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. Author manuscript; available in PMC: 2023 Nov 9.
Published in final edited form as: Prev Med. 2022 Nov 9;164:107335. doi: 10.1016/j.ypmed.2022.107335

A Review of Research on Cigarette Smoking in Preventive Medicine in Recognition of the Journal’s 50th Anniversary

Tyler G Erath 1,2,*, Kaitlyn O Browning 1,2, Carolyn Evemy 1,2,3, Marc Jerome P Feinstein 1,2,3, Rhiannon C Wiley 1,2,3, Elias M Klemperer 1,2,3, Michael DeSarno 1,4, Stephen T Higgins 1,2,3
PMCID: PMC9742989  NIHMSID: NIHMS1849594  PMID: 36334681

Abstract

This report reviews the literature on cigarette smoking published in Preventive Medicine over the past 50 years. The goal is twofold. First, to acknowledge the 50th anniversary of Preventive Medicine and its role in disseminating research on cigarette smoking by providing an abridged summary of smoking research published in the journal from inception through June 23, 2022. Second, to review experimental reports to identify contributions to innovations in tobacco control and regulatory efforts to reduce smoking, the theme of the special issue for which this review is an invited contribution. We searched PubMed using the search terms cigarette/cigarettes, tobacco products, smoking, smoking cessation, Preventive Medicine. Titles and abstracts were reviewed in duplicate, excluding reports not addressing cigarette smoking. Included reports were categorized by study type (original study, commentary, review). Experimental articles were assessed for impact using iCite, a National Institutes of Health web application that provides bibliometric information for articles in defined topic areas. The review identified 1,181 articles on cigarette smoking: 1,018 original studies (86.2%), 107 literature reviews (9.1%), and 56 commentaries (4.7%); 166 of the 1,018 original studies (16%) were experimental reports. In the iCite analysis these 166 experimental articles received 6,366 total citations, a mean (standard error) citation rate/article of 38.35 (±3.21) and mean relative citation ratio of 1.85 (±0.17) which is at the 73rd percentile for NIH-funded field- and time-normalized reports. Overall, this review demonstrates an ongoing and impactful contribution of Preventive Medicine to efforts to reduce cigarette smoking, the most preventable cause of premature death.

Keywords: cigarette smoking, smoking cessation, treatment, prevention, tobacco control, tobacco regulatory science

Introduction

Since the landmark 1964 U.S. Surgeon General’s report (Office of the Surgeon General, 1964), cigarette smoking has been widely and consistently demonstrated to have tremendously adverse impacts on global morbidity and mortality, generating an extensive scientific literature focused on efforts to reduce smoking. Cigarette smoking is the leading cause of preventable death, accounting for 8.2 million deaths per year globally (World Health Organization, 2022a). Although, for example, prevalence of smoking in the U.S. has decreased by almost 70% since 1964 (42% to 13%), there are still an estimated 480,000 U.S. adults who die annually from cigarette smoking or related exposure each year (Centers for Disease Control and Prevention, 2014; Centers for Disease Control and Prevention, 2022; Cornelius et al., 2022). Moreover, combustible cigarette smoking remains by far the most prevalent type of tobacco product use globally (World Health Organization, 2022a).

For all these reasons, reducing cigarette smoking remains a critically important public health research priority with substantial health and economic implications. The positive health implications of decreasing smoking initiation and increasing cessation are enormous, including reductions in risk for numerous chronic diseases including cardiovascular disease and various types of cancer, and, of course, premature death (Centers for Disease Control and Prevention, 2022). Reducing smoking also has the potential to result in substantial economic savings as it is estimated that the total economic cost associated with tobacco use globally is $1.85 trillion, including both direct (e.g., healthcare) and indirect (e.g., lost productivity) costs (Goodchild et al., 2018). Within the U.S., for example, cigarette smoking is estimated to cost approximately $600 billion in 2018 (the most recent estimate), with more than $240 billion in healthcare spending and $185 billion in lost productivity (Centers for Disease Control and Prevention, 2022; Xu et al., 2021).

Research on cigarette smoking includes two broad categories, tobacco control and tobacco regulatory science. The World Health Organization (WHO) defines tobacco control as “a range of supply, demand, and harm reduction strategies that aim to improve the health of a population by eliminating or reducing their consumption of tobacco products and exposure to tobacco smoke” (WHO, 2022b, p. 4; 2003, updated reprint 2004, 2005). Examples of strategies include both price and tax measures to reduce tobacco demand, as well as non-price strategies such as education, smoking cessation and prevention interventions, and protection from second-hand exposure to tobacco smoke.

Tobacco regulatory science (TRS) refers to “the scientific discipline that supports the evaluation of the risks and benefits of tobacco regulatory decisions and provides a robust scientific foundation for regulatory policies” (Ashley et al., 2014; Wipfli et al., 2017). Globally, TRS was put into action through the WHO Framework Convention on Tobacco Control (WHO FCTC), which is an international treaty implemented in 2005 in response to the globalization of the tobacco epidemic, that addresses tobacco control and regulatory issues to reduce tobacco demand and supply (see WHO, 2022b). In the U.S., TRS emerged as an explicit area of tobacco research with passage of the 2009 Tobacco Control Act, which provided the Food and Drug Administration (FDA) with regulatory authority over the marketing, manufacturing, and distribution of tobacco products (United States, 2009). In response, the FDA created the Center for Tobacco Products (FDA-CTP) to oversee implementation (FDA, 2022), and in collaboration with the National Institutes of Health, the Tobacco Regulatory Science program (TRSP) to support extramural Tobacco Centers of Regulatory Science (TCORS; FDA, 2013; FDA, 2022) and other research initiatives to support research that aids in the development of evidence-based regulation (https://prevention.nih.gov/tobacco-regulatory-research). We find this distinction between tobacco control and regulatory science research helpful for the pragmatic purpose of characterizing the various types of tobacco research studies that have appeared in Preventive Medicine over the past 50 years. That said, we also acknowledge that tobacco regulatory science evolved out of the larger tobacco control effort that dates back more than the 50 years covered in this review and that topics currently important to regulatory science research (e.g., messaging strategies, risk perception) have long been and remain a part of the tobacco control research portfolio.

Preventive Medicine is an international medical journal that publishes research on disease prevention, health promotion, and public health policy making (Preventive Medicine, 2022). In service to that overarching mission, the journal has published regularly on cigarette smoking across its five-decade tenure. An overarching purpose of this report is to provide a narrative review of that literature. Our goal in conducting this review was twofold. First, we wanted to recognize the 50th anniversary of Preventive Medicine and its considerable contribution to disseminating research on cigarette smoking by quantifying and providing an abridged summary of published research on this topic from the journal’s first 50 years. Second, we wanted to review the journal’s experimental reports to identify studies that reflect the journal’s efforts to disseminate innovations in tobacco control and regulatory science to reduce cigarette smoking—the topic of the special issue of Preventive Medicine to which this report was an invited contribution. We relied on the NIH’s definition of innovation: “seek to shift current research or clinical practice paradigms by utilizing novel theoretical concepts, approaches or methodologies, instrumentation, or interventions” (National Institutes of Health, 2016). We used the NIH’s iCite web application (Hutchins et al., 2016) as a quantitative measure to identify experimental reports on cigarette smoking in Preventive Medicine that had greater than average influence.

Methods

Search Strategy

We conducted a comprehensive search for studies on cigarette smoking that appeared in Preventive Medicine from the journal’s inception (1972) through June 23, 2022 using the U.S. National Library of Medicine’s search engine PubMed and the following search terms: “(“cigarette”[All Fields] OR “tobacco products”[MeSH Terms] OR (“tobacco”[All Fields] AND “products”[All Fields]) OR “tobacco products”[All Fields] OR “cigarette”[All Fields] OR “cigarettes”[All Fields] OR (“smoking cessation”[MeSH Terms] OR (“smoking”[All Fields] AND “cessation”[All Fields]) OR “smoking cessation”[All Fields]) OR (“cigarette smoking”[MeSH Terms] OR (“cigarette”[All Fields] AND “smoking”[All Fields]) OR “cigarette smoking”[All Fields])) AND “Preventive medicine”[Journal]”.

Screening and Review Procedures

Additional information about the search methods is detailed below and search results are reported in the Consort Diagram (Figure 1). Three authors (TE, KB, CE) reviewed the titles and abstracts of all articles that were identified in the search excluding those that did not address cigarette smoking. Next, to address Aim 1, the same authors reviewed each of the remaining articles and categorized them as either a literature review (i.e., a paper that reported or described the combined results of multiple prior studies), commentary (i.e., a published interpretation or reflection on a scholarly topic or previously published paper), or original research (i.e., communicates novel results of a research study).

Figure 1.

Figure 1

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Flow diagram of included and excluded articles

To address Aim 2, articles reporting original research underwent an additional title and abstract review in duplicate to identify experimental studies (i.e., involved the manipulation of an independent variable and included a comparison group or comparison condition) and exclude non-experimental research. Studies identified as experimental based on the title and abstract then underwent a full-text review in duplicate to confirm that the article reported results of original experimental research.

Experimental articles were designated as falling into one of the following mutually exclusive categories: (a) treatment intervention, (b) prevention intervention, (c) regulatory science study, or (d) toxin or biomarker exposure study. The same authors then extracted data for treatment articles on whether they included an exclusively psychosocial intervention, an intervention that included a pharmacotherapy, or included what was considered an alternative intervention (e.g., medical student/physician training, physical activity). Data for prevention articles were extracted on whether the intervention focused on cigarette smoking only or cigarette smoking plus other substances. Regulatory science articles were examined delineating whether the article focused on reduced nicotine content cigarettes or perceptions of harm and messaging.

Data for all experimental articles were extracted to identify the primary independent variable, the primary dependent variable, the method used to assess the primary dependent variable (biochemical verification or observation, self-report, or combined), whether the primary outcome was statistically significant, and the country in which the study was conducted. Lastly, as discussed above, impact of the experimental reports was analyzed using the iCite web application (NIH, Office of Portfolio Analysis, iCite, 2022). iCite provides metrics of scientific influence (i.e., citation rate) of individual articles that are field-adjusted and benchmarked to NIH publications providing public-domain citation data from the NIH Open Citation Collection. Included among the citation data is the Relative Citation Ratio (RCR), which is a time- and field-normalized citation rate for each article that is benchmarked to 1.0 for a median citation rate for NIH-funded publications in the corresponding year of publication. Fields are defined for individual articles by using their respective co-citation networks. In this review, we designated experimental articles with an RCR above 1.0, that is, a citation rate above the time- and field-normalized NIH median citation rate (i.e., 50th percentile), as representing contributions that had greater than average influence. Papers published in the current U.S. federal government fiscal year (Oct 1 through Sept 30) are excluded from the RCR analysis save for those that received 5 or more citations. Seven of the 166 articles were excluded based on this criterion, leaving 159 that contributed to the RCR analysis.

Results

Aim 1: Preventive Medicine’s Role in Disseminating Research on Cigarette Smoking

The search identified a total of 1,282 articles, 101 of which were excluded for not addressing cigarette smoking, bringing the total to 1,181 articles that met study inclusion criteria and contributed to addressing Aim 1. As depicted in Figure 2, articles on cigarette smoking were published each year from 1972 through June 23, 2022. The number of articles began accelerating around 1984 and continued this trend with some waxing and waning over time, with the steepest acceleration seen following 2013—the first year of the NIH-FDA TCORS initiative. Among the 1,181 articles, 1,018 (86.2%) were original studies, 107 (9.1%) literature reviews, and 56 (4.7%) commentaries.

Figure 2.

Figure 2

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Cumulative number of Preventive Medicine articles on cigarette smoking by year and article type

Aim 2: Experimental Preventive Medicine Articles on Tobacco Control and Tobacco Regulatory Science to Reduce Cigarette Smoking

Based on the inclusionary criteria for being categorized as an experimental study, 938 articles were excluded after title and abstract review, leaving 243 articles that advanced to full-text review. An additional 77 articles were excluded because they did not use an experimental design, leaving 166 original, experimental articles focused on cigarette smoking relevant to Aim 2 (see Figure 1). As noted above, an additional seven articles were excluded from the RCR analysis based on the criterion of a publication date in the most recent fiscal year. These 166 experimental articles garnered 6,366 citations with a mean (standard error) of 38.35 (±3.21) citations per article. The mean RCR for the 159 articles meeting criteria was 1.85 (±0.17) which is at the 73rd NIH time- and field-normalized percentile; 99 of those 159 articles (62.26%) had an RCR that exceeded the NIH median 1.0 and 50th normalized percentile, supporting greater than average influence for NIH-supported research in this field. A brief overview of the experimental reports categorized by study type is provided below (see also Figure 3) and detailed in Supplemental Tables 1–4.

Figure 3.

Figure 3

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Cumulative number of experimental Preventive Medicine articles on cigarette smoking by year and study type

Treatment Studies

One hundred and ten of the 166 experimental articles (66.27%) examined a treatment intervention focused on reducing cigarette smoking (Supplemental Table 1). These 110 treatment articles garnered 4,317 citations with a mean of 39.25 (±3.57) citations per article. The mean RCR for the 106 articles meeting eligibility criteria was 1.67 (±0.14), which is at the 69th normalized percentile; 64 of these 106 articles (60.38%) had an RCR that exceeded the NIH median 1.0 and 50th normalized percentile, supporting greater that average influence for NIH-supported research in this field (Table 1).

Table 1.

Treatment Studies with an iCite RCR greater than 1.0

Year Authors Participants Intervention Outcome* Measure RCR Country
Psychosocial
1981 Powell & McCann Adult daily smokers Education; counseling; peer support Cigarette abstinence SR 2.42 USA
1984 Li et al. Women smokers Education Cigarette abstinence* SR & Bio 3.07 USA
1985 Kornitzer & Rose Men aged 40–59 Education Cigarettes per day* SR 1.42 UK; Belgium; Italy; Poland
1985 Cutler et al. Men at risk for heart disease Counseling; education Cigarette abstinence SR & Bio 1.83 USA
1985 Holme et al. Men at risk for heart disease Education Cigarettes per day SR & Bio 3.34 Norway
1990 Orleans et al. Adult smokers with comorbid. Education; counseling Cigarettes per day* SR 2.82 USA
1991 Ockene et al. Male smokers Education Cigarette abstinence* SR & Bio 1.24 USA
1995 Mudde et al. Adults aged 25–65 Education; counseling Cigarette abstinence SR 1.06 Netherlands
1996 Voorhees et al. Black adult smokers Education; counseling; peer support Cigarette abstinence SR & Bio 4.86 USA
1996 Morgan et al. Adult smokers aged 50–74 Education; counseling Cigarette abstinence* SR 2.26 USA
1998 Boyd et al. African American adults Marketing Treatment calls made* Obs 1.51 USA
1998 Orleans et al. African American adult smokers Education; counseling Cigarette abstinence SR 2.81 USA
1998 Secker-Walker et al. Pregnant smokers Counseling; education Cigarettes per day* SR & Bio 2.22 USA
1999 Manfredi et al. Adult smokers Education; counseling Intention to quit* SR 1.98 USA
1999 Dijkstra et al. Adult smokers Education Intention to quit* SR 2.83 Netherlands
1999 McBride et al. Female smokers Education; counseling Cigarette abstinence SR 1.89 USA
2000 Martinson et al. Adolescents Financial incentives Intervention responses* SR 1.78 USA
2000 Dornelas et al. Smokers with recent cardiac event Counseling Cigarette abstinence* SR 3.69 USA
2001 Prochaska et al. Adult smokers Education; counseling Cigarette abstinence* SR 3.89 USA
2001 Pieterse et al. Adult smokers Education; social support Cigarette abstinence* SR 2.52 Netherlands
2001 Aveyard et al. 9th grade students Computer education Cigarette abstinence SR 1.57 United Kingdom
2002 Bovet et al. Adult smokers Education; counseling Cigarette abstinence* SR 1.60 Switzerland
2002 Campbell et al. Adults Computer education Cigarette abstinence SR 4.93 USA
2002 Murray et al. Smokers with airway obstruction Education Cigarette abstinence SR 1.11 USA
2005 Hennrikus et al. Recently hospitalized smokers Education; counseling Cigarette abstinence SR & Bio 2.24 USA
2005 Wolfenden et al. Clinicians in a preoperative care Computer education Delivery of tobacco Tx* SR & Bio 1.47 Australia
2005 Ferreira-Borges Pregnant smokers Education; counseling Cigarette abstinence* SR & Bio 1.11 Portugal
2005 Prochaska et al. Adult smokers Education; counseling Cigarette abstinence* SR 7.20 USA
2005 Borrelli et al. Smokers receiving home medical care Education; counseling Cigarette Bio 1.90 USA
2005 Hilberink et al. Smokers with COPD Education; counseling Cigarette abstinence* SR 1.45 Netherlands
2008 Prochaska et al. Adult smokers Counseling Cigarette abstinence SR 5.44 USA
2008 An et al. College student smokers Education; peer support; $ incentives Cigarette abstinence* SR & Bio 2.31 USA
2010 Hennrikus et al. Pregnant smokers Counseling; peer support Cigarette abstinence SR & Bio 1.13 USA
2010 Harris et al. College student smokers Counseling Cigarette abstinence SR & Bio 1.56 USA
2014 Higgins et al. Pregnant smokers Financial incentives Cigarette abstinence* SR & Bio 2.99 USA
2015 Virtanen et al. Smokers who visited dentist Education Cigarette abstinence SR 1.03 Sweden
2016 Stanczyk et al. Adult smokers Computer education Cigarette abstinence* SR & Bio 1.47 Netherlands
2020 Kurti et al. Pregnant smokers Financial incentives; counseling Cigarette abstinence* SR & Bio 3.97 USA
Pharmacotherapy
1984 Fagerström Adult smokers Counseling; NRT Cigarette abstinence* SR & Bio 6.63 USA
1988 Sutton & Hallett Adult smokers Education; peer advice; NRT Cigarette abstinence SR & Bio 1.86 United Kingdom
1989 Maheu et al. Adult smokers Education; aversive Cigarette abstinence* SR & Bio 1.96 USA
1991 Hughes et al. Adult smokers smoking; NRT Counseling; NRT Cigarette abstinence* SR & Bio 3.42 USA
1992 Hebert et al. Adult smokers Education; counseling; NRT Cigarette abstinence* SR 1.62 USA
1993 O’Hara et al. Adult smokers Education; counseling; NRT Cigarette abstinence SR & Bio 1.87 USA
1994 Allen et al. Adult smokers NRT Cardiovasc. Measures* Obs 1.43 USA
1995 Kornitzer et al. Adult smokers NRT Cigarette Abstinence* SR & Bio 6.41 Belgium, Sweden
1997 Clavel-Chapelon et al. Adult smokers Acupuncture; NRT Cigarette abstinence SR & Bio 1.10 France
1998 Lewis et al. Hospitalized smokers Counseling; NRT Cigarette abstinence SR & Bio 2.18 USA
1999 Daughton et al. Adult smokers Counseling; NRT Cigarette abstinence* SR 1.95 USA
2000 Solomon et al. Low SES women smokers Peer counseling; NRT Cigarette abstinence* SR 1.88 USA
2004 Stanton et al. Male smokers with pregnant partners Education; NRT Cigarette abstinence* SR & Bio 1.44 Australia
2005 Solomon et al. Low SES women smokers Peer counseling; NRT Cigarette abstinence* SR 1.30 USA
2005 Pisinger et al. Adult smokers Education; counseling; NRT Cigarettes per day SR 1.65 Denmark
2005 Pisinger et al. Adult smokers Education; counseling; NRT Cigarettes per day SR 1.83 Denmark
2006 Fang et al. Chinese and Korean smokers Education; counseling; NRT Cigarette abstinence* SR 1.59 USA
2008 Pisinger et al. Adult smokers Education; counseling; NRT Cigarette abstinence* SR 1.12 Denmark
2008 Prochaska, Hall et al. Adult smokers Peer counseling; physical activity; NRT Cigarettes per day* SR & Bio 2.48 USA
2016 Andrews et al. Low-income women smokers Counseling; peer support; NRT Cigarette abstinence* SR & Bio 1.08 USA
Alternative
1996 Roche et al. 5th year medical students Training; education; feedback Training effectiveness* Obs 3.30 Australia
1996 Ward & Sanson-Fisher Medical trainees Training; education Training effectiveness* Obs 1.87 Australia
1997 He et al. Adult smokers Acupuncture Cigarettes per day* SR & Bio 1.20 Norway
1998 Richmond et al. Family physicians Training; education Training effectiveness* SR & Obs 1.51 Australia
2002 Wakefield et al. Low-income smokers with asthmatic children Education; counseling; feedback Smoking in home SR 1.99 Australia
2003 Roski et al. Medical clinic practices Financial incentives Patient tobacco use* Obs 3.75 USA
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*

Indicates authors reported significant primary outcome.

Bio=Biochemical verification; Obs=Observational measurement; SR=Self-reported outcome; NRT=Nicotine replacement therapy.

These 64 higher impact studies included a body of controlled trials examining innovative psychosocial interventions to promote smoking cessation as part of interventions to reduce multiple risk behaviors in adults with cardiovascular and other smoking-related medical problems (e.g., Cutler et al., 1985; Holme et al., 1985; Orleans et al., 1990) and interventions focused exclusively on smoking cessation during or following medical treatment for other conditions (Dornelas et al., 2000; Hennrikus et al., 2005; Virtanen et al., 2015). Another body of research focused on improving cessation rates among pregnant women including innovations around the use of financial incentives (e.g., Secker-Walker et al., 1998; Ferreira-Borges, 2005; Higgins et al., 2014; Kurti et al., 2020). Other innovations focused on the use of computer tailoring around the transtheoretical model of behavior change and motivational interviewing for reducing multiple risk behaviors including smoking (e.g., Dijkstra et al., 1999; Prochaska et al., 2001; Prochaska, Butterworth, et al., 2008; Stanczyk et al. 2016).

A major innovation discernible among these treatment studies is a body of work on nicotine replacement therapy (NRT), starting with early seminal studies demonstrating the efficacy of nicotine gum (e.g., Fagerstrom 1984; Sutton & Hallett, 1988), development of transdermal NRT (Allen et al., 1994), matching of transdermal NRT dose to smoking level (e.g., Solomon et al., 2000), combined use of short- and long-acting NRT (e.g., Kornitzer et al., 1995), and extending the safety profile of NRT to populations with co-morbid medical conditions (e.g., Wiggers et al., 2005). Also included is an innovative study examining moderate to vigorous physical activity as relapse prevention intervention among adults who received a multi-element intervention including combined transdermal NRT and bupropion (Prochaska, Hall, et al., 2008).

Prevention Studies

Twenty-four of the 166 experimental articles (14.46%) tested a prevention-based intervention (Supplemental Table 2). These 24 prevention articles garnered 1,495 citations with a mean of 62.29 (±13.15) citations per article. The mean RCR for the 23 articles meeting eligibility criteria was 3.63 (±0.87), which is at the 88th normalized percentile; 22 of these 23 articles (95.65%) had an RCR that exceeded the NIH median 1.0 and 50th normalized percentile, supporting greater than average influence for NIH-supported research in this field (Table 2).

Table 2.

Prevention studies with an iCite RCR greater than 1.0

Year First Author Participants Intervention Outcome* Measure RCR Country
Cigarette smoking
1980 Botvin et al. 8th, 9th, and 10th grade students Education; life skills training Smoking initiation* SR 13.27 USA
1982 Botvin & Eng 7th grade students Education; life skills training Smoking initiation* SR & Bio 9.69 USA
1984 Tell et al. 5th, 6th, and 7th grade students Education; life skills training Smoking initiation* SR & Bio 2.74 Norway
1995 Flay et al. 7th grade students Education; life skills training Smoking intention SR 2.73 USA
1997 Flynn et al. 4th, 5th, and 6th grade students Education; media Past week cigarette use* SR 2.11 USA
2003 Curry et al. Families with children Education; life skills training; marketing Past month cigarette use* SR 1.23 USA
2006 Schulze et al. 7th grade students Education; life skills training Smoking prevalence SR 1.40 USA
2014 Hiemstra et al. Adolescents and their mothers Education; life skills training child & parent smoking SR 1.11 Netherlands
2014 Gorini et al. High school students Education; life skills training Past month cigarette use SR 1.12 Italy
Cigarette smoking plus substance use
1989 Pentz et al. 6th and 7th grade students Education; life skills training; media Past month cigarette use SR & Bio 2.89 USA
1990 Graham et al. 7th grade students Education; life skills training Lifetime, past mo. smoking* SR & 4.1 USA
1991 Hansen & Graham 7th grade students Education; life skills training Lifetime, past mo. smoking* Bio SR 17.26 USA
1993 Bell et al. 9th grade students Education; life skills training Substance use beliefs* SR 3.27 USA
1996 Clayton et al. 6th grade students Education; life skills training Smoking intention SR 4.99 USA
1998 Sussman et al. 9th, 10th, and 11th grade students Education; life skills training Past month cigarette use SR 3.34 USA
1998 Palmer et al. 7th grade students Education; life skills training Lifetime, past mo. smoking* SR 1.45 USA
2001 Dent et al. 9th, 10th, and 11th grade students Education; life skills training Past month cigarette use SR 1.18 USA
2003 Sussman et al. High school students Education; life skills training Past month cigarette use* SR 1.50 USA
2006 Sun et al. 9th, 10th, and 11th grade students Education; life skills training Past month cigarette use SR 1.76 USA
2007 Faggiano et al. Students aged 12–14 years Education; life skills training Lifetime cigarette use SR 1.58 Austria; Belgium; Germany; Greece; Italy; Spain; Sweden
2008 Sun et al. High school students Education; life skills training Past month cigarette use SR 1.14 USA
2008 Faggiano et al. 7th, 8th, and 9th grade students Education; life skills training Lifetime cigarette use* SR 3.16 Austria; Belgium; Germany; Greece; Italy; Spain; Sweden
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*

Indicates authors reported significant primary outcome.

Bio=Biochemical verification; Obs=Observational measurement; SR=Self-reported outcome.

The higher impact prevention studies included highly innovative seminal studies by Botvin and colleagues combining education and life-skills training with elementary school students (Botvin et al. 1980; Botvin et al. 1982). Subsequent reports largely reflected innovations along the lines of integrating that approach with training on resisting psychological and social influences (Flay et al., 1995; Tell et al., 1984), use of mass media to increase reach (Flynn et al., 1997), involvement of parents and families (Curry et al., 2003), and extensions to older students (Gorini et al., 2014; Hiemstra et al., 2014).

Regulatory Studies

Nineteen of the 166 experimental articles (11.45%) examined topics associated with tobacco regulatory science (Supplemental Table 3). These 19 regulatory articles garnered 231 citations with a mean of 12.16 (±2.28) citations per article. The mean RCR for the 18 articles meeting eligibility criteria was 1.20 (±0.20), which is at the 57th normalized percentile; 7 of these 18 articles (38.89%) had an RCR that exceeded the NIH median 1.0 and 50th normalized percentile, supporting greater than average influence for NIH-supported research in this field (Table 3).

Table 3.

Regulatory science studies with an iCite RCR greater than 1.0

Year First Author Participants Intervention Outcome* Measure RCR Country
Low nicotine content cigarettes
2018 Higgins et al. Adult smokers Tobacco dependence severity Cigarette abuse liability & craving* SR & Bio 2.01 United States
Messaging and perceptions of harm
1986 Hansen & Malotte 6th through 12th grade students Exposure comparison Disease risk from smoking* SR 3.12 United States
1989 Brannon et al. 7th grade students Intervention modality Program efficacy & satisfaction* SR 1.10 United States
2017 Pepper et al. Adult smokers Exposure comparison Harm perception SR 1.56 United States
2018 Noar et al. Adult smokers Messaging content Message effectiveness* SR 2.16 United States
2019 Epperson et al. Adult never, former, and current smokers Exposure comparison Health risk perception* SR 1.97 United States
2020 Hall et al. Adults Warning and message comparison Message effectiveness* SR 2.27 United States
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*

Indicates authors reported significant primary outcome.

Bio=Biochemical verification; Obs=Observational measurement; SR=Self-reported outcome.

These higher impact regulatory studies included research demonstrating that reducing nicotine content in cigarettes to minimally addictive levels can reduce the addiction potential of smoking in vulnerable populations and across a wide range of nicotine dependence severity levels (Higgins et al., 2018). Also included among this work are innovative studies on risk perception including a seminal study (Hansen & Malotte, 1986) characterizing what is now a well-established bias in smoking risk perception wherein people rate smoking-related risks to themselves as being less than the risks of smoking they assign to others. These early studies establishing biases in smoking-related risk perception were followed by a series of studies demonstrating the importance of integrating knowledge on human biases in risk perceptions for understanding dual use (Pepper et al., 2017) and developing effective message framing to reduce smoking (Noar et al., 2018; Hall et al., 2020).

Toxicant and Biomarker Studies

Thirteen of the 166 experimental reports (7.83%) focused primarily on cigarette toxicant exposure or biomarker levels (i.e., evaluations of cigarette characteristics or a biological parameter associated with cigarette smoking; Supplemental Table 4). The 13 toxicant and biomarker articles garnered 323 citations with a mean of 24.85 (±4.67) citations per article. The mean RCR of these 13 articles was 1.02 (±0.18), which is at the 51st normalized percentile; 6 of the 13 articles (46.15%) had an RCR that exceeded the NIH median 1.0 and 50th normalized percentile, supporting greater than average influence for NIH-supported research in this field (Table 4).

Table 4.

Toxicant and biomarker studies with an iCite RCR greater than 1.0

Year First Author Participants Intervention Outcome* Measure RCR Country
1983 Rickert et al. Automated smoking machine Cigarette type & smoking style Tar, nicotine, & CO of smoke Obs 2.54 Canada
1992 Schramm et al. Adult smokers Data collection type Cotinine level Obs 1.12 United States
1996 Prokhorov et al. 12th grade & college students Cigarette smoking exposure Pulmonary & respiratory function* Obs 1.38 United States
2005 Morimoto et al. Adult smokers Fermented milk Natural killer cell activity* Obs 1.18 United States
2006 Ito et al. Adult smokers with cancer Biomarker feedback on L-myc polymorphism Cigarette smoking abstinence SR 1.21 Japan
2007 Pisinger & Jorgensen Adult smokers Cigarette abstinence Waist circumference* Obs 1.69 Denmark
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*

Indicates authors reported significant primary outcome.

Bio=Biochemical verification; Obs=Observational measurement; SR=Self-reported outcome.

Included among the 6 higher impact studies was an early report demonstrating that toxin exposure profiles generated by cigarette-smoking machines using standard smoking protocols substantially underrepresented exposure levels when cigarettes are intensively smoked (Rickert et al., 1983), development of methods to biochemically verify smoking status using salivary cotinine (Schramm et al., 1992), correspondence between exposure levels and biological function (Prokhorov et al., 1996; Morimoto et al., 2005), biomarker feedback on such impacts to discourage smoking (Ito et al., 2006), and the relationship between smoking abstinence and weight gain (Pisinger & Jorgensen, 2007).

Discussion

This review has addressed a twofold overarching aim of characterizing the contributions of Preventive Medicine to research on cigarette smoking in recognition of its 50th anniversary, with a particular focus on the experimental studies that contributed to innovations in tobacco control and regulatory science to reduce smoking. Regarding the first component of this twofold aim, the review identified 1,181 reports on cigarette smoking that have appeared in Preventive Medicine over the past almost 50 years or, put differently, an average of 23.6 reports per year on the topic for 50 consecutive years. This is a notable contribution by any standard that we are familiar with, especially when considering that Preventive Medicine is not a specialty journal in addictions research. Indeed, this annual publication rate is the equivalent of the journal dedicating a special issue to the topic of cigarette smoking each year for 50 consecutive years. These reports span the type of articles one would expect in a mainstream medical journal, with most articles (86.2%) reporting original research along with smaller proportions devoted to literature reviews (9.1%) and commentaries (4.7%). Regarding patterns over time, publication rate accelerated discernibly in the mid 1980s as recognition of the terrible adverse health and economic impacts of the smoking epidemic grew along with the advent of evidence-based treatment and prevention interventions. Some waxing and waning in publication rate is discernable across subsequent years, but perhaps most encouraging is that the steepest acceleration has occurred in the past decade underscoring that interest in cigarette smoking research at Preventive Medicine remains strong.

Regarding the second component of this twofold aim, numerous contributions to innovations in tobacco control and regulatory science to reduce smoking are discernible among the experimental reports that have appeared in Preventive Medicine over the past 50 years. Importantly, most of these articles had greater than average time- and field-normalized impact for NIH-supported research, which is a substantive accomplishment when considering cigarette smoking’s status as the most preventable cause of premature death. These higher impact studies are distributed across the four categories that were used to organize the experimental reports, with important seminal research appearing in each. Not surprisingly, treatment outcome research is the category with the largest overall number of articles and the largest number of articles with above-average impact, including studies representing key innovations in the development of psychosocial, pharmacological, and combined interventions in both the general population and vulnerable populations of adults who smoke. While smaller in number, prevention research was the most impactful with 2.2-fold fewer articles than treatment research, but a 2.8-fold greater mean relative citation ratio per article. Considering that tobacco regulatory science is still a relatively new research area, it could be expected to be smaller in size and impact than the treatment or prevention research areas, but nonetheless included innovative research in several areas that are having greater than average impact. Similarly, the biomarker and toxin exposure category was the smallest in terms of scope and impact, but also contained articles that represented above-average impact. Considered together, we believe this review documents a sustained pattern of Preventive Medicine disseminating impactful experimental research on innovations in tobacco control and regulatory science efforts to reduce smoking.

Of course, this review was conducted to celebrate the 50th anniversary of Preventive Medicine and as such extrapolation of results beyond this scholarly outlet should be avoided or made cautiously. We also want to acknowledge that while citation rate is a commonly used metric for inferring scientific impact, it is not without limitations (Aksnes et al., 2019) including, for example, the failure to assess impact beyond influence on the behavior of other researchers, which is an important feature of dissemination but certainly does not assure implementation (Ravenscroft et al., 2017). While we believe the NIH iIndex app is an innovative new research tool for assessing impact, it is also limited by its exclusive use of NIH-supported research and the PubMed search engine for comparisons. These limitations notwithstanding, we believe that this review offers compelling evidence that Preventive Medicine has been an active and substantive disseminator of research on cigarette smoking over the past 50 years, including innovative and impactful experimental studies on reducing smoking, and that commitment appears to be stronger than ever over the most recent decade.

Supplementary Material

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Highlights.

  • This report reviews cigarette smoking in Preventive Medicine over the last 50 years

  • The review found 1,181 cigarette smoking reports, averaging 23.6 articles per year

  • iCite analysis found greater-than average impact for 62.3% of experimental reports

  • A sustained pattern of publishing influential research on smoking was observed

Funding:

This research was supported by the National Institute on Drug Abuse Institutional Training Award T32DA007242 (CE, MPF, KOB, STH); National Institute on Drug Abuse (National Institute on Drug Abuse) and Food and Drug Administration (FDA) Tobacco Centers of Regulatory Science (TCORS) Award U54DA036114 (TGE, RCW EMK, STH); National Institute of General Medical Sciences (NIGMS) Center of Biomedical Research Excellence award P20GM103644 (EMK, STH).

Footnotes

Conflicts of Interest: The authors have no conflicts of interest to disclose.

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Declaration of interests

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

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