who is former director of the Centers for Disease Control and Prevention’s Office on Smoking and Health, called PMI’s partnership with Medscape “the ultimate example of the fox not only signing up to guard the hen house but offering to sit on the eggs.” He added, “It is a perversion of ethics surrounding continuing medical education to allow the very companies that caused and profit from the continuing epidemic of tobacco related death and disease to be involved in any way.”

Pamela Ling, director of the Center for Tobacco Control Research and Education at the University of California, San Francisco, applauded Medscape for its U turn, adding that tobacco companies had a long history of using social scientists and other expert voices to normalise tobacco and nicotine use and to downplay the harms. 3 “However, the entry into the world of medical education is particularly audacious,” said Ling. “In the past, medical education sponsored by the manufacturers of the leading preventable cause of death would have been ridiculous. As tobacco companies remake their image into pharmaceutical-like nicotine purveyors, it appears they have been emboldened to enter this arena.” 4 5

Nick Hopkinson, professor of respiratory medicine at Imperial College London, commented, “It’s astonishing, given the strict ethical codes that exist to exclude the tobacco industry, that Medscape thought that it would go unnoticed or be tolerated. They will need to undertake a thorough assessment as to how this appalling decision was made and ensure that policies and processes are in place to ensure that it cannot happen again.”

The BMJ contacted three Medscape employees, who reported widespread internal disappointment with the company’s decision to produce the courses. One said, “The programmes, and the way they were developed, distort scientific knowledge, crossing an ethical line that is made worse by the common knowledge of the tobacco industry’s role in hiding the dangers of its toxic products in the pursuit of profit. It’s also a departure from Medscape’s practice of presenting balanced, accurate, vetted content conveyed by expert faculty without ties to any related industry. ”

The employees said that there had been no official internal communication on either the PMI deal or Medscape’s decision to drop the partnership in the face of protests.

An email sent by the general manager of Medscape Education to National Jewish Health, a leading US respiratory hospital, said that an “extensive review” had found that using PMI as a funder was in “full compliance” with standards and that the funder had no input on the planning of the series. The email, seen by The BMJ , continued: “Upon reflection, we acknowledge that the use of this funder was a misjudgment that was out of character for Medscape Education and that doing so may have disappointed our members.”

“We have permanently removed the ‘Smoking Cessation’ educational series from Medscape Education’s offerings,” the manager said in the email, adding that the organisation had “established a policy that Medscape Education will not accept funding from any organization affiliated with the tobacco industry.”

Medscape did not reply to multiple efforts by The BMJ to reach out for comment and did not confirm the course change. The BMJ verified the authenticity of the email and could not find any of the courses on Medscape’s website.

Call for global ban

Medscape’s backpedalling was welcomed, but critics demanded that tobacco industry funded medical education should not be accredited by the responsible bodies in the first place.

“I am very pleased that Medscape is doing the right thing,” Anthony Gerber, director of pulmonary research at National Jewish Health, told The BMJ . But he added that there remained a significant problem with accreditation bodies allowing programmes to be sponsored by tobacco, “and the medical community needs to exert pressure to reverse this policy. If PMI and others really want to help undo the incomprehensible damage they have done and continue to do, there are ways to acceptably donate money—but sponsoring CME with your name attached as a ‘whitewashing’ effort is not one of them.”

The BMJ contacted two certification bodies, the Accreditation Council for Continuing Medical Education (ACCME) and the American Board of Internal Medicine (ABIM), to ask whether they would consider banning tobacco funded courses that count towards education credits. Medscape is “accredited with commendation” by ACCME. The certification body was conducting a formal inquiry with Medscape, it told The BMJ , adding that it could not comment on details or possible considerations of a general ban. ABIM allows ACCME accredited courses to be counted towards its Maintenance of Certification programme, through which physicians need to earn points every five years to remain certified. The organisation deferred responsibility for setting standards to ACCME.

Ling commented, “If the programme was compliant with ACCME standards, then the standards need to be strengthened to ensure they don’t allow merchants of death to educate doctors.”

Ambitious plans

An internal Medscape document seen by The BMJ and The Examination hinted at the scope and aim of the programme. The document, titled “Clinical Curriculum for PMI” and “Towards a Smoke-Free Future,” mentioned “A PMI educational destination designed to deliver impact” with “13 total program deliverables to launch from early 2024/mid 2024,” to include over 65 000 “anticipated online learners by end of 2024/mid 2025.”

It added, “The PMI curriculum will deliver impact to the largest community of physicians and HCPs [healthcare professionals] in the US—the Medscape Membership Network.” It gave the cost of the programme as $2 878 500 (£2.3m; €2.7m) and mentioned a cost per learner of $44.

“The PMI Curriculum for HCPs comprises of 13 educational activities addressing 6 key topics,” the document said. These activities included “6 foundational curbside consult modules + 6 podcasts,” a “TV-like series featuring a professional host and expert specialists in their real- world practice settings” with six episodes, and an activity called “Medscape clinic + podcast,” featuring “3 clinic simulation vignettes with clinician and patient actors interspersed with 3 expert commentaries on each encounter.” Only five of these activities had apparently been launched.

Ling commented, “While Medscape stated that the funder has had no input in the planning of the series, calling the series ‘The PMI Curriculum’ and ‘A PMI Educational Destination’ in the document implies that the curriculum is PMI’s.”

Robert Jackler, Sewall professor emeritus at the Stanford University School of Medicine, added, “Medscape’s subtitle for the series—‘Towards a Smoke-Free Future’—is a heavily promoted PMI corporate slogan. As there are many accredited CME providers who may be tempted by PMI’s financially generous proposals, accreditation bodies which oversee providers need to join Medscape and send a clear message that the tobacco industry has no business funding CME.

“PMI’s engagement of Medscape was not an isolated occurrence but rather is part of a global campaign.”

Philip Morris and CME in South Africa

In South Africa, the Alliance of South Africa Independent Practitioners Associations (ASAIPA)—a coalition of health practitioner associations and a medical education provider—has hosted seminars sponsored by Philip Morris South Africa. The course has triggered a complaint from the National Council Against Smoking to the doctors’ regulator, the Health Professions Council of South Africa (HPCSA), expressing “deep concerns.”

The first seminar, in November 2023, was held around the same time as parliamentary hearings were taking place around the country on a bill that would regulate electronic nicotine delivery systems (ENDS) as tobacco products, the complaint noted. “Accepting funding of CPD from a tobacco company is unethical and stands contrary to . . . the World Health Organisation’s Framework Convention on Tobacco Control,” said the HPCSA complaint. The seminar was delivered by an advocate for ENDS, the National Council Against Smoking noted. The speaker, Vivian Manyeki, had not published any peer reviewed research on the topics of harm reduction or tobacco cessation, it said, noting that “she is allied with the African Harm Reduction Alliance which is openly promoting ENDS (electronic nicotine delivery systems) as a public health measure,” citing media appearances.

Shortly after the National Council Against Smoking issued its complaint to HPCSA it noticed the announcement of a second seminar for April 2024, this time with Kgosi Letlape as speaker. 6 Letlape, a past president of HPCSA, is an influential South African ophthalmologist who was also president of the World Medical Association and chair of the South African Medical Association, who also has tobacco industry ties demonstrated by speaking at tobacco industry events. Letlape is also a cofounder of the African Harm Reduction Alliance.

“I did not even know who Philip Morris is”

An ASAIPA spokesperson forwarded a general statement saying, “At ASAIPA, our mission is clear: to serve as a tireless advocate for the public good.” ASAIPA’s chair, George Aldrich, responded in an email apparently not meant to be seen by The BMJ that, although he “did not attend this CPD to know what was presented,” it was “by a doctor for doctors” and “did not promote or advertise any tobacco products.” Aldrich added, “We did not know the speaker, but our doctors are professional and will not be influenced that easily. Nothing in the invite was related to smoking or vaping and was a totally independent subject. The only issue is the sponsor of this CPD, but I did not even know who Philip Morris is.”

HPCSA, Manyeki, and Letlape did not reply to The BMJ ’s request for comment.

Emerging Market Healthcare, which describes itself as “a provider & patient initiative within the base of 200 Black doctors from disadvantaged areas of the Western Cape,” had already announced similar courses in 2022, which had also prompted a complaint by the National Council Against Smoking to the company.

The complaint said, “We are gravely concerned that the facilitator for the EMC [Emerging Market Healthcare] masterclass course is Prof Praneet Valodia, who serves as a consultant to Philip Morris, South Africa (PMSA), a subsidiary of Philip Morris International (PMI). 7 PMI—which is the largest cigarette manufacturer (and part of the tobacco industry), has a history of funding researchers, medical professionals and setting up front groups in ways meant to intentionally confuse the public and advance their own interests.” The National Council Against Smoking urged Emerging Market Healthcare to reconsider its decision to affiliate or collaborate Valodia and to discontinue the second leg of the masterclass course.

The second course of the series was then cancelled, said Olalekan Ayo-Yusuf, president of the National Council Against Smoking and head of the School of Health Systems and Public Health at University of Pretoria. But apparently PMI quickly found another supplier, he told The BMJ . “I was surprised that they’ve become so emboldened,” Ayo-Yusuf said of PMI’s move into medical education. “Tobacco control was so strong in South Africa for many years.”

Leslie London, chair of public health medicine at the University of Cape Town, said, “Industry should be held accountable and should put money into health promotion, but it should be put into an independent foundation which they do not control.”

Valodia replied, “I am an academic and scientist and deliver presentations on independent, evidence based science. I only respond to scientific discussions and am not involved in debates relating to funding by tobacco companies or anything else unrelated to the science and innovation. My only interest is to assist smokers and hence I do not think that it is appropriate for me to respond.”

Emerging Market Healthcare did not reply to The BMJ ’s request for comment.

Gulf countries

In Saudi Arabia the educational provider Middle East Medical Portal was providing courses until last year on harm reduction in healthcare and the impact of smoking on public health (1 CME point). The course was advertised as a “CME webinar for healthcare/research professionals in the Gulf Council Countries” 8 —Saudi Arabia, Kuwait, Bahrain, the United Arab Emirates, Oman, and Qatar.

The website stated, “This educational CME is sponsored by Philip Morris Management Services (Middle East) Limited.” The course consisted of a webinar led by the speaker Tara Rampal, “a consultant anaesthetist and public health expert in the NHS and CEO of Quest Prehabilitation,” the announcement said. An earlier version of the course from 2022 said that it was sponsored by “PMI Science” and featured a prominent PMI logo. 9

The mention of the course was deleted after The BMJ reached out. Nathan Nagel, chief executive of Middle East Medical Portal, told The BMJ , “We are a tiny, two person company, and we missed deleting old material that shouldn’t have been on the site. We are overwhelmed with just trying to stay afloat in business. We stopped working with PMI in 2023.”

Tara Rampal did not reply to The BMJ ’s request for comment.

Financial disclosures at Medscape

The now withdrawn Medscape series funded by PMI also featured a speaker with financial ties to industry. Brad Rodu, a professor of medicine and holder of a chair endowed by the US Smokeless Tobacco Company and Swedish Match North America (now owned by PMI), was presented on Medscape’s site as having “no relevant financial relationships.” When questioned by The BMJ , Medscape at first said that according to the ACCME standards it didn’t need to disclose financial relationships if they didn’t concern a healthcare company or were older than two years. 1 However, The BMJ has found that in addition to the endowed professorship, Rodu acted as a speaker at the industry’s Global Tobacco and Nicotine Forum in 2022, within the two year window mentioned by Medscape. 10

Rodu replied that he wasn’t paid for his presentation at the 2022 forum. He said, “For the past 30 years my policy has been to present my work to any interested audience. If I am invited to participate and/or make a presentation at a meeting, I ask for reimbursement for travel expenses in order to preserve scarce university resources.”

This feature has been funded by the BMJ Investigations Unit. For details see bmj.com/investigations

Competing interests: I have read and understood BMJ policy on declaration of interests and have no interests to declare.

Provenance and peer review: Commissioned; externally peer reviewed.

• ↵ Chapman M. Medscape severs ties with tobacco industry after backlash over $3M Philip Morris International deal. Examination 2024. https://www.theexamination.org/articles/medscape-severs-ties-with-tobacco-industry-after-backlash-over-3m-philip-morris-international-deal
• Landman A ,
• Cortese DK ,
• Fugh-Berman A
• Hendlin YH ,
• ↵ Alliance of South Africa Independent Practitioners Associations. Webinar alert: Philip Morris CME webinar—18 April 2024. https://s-it.cmail20.com/t/d-e-eyujjll-tlltdujidk-k
• ↵ Middle East Medical Portal. Harm reduction in healthcare/smoking and the impact on public health (1 CME Point). 2022. https://web.archive.org/web/20240416103416/https://www.middleeastmedicalportal.com/webinars/harm-reduction-in-healthcare-and-the-impact-on-public-health/
• ↵ Middle East Medical Portal. 1 CME: Harm reduction in healthcare and the impact on public health. 2022. Available at: https://web.archive.org/web/20220630071417/https:/www.middleeastmedicalportal.com/webinars/harm-reduction-in-healthcare-and-the-impact-on-public-health/
• ↵ Brad Rodu. Tobacco Rep 2022 Oct 16. https://tobaccoreporter.com/2022/10/16/brad-rodu-challenging-the-tobacco-control-industry-studies/

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• Anal Cancer

US geographic region results in vastly different anal cancer risk for people with HIV

A new study that followed a cohort of more than 110,000 people establishes significant disparities in the risk of anal cancer for people with HIV and for men who have sex with men with HIV, depending on the region of the country they live in.

It’s known that people with HIV have the highest risk of anal cancer, said lead author Ashish A. Deshmukh, Ph.D. , co-leader of the Cancer Control Research Program at MUSC Hollings Cancer Center . But this study, published in the Journal of the National Cancer Institute on May 7, is the first to show vast geographic disparities in anal cancer risk and an association with opportunistic illnesses and co-morbidities, like diabetes, chronic kidney disease and cardiovascular disease, for people with HIV. Almost all cases of anal cancer are caused by the human papillomavirus (HPV). It seems that there’s some as-yet-unknown effect, such as inflammation, in people with co-morbidities that allows the HPV to gain a foothold and cause cancer to develop, the paper notes. People with HIV have a greater relative risk of anal cancer compared with people without HIV, no matter where they live. But the study showed that the relative risk varies across the country – it’s higher for people with HIV in the Midwest or South than the West or Northeast. “In the Northeast, the risk for people with HIV compared to people without HIV is 16-fold higher,” Deshmukh said. “But for people with HIV in the Midwest, the risk increases to almost 47.5-fold, reaching nearly 100-fold for men who have sex with men with HIV.” Deshmukh has a few preliminary theories about the causes of these differences but cautioned that this study doesn’t attempt to determine the reasons. “The objective was to understand whether there are disparities and what may be important risk factors,” he said. The results of this study provide the foundation for further research into the causes underlying these disparities. However, he noted that screening rates for anal cancer are relatively higher in the Northeast and West. New York state, for example, stands out as the only state with established guidelines for anal cancer screening, a rarity given the absence of national guidelines and the lack of specific protocols in other states for this relatively rare cancer, among the general population. Various professional societies have begun to develop screening guidelines. In fact, Deshmukh contributed to the recent International Anal Neoplasia Society’s consensus guidelines, published in January. Those guidelines started with the premise of beginning screening at specific ages based on risk – for example, beginning screening at age 35 for men with HIV who have sex with men and 45 for women with HIV and other men with HIV. However, this new study suggests that guidelines should consider risk factors like previous opportunistic illnesses or having had a CD4 count below 200. CD4 count is the number of CD4 T-cells, a type of white blood cell, in the blood. A count above 500 is considered healthy, but a count below 200 can trigger an AIDS diagnosis. Deshmukh said that he hopes to see the U.S. Preventive Services Task Force develop guidelines for anal cancer screening. The task force previously determined that there wasn’t enough information about the risk-benefit balance of anal cancer screening to issue guidelines, Deshmukh said. However, his ongoing research will provide direct evidence quantifying the potential harms versus benefits of screening for anal cancer among people with HIV. “We hope that the U.S. Preventive Services Task Force will again take on this topic and evaluate the evidence once we have more data on the harms and benefits of anal cancer screening,” he said.

The current paper notes that anal cancer among people with HIV appears to be on the decline. However, it warns that geographic disparities could increase if the differences in screening activity remain.

This work was supported by National Institutes of Health grants R01CA232888, U01AI069918, F31AI124794, F31DA037788, G12MD007583, K01AI093197, K01AI131895, K23EY013707, K24AI065298, K24AI118591, K24DA000432, KL2TR000421, N01CP01004, N02CP055504, N02CP91027, P30AI027757, P30AI027763, P30AI027767, P30AI036219, P30AI050409, P30AI050410, P30AI094189, P30AI110527, P30MH62246, R01AA016893, R01DA011602, R01DA012568, R01AG053100, R24AI067039, R34DA045592, U01AA013566, U01AA020790, U01AI038855, U01AI038858, U01AI068634, U01AI068636, U01AI069432, U01AI069434, U01DA036297, U01DA036935, U10EY008057, U10EY008052, U10EY008067, U01HL146192, U01HL146193, U01HL146194, U01HL146201, U01HL146202, U01HL146203, U01HL146204, U01HL146205, U01HL146208, U01HL146240, U01HL146241, U01HL146242, U01HL146245, U01HL146333, U24AA020794, U54GM133807, UL1RR024131, UL1TR000004, UL1TR000083, UL1TR002378, Z01CP010214 and Z01CP010176, and the Intramural Research Program of the National Cancer Institute; contracts CDC-200-2006-18797 and CDC-200-2015-63931 from the Centers for Disease Control and Prevention, US; contract 90047713 from the Agency for Healthcare Research and Quality, US; contract 90051652 from the Health Resources and Services Administration, US; the Grady Health System; grants CBR-86906, CBR-94036, HCP-97105 and TGF-96118 from the Canadian Institutes of Health Research, Canada; Ontario Ministry of Health and Long Term Care, and the Government of Alberta, Canada. Additional support was provided by the National Institute Of Allergy And Infectious Diseases (NIAID), National Cancer Institute (NCI), National Heart, Lung, and Blood Institute (NHLBI), Eunice Kennedy Shriver National Institute Of Child Health & Human Development (NICHD), National Human Genome Research Institute (NHGRI), National Institute for Mental Health (NIMH) and National Institute on Drug Abuse (NIDA), National Institute On Aging (NIA), National Institute Of Dental & Craniofacial Research (NIDCR), National Institute Of Neurological Disorders And Stroke (NINDS), National Institute Of Nursing Research (NINR), National Institute on Alcohol Abuse and Alcoholism (NIAAA), National Institute on Deafness and Other Communication Disorders (NIDCD), and National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). These data were collected by cancer registries participating in the National Program of Cancer Registries (NPCR) of the Centers for Disease Control and Prevention (CDC) The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or the Centers for Disease Control and Prevention.

Cancer and HIV

As people with HIV live longer, they are more likely to get cancers that come with age but HIV might complicate treatment.

HPV Vaccination

Researchers find stagnant HPV vaccine rates among young adults, though LGBTQ vaccination rates are a bright spot.

Vaccine Hesitation

The parents of millions of teens don't intend to vaccinate them against HPV, a virus that can cause six types of cancer.

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About the Author

Leslie Cantu MUSC Hollings Cancer Center

Categories: Cancer , Research

Expiring TCJA Tax Provisions in 2026 Would Produce Substantial Tax Hike across the U.S.

At the end of 2025, the individual tax A tax is a mandatory payment or charge collected by local, state, and national governments from individuals or businesses to cover the costs of general government services, goods, and activities. provisions in the Tax Cuts and Jobs Act ( TCJA ) expire all at once . Without congressional action, most taxpayers will see a notable tax increase relative to current policy in 2026.

In 2026, business taxes will also be higher as 100 percent bonus depreciation Bonus depreciation allows firms to deduct a larger portion of certain “short-lived” investments in new or improved technology, equipment, or buildings in the first year. Allowing businesses to write off more investments partially alleviates a bias in the tax code and incentivizes companies to invest more, which, in the long run, raises worker productivity, boosts wages, and creates more jobs. continues to phase down and TCJA base broadeners like research and development (R&D) amortization and a tighter limit on interest deductions remain in effect.

Policymakers may consider extending the current TCJA policy for individual tax provisions and canceling the business tax hikes. Tax Foundation estimates that permanence for the individual and business provisions (excluding the estate tax An estate tax is imposed on the net value of an individual’s taxable estate, after any exclusions or credits , at the time of death. The tax is paid by the estate itself before assets are distributed to heirs. changes) would cost about $3.8 trillion over the 10-year budget window from 2025 through 2034.

To visualize what’s at stake, Tax Foundation has estimated the average change in taxes paid per taxpayer under TCJA expiration relative to current policy across each congressional district. The congressional district map below shows the tax increase households will face if TCJA individual tax provisions expire and business taxes increase as scheduled.

The tax hikes from TCJA expiration would vary across the United States . The largest average tax hikes would be experienced by taxpayers who reside in California ’s congressional districts. For example, the congressional district covering the San Francisco area would see an average tax hike of $16,127 per taxpayer, the highest in the U.S.

By contrast, northern New York City would see an average tax increase of $807 per taxpayer under TCJA expiration. Across all congressional districts, the average tax increase costs each taxpayer about $2,853 compared to current policy where TCJA remains in place and the business tax hikes are canceled.

Individual tax provisions also exhibit geographic variation. For example, the $10,000 cap on state and local tax (SALT) deductions tends to have the greatest impact on taxpayers in higher tax localities on the coasts of the U.S.

Tax Foundation estimates permanence for TCJA would create about 904,000 full-time equivalent jobs, ranging from more than 136,000 jobs in California and 75,000 jobs in Texas to about 1,660 new jobs in Vermont .

The resulting increase in employment would otherwise not occur if the TCJA is allowed to expire as scheduled in 2026 or is not made permanent. The map provides a state-level breakdown of the full-time equivalent jobs that would be lost if the TCJA individual provisions are not made permanent and the domestic TCJA-related business tax hikes are not canceled. In other words, it illustrates the potential job gains forfeited by allowing the TCJA to expire rather than be made permanent.

The choice to let TCJA provisions expire or to extend them will also forfeit broader economic gains. Making the TCJA individual tax provisions permanent and canceling TCJA-related business tax hikes would raise long-run GDP by about 1.1 percent, increase wages by about 0.3 percent, and create a 0.9 percent larger national capital stock.

The Impact Of TCJA Expirations By Congressional District, 2026

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Methodology

We estimate the geographic distribution of tax changes under an extension of the TCJA individual provisions and cancellation of domestic business provisions using conventional revenue estimates at the national level generated by the Tax Foundation’s General Equilibrium Model. In this map, we do not include the impact of making permanent the TCJA’s estate tax changes.

We then allocate to filers in congressional districts using data from the IRS Statistics of Income for individual tax returns in 2021. (Conventional revenue estimates do not include impacts on GDP and other economic aggregates.) The IRS data provides various tax characteristics broken down by congressional district (CD). For consistency with the latest SOI data, we use CDs as they existed in 2021, which may not map onto existing CDs due to redistricting.

From the IRS data, certain tax characteristics are used to allocate to CDs the conventional national revenue estimates for each of the TCJA provisions, as described in Table 2, and then averaged by the number of filers in each CD. This analysis’s accuracy is limited by the extent of the IRS data at the CD level.

For the TCJA business provisions, we assume these fall partly on capital income and partly on labor income, in accordance with several studies . In particular , we assume the corporate tax is initially borne mainly by capital income (90 percent in the first year), and over time the burden shifts to labor income until it is evenly split across capital and labor income in the long run (50 percent capital income and 50 percent labor income in the fifth year and beyond).

Our state-level jobs impacts are allocated based on the national jobs estimated from the Tax Foundation General Equilibrium Model and the distribution of labor and capital income across the states.

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