literature review should include

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Writing a Literature Review

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A literature review is a document or section of a document that collects key sources on a topic and discusses those sources in conversation with each other (also called synthesis ). The lit review is an important genre in many disciplines, not just literature (i.e., the study of works of literature such as novels and plays). When we say “literature review” or refer to “the literature,” we are talking about the research ( scholarship ) in a given field. You will often see the terms “the research,” “the scholarship,” and “the literature” used mostly interchangeably.

Where, when, and why would I write a lit review?

There are a number of different situations where you might write a literature review, each with slightly different expectations; different disciplines, too, have field-specific expectations for what a literature review is and does. For instance, in the humanities, authors might include more overt argumentation and interpretation of source material in their literature reviews, whereas in the sciences, authors are more likely to report study designs and results in their literature reviews; these differences reflect these disciplines’ purposes and conventions in scholarship. You should always look at examples from your own discipline and talk to professors or mentors in your field to be sure you understand your discipline’s conventions, for literature reviews as well as for any other genre.

A literature review can be a part of a research paper or scholarly article, usually falling after the introduction and before the research methods sections. In these cases, the lit review just needs to cover scholarship that is important to the issue you are writing about; sometimes it will also cover key sources that informed your research methodology.

Lit reviews can also be standalone pieces, either as assignments in a class or as publications. In a class, a lit review may be assigned to help students familiarize themselves with a topic and with scholarship in their field, get an idea of the other researchers working on the topic they’re interested in, find gaps in existing research in order to propose new projects, and/or develop a theoretical framework and methodology for later research. As a publication, a lit review usually is meant to help make other scholars’ lives easier by collecting and summarizing, synthesizing, and analyzing existing research on a topic. This can be especially helpful for students or scholars getting into a new research area, or for directing an entire community of scholars toward questions that have not yet been answered.

What are the parts of a lit review?

Most lit reviews use a basic introduction-body-conclusion structure; if your lit review is part of a larger paper, the introduction and conclusion pieces may be just a few sentences while you focus most of your attention on the body. If your lit review is a standalone piece, the introduction and conclusion take up more space and give you a place to discuss your goals, research methods, and conclusions separately from where you discuss the literature itself.

Introduction:

• An introductory paragraph that explains what your working topic and thesis is
• A forecast of key topics or texts that will appear in the review
• Potentially, a description of how you found sources and how you analyzed them for inclusion and discussion in the review (more often found in published, standalone literature reviews than in lit review sections in an article or research paper)
• Summarize and synthesize: Give an overview of the main points of each source and combine them into a coherent whole
• Analyze and interpret: Don’t just paraphrase other researchers – add your own interpretations where possible, discussing the significance of findings in relation to the literature as a whole
• Critically Evaluate: Mention the strengths and weaknesses of your sources
• Write in well-structured paragraphs: Use transition words and topic sentence to draw connections, comparisons, and contrasts.

Conclusion:

• Summarize the key findings you have taken from the literature and emphasize their significance
• Connect it back to your primary research question

How should I organize my lit review?

Lit reviews can take many different organizational patterns depending on what you are trying to accomplish with the review. Here are some examples:

• Chronological : The simplest approach is to trace the development of the topic over time, which helps familiarize the audience with the topic (for instance if you are introducing something that is not commonly known in your field). If you choose this strategy, be careful to avoid simply listing and summarizing sources in order. Try to analyze the patterns, turning points, and key debates that have shaped the direction of the field. Give your interpretation of how and why certain developments occurred (as mentioned previously, this may not be appropriate in your discipline — check with a teacher or mentor if you’re unsure).
• Thematic : If you have found some recurring central themes that you will continue working with throughout your piece, you can organize your literature review into subsections that address different aspects of the topic. For example, if you are reviewing literature about women and religion, key themes can include the role of women in churches and the religious attitude towards women.
• Qualitative versus quantitative research
• Empirical versus theoretical scholarship
• Divide the research by sociological, historical, or cultural sources
• Theoretical : In many humanities articles, the literature review is the foundation for the theoretical framework. You can use it to discuss various theories, models, and definitions of key concepts. You can argue for the relevance of a specific theoretical approach or combine various theorical concepts to create a framework for your research.

What are some strategies or tips I can use while writing my lit review?

Any lit review is only as good as the research it discusses; make sure your sources are well-chosen and your research is thorough. Don’t be afraid to do more research if you discover a new thread as you’re writing. More info on the research process is available in our "Conducting Research" resources .

As you’re doing your research, create an annotated bibliography ( see our page on the this type of document ). Much of the information used in an annotated bibliography can be used also in a literature review, so you’ll be not only partially drafting your lit review as you research, but also developing your sense of the larger conversation going on among scholars, professionals, and any other stakeholders in your topic.

Usually you will need to synthesize research rather than just summarizing it. This means drawing connections between sources to create a picture of the scholarly conversation on a topic over time. Many student writers struggle to synthesize because they feel they don’t have anything to add to the scholars they are citing; here are some strategies to help you:

• It often helps to remember that the point of these kinds of syntheses is to show your readers how you understand your research, to help them read the rest of your paper.
• Writing teachers often say synthesis is like hosting a dinner party: imagine all your sources are together in a room, discussing your topic. What are they saying to each other?
• Look at the in-text citations in each paragraph. Are you citing just one source for each paragraph? This usually indicates summary only. When you have multiple sources cited in a paragraph, you are more likely to be synthesizing them (not always, but often
• Read more about synthesis here.

The most interesting literature reviews are often written as arguments (again, as mentioned at the beginning of the page, this is discipline-specific and doesn’t work for all situations). Often, the literature review is where you can establish your research as filling a particular gap or as relevant in a particular way. You have some chance to do this in your introduction in an article, but the literature review section gives a more extended opportunity to establish the conversation in the way you would like your readers to see it. You can choose the intellectual lineage you would like to be part of and whose definitions matter most to your thinking (mostly humanities-specific, but this goes for sciences as well). In addressing these points, you argue for your place in the conversation, which tends to make the lit review more compelling than a simple reporting of other sources.

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What is a Literature Review? How to Write It (with Examples)

A literature review is a critical analysis and synthesis of existing research on a particular topic. It provides an overview of the current state of knowledge, identifies gaps, and highlights key findings in the literature. 1 The purpose of a literature review is to situate your own research within the context of existing scholarship, demonstrating your understanding of the topic and showing how your work contributes to the ongoing conversation in the field. Learning how to write a literature review is a critical tool for successful research. Your ability to summarize and synthesize prior research pertaining to a certain topic demonstrates your grasp on the topic of study, and assists in the learning process. 

Table of Contents

• What is the purpose of literature review? 
• a. Habitat Loss and Species Extinction: 
• b. Range Shifts and Phenological Changes: 
• c. Ocean Acidification and Coral Reefs: 
• d. Adaptive Strategies and Conservation Efforts: 

How to write a good literature review 

• Choose a Topic and Define the Research Question: 
• Decide on the Scope of Your Review: 
• Select Databases for Searches: 
• Conduct Searches and Keep Track: 
• Review the Literature: 
• Organize and Write Your Literature Review: 
• How to write a literature review faster with Paperpal? 
• Frequently asked questions 

What is a literature review?

A well-conducted literature review demonstrates the researcher’s familiarity with the existing literature, establishes the context for their own research, and contributes to scholarly conversations on the topic. One of the purposes of a literature review is also to help researchers avoid duplicating previous work and ensure that their research is informed by and builds upon the existing body of knowledge.

What is the purpose of literature review?

A literature review serves several important purposes within academic and research contexts. Here are some key objectives and functions of a literature review: 2  

1. Contextualizing the Research Problem: The literature review provides a background and context for the research problem under investigation. It helps to situate the study within the existing body of knowledge. 

2. Identifying Gaps in Knowledge: By identifying gaps, contradictions, or areas requiring further research, the researcher can shape the research question and justify the significance of the study. This is crucial for ensuring that the new research contributes something novel to the field. 

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3. Understanding Theoretical and Conceptual Frameworks: Literature reviews help researchers gain an understanding of the theoretical and conceptual frameworks used in previous studies. This aids in the development of a theoretical framework for the current research. 

4. Providing Methodological Insights: Another purpose of literature reviews is that it allows researchers to learn about the methodologies employed in previous studies. This can help in choosing appropriate research methods for the current study and avoiding pitfalls that others may have encountered. 

5. Establishing Credibility: A well-conducted literature review demonstrates the researcher’s familiarity with existing scholarship, establishing their credibility and expertise in the field. It also helps in building a solid foundation for the new research. 

6. Informing Hypotheses or Research Questions: The literature review guides the formulation of hypotheses or research questions by highlighting relevant findings and areas of uncertainty in existing literature. 

Literature review example

Let’s delve deeper with a literature review example: Let’s say your literature review is about the impact of climate change on biodiversity. You might format your literature review into sections such as the effects of climate change on habitat loss and species extinction, phenological changes, and marine biodiversity. Each section would then summarize and analyze relevant studies in those areas, highlighting key findings and identifying gaps in the research. The review would conclude by emphasizing the need for further research on specific aspects of the relationship between climate change and biodiversity. The following literature review template provides a glimpse into the recommended literature review structure and content, demonstrating how research findings are organized around specific themes within a broader topic. 

Literature Review on Climate Change Impacts on Biodiversity:

Climate change is a global phenomenon with far-reaching consequences, including significant impacts on biodiversity. This literature review synthesizes key findings from various studies: 

a. Habitat Loss and Species Extinction:

Climate change-induced alterations in temperature and precipitation patterns contribute to habitat loss, affecting numerous species (Thomas et al., 2004). The review discusses how these changes increase the risk of extinction, particularly for species with specific habitat requirements. 

b. Range Shifts and Phenological Changes:

Observations of range shifts and changes in the timing of biological events (phenology) are documented in response to changing climatic conditions (Parmesan & Yohe, 2003). These shifts affect ecosystems and may lead to mismatches between species and their resources. 

c. Ocean Acidification and Coral Reefs:

The review explores the impact of climate change on marine biodiversity, emphasizing ocean acidification’s threat to coral reefs (Hoegh-Guldberg et al., 2007). Changes in pH levels negatively affect coral calcification, disrupting the delicate balance of marine ecosystems. 

d. Adaptive Strategies and Conservation Efforts:

Recognizing the urgency of the situation, the literature review discusses various adaptive strategies adopted by species and conservation efforts aimed at mitigating the impacts of climate change on biodiversity (Hannah et al., 2007). It emphasizes the importance of interdisciplinary approaches for effective conservation planning. 

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Writing a literature review involves summarizing and synthesizing existing research on a particular topic. A good literature review format should include the following elements. 

Introduction: The introduction sets the stage for your literature review, providing context and introducing the main focus of your review. 

• Opening Statement: Begin with a general statement about the broader topic and its significance in the field. 
• Scope and Purpose: Clearly define the scope of your literature review. Explain the specific research question or objective you aim to address. 
• Organizational Framework: Briefly outline the structure of your literature review, indicating how you will categorize and discuss the existing research. 
• Significance of the Study: Highlight why your literature review is important and how it contributes to the understanding of the chosen topic. 
• Thesis Statement: Conclude the introduction with a concise thesis statement that outlines the main argument or perspective you will develop in the body of the literature review. 

Body: The body of the literature review is where you provide a comprehensive analysis of existing literature, grouping studies based on themes, methodologies, or other relevant criteria. 

• Organize by Theme or Concept: Group studies that share common themes, concepts, or methodologies. Discuss each theme or concept in detail, summarizing key findings and identifying gaps or areas of disagreement. 
• Critical Analysis: Evaluate the strengths and weaknesses of each study. Discuss the methodologies used, the quality of evidence, and the overall contribution of each work to the understanding of the topic. 
• Synthesis of Findings: Synthesize the information from different studies to highlight trends, patterns, or areas of consensus in the literature. 
• Identification of Gaps: Discuss any gaps or limitations in the existing research and explain how your review contributes to filling these gaps. 
• Transition between Sections: Provide smooth transitions between different themes or concepts to maintain the flow of your literature review. 

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Conclusion: The conclusion of your literature review should summarize the main findings, highlight the contributions of the review, and suggest avenues for future research. 

• Summary of Key Findings: Recap the main findings from the literature and restate how they contribute to your research question or objective. 
• Contributions to the Field: Discuss the overall contribution of your literature review to the existing knowledge in the field. 
• Implications and Applications: Explore the practical implications of the findings and suggest how they might impact future research or practice. 
• Recommendations for Future Research: Identify areas that require further investigation and propose potential directions for future research in the field. 
• Final Thoughts: Conclude with a final reflection on the importance of your literature review and its relevance to the broader academic community. 

Conducting a literature review

Conducting a literature review is an essential step in research that involves reviewing and analyzing existing literature on a specific topic. It’s important to know how to do a literature review effectively, so here are the steps to follow: 1  

Choose a Topic and Define the Research Question:

• Select a topic that is relevant to your field of study. 
• Clearly define your research question or objective. Determine what specific aspect of the topic do you want to explore? 

Decide on the Scope of Your Review:

• Determine the timeframe for your literature review. Are you focusing on recent developments, or do you want a historical overview? 
• Consider the geographical scope. Is your review global, or are you focusing on a specific region? 
• Define the inclusion and exclusion criteria. What types of sources will you include? Are there specific types of studies or publications you will exclude? 

Select Databases for Searches:

• Identify relevant databases for your field. Examples include PubMed, IEEE Xplore, Scopus, Web of Science, and Google Scholar. 
• Consider searching in library catalogs, institutional repositories, and specialized databases related to your topic. 

Conduct Searches and Keep Track:

• Develop a systematic search strategy using keywords, Boolean operators (AND, OR, NOT), and other search techniques. 
• Record and document your search strategy for transparency and replicability. 
• Keep track of the articles, including publication details, abstracts, and links. Use citation management tools like EndNote, Zotero, or Mendeley to organize your references. 

Review the Literature:

• Evaluate the relevance and quality of each source. Consider the methodology, sample size, and results of studies. 
• Organize the literature by themes or key concepts. Identify patterns, trends, and gaps in the existing research. 
• Summarize key findings and arguments from each source. Compare and contrast different perspectives. 
• Identify areas where there is a consensus in the literature and where there are conflicting opinions. 
• Provide critical analysis and synthesis of the literature. What are the strengths and weaknesses of existing research? 

Organize and Write Your Literature Review:

• Literature review outline should be based on themes, chronological order, or methodological approaches. 
• Write a clear and coherent narrative that synthesizes the information gathered. 
• Use proper citations for each source and ensure consistency in your citation style (APA, MLA, Chicago, etc.). 
• Conclude your literature review by summarizing key findings, identifying gaps, and suggesting areas for future research. 

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How to write a literature review faster with Paperpal?

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• Cite with Confidence: Paperpal makes it easy to incorporate relevant citations and references into your writing, ensuring your arguments are well-supported by credible sources. This translates to a polished, well-researched literature review. 

The literature review sample and detailed advice on writing and conducting a review will help you produce a well-structured report. But remember that a good literature review is an ongoing process, and it may be necessary to revisit and update it as your research progresses. By combining effortless research with an easy citation process, Paperpal Research streamlines the literature review process and empowers you to write faster and with more confidence. Try Paperpal Research now and see for yourself.  

Frequently asked questions

A literature review is a critical and comprehensive analysis of existing literature (published and unpublished works) on a specific topic or research question and provides a synthesis of the current state of knowledge in a particular field. A well-conducted literature review is crucial for researchers to build upon existing knowledge, avoid duplication of efforts, and contribute to the advancement of their field. It also helps researchers situate their work within a broader context and facilitates the development of a sound theoretical and conceptual framework for their studies.

Literature review is a crucial component of research writing, providing a solid background for a research paper’s investigation. The aim is to keep professionals up to date by providing an understanding of ongoing developments within a specific field, including research methods, and experimental techniques used in that field, and present that knowledge in the form of a written report. Also, the depth and breadth of the literature review emphasizes the credibility of the scholar in his or her field.  

Before writing a literature review, it’s essential to undertake several preparatory steps to ensure that your review is well-researched, organized, and focused. This includes choosing a topic of general interest to you and doing exploratory research on that topic, writing an annotated bibliography, and noting major points, especially those that relate to the position you have taken on the topic. 

Literature reviews and academic research papers are essential components of scholarly work but serve different purposes within the academic realm. 3 A literature review aims to provide a foundation for understanding the current state of research on a particular topic, identify gaps or controversies, and lay the groundwork for future research. Therefore, it draws heavily from existing academic sources, including books, journal articles, and other scholarly publications. In contrast, an academic research paper aims to present new knowledge, contribute to the academic discourse, and advance the understanding of a specific research question. Therefore, it involves a mix of existing literature (in the introduction and literature review sections) and original data or findings obtained through research methods. 

Literature reviews are essential components of academic and research papers, and various strategies can be employed to conduct them effectively. If you want to know how to write a literature review for a research paper, here are four common approaches that are often used by researchers.  Chronological Review: This strategy involves organizing the literature based on the chronological order of publication. It helps to trace the development of a topic over time, showing how ideas, theories, and research have evolved.  Thematic Review: Thematic reviews focus on identifying and analyzing themes or topics that cut across different studies. Instead of organizing the literature chronologically, it is grouped by key themes or concepts, allowing for a comprehensive exploration of various aspects of the topic.  Methodological Review: This strategy involves organizing the literature based on the research methods employed in different studies. It helps to highlight the strengths and weaknesses of various methodologies and allows the reader to evaluate the reliability and validity of the research findings.  Theoretical Review: A theoretical review examines the literature based on the theoretical frameworks used in different studies. This approach helps to identify the key theories that have been applied to the topic and assess their contributions to the understanding of the subject.  It’s important to note that these strategies are not mutually exclusive, and a literature review may combine elements of more than one approach. The choice of strategy depends on the research question, the nature of the literature available, and the goals of the review. Additionally, other strategies, such as integrative reviews or systematic reviews, may be employed depending on the specific requirements of the research.

The literature review format can vary depending on the specific publication guidelines. However, there are some common elements and structures that are often followed. Here is a general guideline for the format of a literature review:  Introduction:   Provide an overview of the topic.  Define the scope and purpose of the literature review.  State the research question or objective.  Body:   Organize the literature by themes, concepts, or chronology.  Critically analyze and evaluate each source.  Discuss the strengths and weaknesses of the studies.  Highlight any methodological limitations or biases.  Identify patterns, connections, or contradictions in the existing research.  Conclusion:   Summarize the key points discussed in the literature review.  Highlight the research gap.  Address the research question or objective stated in the introduction.  Highlight the contributions of the review and suggest directions for future research.

Both annotated bibliographies and literature reviews involve the examination of scholarly sources. While annotated bibliographies focus on individual sources with brief annotations, literature reviews provide a more in-depth, integrated, and comprehensive analysis of existing literature on a specific topic. The key differences are as follows: 

References 

• Denney, A. S., & Tewksbury, R. (2013). How to write a literature review.  Journal of criminal justice education ,  24 (2), 218-234. 
• Pan, M. L. (2016).  Preparing literature reviews: Qualitative and quantitative approaches . Taylor & Francis. 
• Cantero, C. (2019). How to write a literature review.  San José State University Writing Center . 

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• What is a Literature Review? | Guide, Template, & Examples

What is a Literature Review? | Guide, Template, & Examples

Published on 22 February 2022 by Shona McCombes . Revised on 7 June 2022.

What is a literature review? A literature review is a survey of scholarly sources on a specific topic. It provides an overview of current knowledge, allowing you to identify relevant theories, methods, and gaps in the existing research.

There are five key steps to writing a literature review:

• Search for relevant literature
• Evaluate sources
• Identify themes, debates and gaps
• Outline the structure
• Write your literature review

A good literature review doesn’t just summarise sources – it analyses, synthesises, and critically evaluates to give a clear picture of the state of knowledge on the subject.

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Table of contents

Why write a literature review, examples of literature reviews, step 1: search for relevant literature, step 2: evaluate and select sources, step 3: identify themes, debates and gaps, step 4: outline your literature review’s structure, step 5: write your literature review, frequently asked questions about literature reviews, introduction.

• Quick Run-through
• Step 1 & 2

When you write a dissertation or thesis, you will have to conduct a literature review to situate your research within existing knowledge. The literature review gives you a chance to:

• Demonstrate your familiarity with the topic and scholarly context
• Develop a theoretical framework and methodology for your research
• Position yourself in relation to other researchers and theorists
• Show how your dissertation addresses a gap or contributes to a debate

You might also have to write a literature review as a stand-alone assignment. In this case, the purpose is to evaluate the current state of research and demonstrate your knowledge of scholarly debates around a topic.

The content will look slightly different in each case, but the process of conducting a literature review follows the same steps. We’ve written a step-by-step guide that you can follow below.

Prevent plagiarism, run a free check.

Writing literature reviews can be quite challenging! A good starting point could be to look at some examples, depending on what kind of literature review you’d like to write.

• Example literature review #1: “Why Do People Migrate? A Review of the Theoretical Literature” ( Theoretical literature review about the development of economic migration theory from the 1950s to today.)
• Example literature review #2: “Literature review as a research methodology: An overview and guidelines” ( Methodological literature review about interdisciplinary knowledge acquisition and production.)
• Example literature review #3: “The Use of Technology in English Language Learning: A Literature Review” ( Thematic literature review about the effects of technology on language acquisition.)
• Example literature review #4: “Learners’ Listening Comprehension Difficulties in English Language Learning: A Literature Review” ( Chronological literature review about how the concept of listening skills has changed over time.)

You can also check out our templates with literature review examples and sample outlines at the links below.

Download Word doc Download Google doc

Before you begin searching for literature, you need a clearly defined topic .

If you are writing the literature review section of a dissertation or research paper, you will search for literature related to your research objectives and questions .

If you are writing a literature review as a stand-alone assignment, you will have to choose a focus and develop a central question to direct your search. Unlike a dissertation research question, this question has to be answerable without collecting original data. You should be able to answer it based only on a review of existing publications.

Make a list of keywords

Start by creating a list of keywords related to your research topic. Include each of the key concepts or variables you’re interested in, and list any synonyms and related terms. You can add to this list if you discover new keywords in the process of your literature search.

• Social media, Facebook, Instagram, Twitter, Snapchat, TikTok
• Body image, self-perception, self-esteem, mental health
• Generation Z, teenagers, adolescents, youth

Search for relevant sources

Use your keywords to begin searching for sources. Some databases to search for journals and articles include:

• Your university’s library catalogue
• Google Scholar
• Project Muse (humanities and social sciences)
• Medline (life sciences and biomedicine)
• EconLit (economics)
• Inspec (physics, engineering and computer science)

You can use boolean operators to help narrow down your search:

Read the abstract to find out whether an article is relevant to your question. When you find a useful book or article, you can check the bibliography to find other relevant sources.

To identify the most important publications on your topic, take note of recurring citations. If the same authors, books or articles keep appearing in your reading, make sure to seek them out.

You probably won’t be able to read absolutely everything that has been written on the topic – you’ll have to evaluate which sources are most relevant to your questions.

For each publication, ask yourself:

• What question or problem is the author addressing?
• What are the key concepts and how are they defined?
• What are the key theories, models and methods? Does the research use established frameworks or take an innovative approach?
• What are the results and conclusions of the study?
• How does the publication relate to other literature in the field? Does it confirm, add to, or challenge established knowledge?
• How does the publication contribute to your understanding of the topic? What are its key insights and arguments?
• What are the strengths and weaknesses of the research?

Make sure the sources you use are credible, and make sure you read any landmark studies and major theories in your field of research.

You can find out how many times an article has been cited on Google Scholar – a high citation count means the article has been influential in the field, and should certainly be included in your literature review.

The scope of your review will depend on your topic and discipline: in the sciences you usually only review recent literature, but in the humanities you might take a long historical perspective (for example, to trace how a concept has changed in meaning over time).

Remember that you can use our template to summarise and evaluate sources you’re thinking about using!

Take notes and cite your sources

As you read, you should also begin the writing process. Take notes that you can later incorporate into the text of your literature review.

It’s important to keep track of your sources with references to avoid plagiarism . It can be helpful to make an annotated bibliography, where you compile full reference information and write a paragraph of summary and analysis for each source. This helps you remember what you read and saves time later in the process.

You can use our free APA Reference Generator for quick, correct, consistent citations.

To begin organising your literature review’s argument and structure, you need to understand the connections and relationships between the sources you’ve read. Based on your reading and notes, you can look for:

• Trends and patterns (in theory, method or results): do certain approaches become more or less popular over time?
• Themes: what questions or concepts recur across the literature?
• Debates, conflicts and contradictions: where do sources disagree?
• Pivotal publications: are there any influential theories or studies that changed the direction of the field?
• Gaps: what is missing from the literature? Are there weaknesses that need to be addressed?

This step will help you work out the structure of your literature review and (if applicable) show how your own research will contribute to existing knowledge.

• Most research has focused on young women.
• There is an increasing interest in the visual aspects of social media.
• But there is still a lack of robust research on highly-visual platforms like Instagram and Snapchat – this is a gap that you could address in your own research.

There are various approaches to organising the body of a literature review. You should have a rough idea of your strategy before you start writing.

Depending on the length of your literature review, you can combine several of these strategies (for example, your overall structure might be thematic, but each theme is discussed chronologically).

Chronological

The simplest approach is to trace the development of the topic over time. However, if you choose this strategy, be careful to avoid simply listing and summarising sources in order.

Try to analyse patterns, turning points and key debates that have shaped the direction of the field. Give your interpretation of how and why certain developments occurred.

If you have found some recurring central themes, you can organise your literature review into subsections that address different aspects of the topic.

For example, if you are reviewing literature about inequalities in migrant health outcomes, key themes might include healthcare policy, language barriers, cultural attitudes, legal status, and economic access.

Methodological

If you draw your sources from different disciplines or fields that use a variety of research methods , you might want to compare the results and conclusions that emerge from different approaches. For example:

• Look at what results have emerged in qualitative versus quantitative research
• Discuss how the topic has been approached by empirical versus theoretical scholarship
• Divide the literature into sociological, historical, and cultural sources

Theoretical

A literature review is often the foundation for a theoretical framework . You can use it to discuss various theories, models, and definitions of key concepts.

You might argue for the relevance of a specific theoretical approach, or combine various theoretical concepts to create a framework for your research.

Like any other academic text, your literature review should have an introduction , a main body, and a conclusion . What you include in each depends on the objective of your literature review.

The introduction should clearly establish the focus and purpose of the literature review.

If you are writing the literature review as part of your dissertation or thesis, reiterate your central problem or research question and give a brief summary of the scholarly context. You can emphasise the timeliness of the topic (“many recent studies have focused on the problem of x”) or highlight a gap in the literature (“while there has been much research on x, few researchers have taken y into consideration”).

Depending on the length of your literature review, you might want to divide the body into subsections. You can use a subheading for each theme, time period, or methodological approach.

As you write, make sure to follow these tips:

• Summarise and synthesise: give an overview of the main points of each source and combine them into a coherent whole.
• Analyse and interpret: don’t just paraphrase other researchers – add your own interpretations, discussing the significance of findings in relation to the literature as a whole.
• Critically evaluate: mention the strengths and weaknesses of your sources.
• Write in well-structured paragraphs: use transitions and topic sentences to draw connections, comparisons and contrasts.

In the conclusion, you should summarise the key findings you have taken from the literature and emphasise their significance.

If the literature review is part of your dissertation or thesis, reiterate how your research addresses gaps and contributes new knowledge, or discuss how you have drawn on existing theories and methods to build a framework for your research. This can lead directly into your methodology section.

A literature review is a survey of scholarly sources (such as books, journal articles, and theses) related to a specific topic or research question .

It is often written as part of a dissertation , thesis, research paper , or proposal .

There are several reasons to conduct a literature review at the beginning of a research project:

• To familiarise yourself with the current state of knowledge on your topic
• To ensure that you’re not just repeating what others have already done
• To identify gaps in knowledge and unresolved problems that your research can address
• To develop your theoretical framework and methodology
• To provide an overview of the key findings and debates on the topic

Writing the literature review shows your reader how your work relates to existing research and what new insights it will contribute.

The literature review usually comes near the beginning of your  dissertation . After the introduction , it grounds your research in a scholarly field and leads directly to your theoretical framework or methodology .

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• 04 December 2020
• Correction 09 December 2020

How to write a superb literature review

Andy Tay is a freelance writer based in Singapore.

You can also search for this author in PubMed   Google Scholar

Literature reviews are important resources for scientists. They provide historical context for a field while offering opinions on its future trajectory. Creating them can provide inspiration for one’s own research, as well as some practice in writing. But few scientists are trained in how to write a review — or in what constitutes an excellent one. Even picking the appropriate software to use can be an involved decision (see ‘Tools and techniques’). So Nature asked editors and working scientists with well-cited reviews for their tips.

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doi: https://doi.org/10.1038/d41586-020-03422-x

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Updates & Corrections

Correction 09 December 2020 : An earlier version of the tables in this article included some incorrect details about the programs Zotero, Endnote and Manubot. These have now been corrected.

Hsing, I.-M., Xu, Y. & Zhao, W. Electroanalysis 19 , 755–768 (2007).

Article   Google Scholar  

Ledesma, H. A. et al. Nature Nanotechnol. 14 , 645–657 (2019).

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Brahlek, M., Koirala, N., Bansal, N. & Oh, S. Solid State Commun. 215–216 , 54–62 (2015).

Choi, Y. & Lee, S. Y. Nature Rev. Chem . https://doi.org/10.1038/s41570-020-00221-w (2020).

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How to Write a Literature Review

What is a literature review.

• What Is the Literature
• Writing the Review

A literature review is much more than an annotated bibliography or a list of separate reviews of articles and books. It is a critical, analytical summary and synthesis of the current knowledge of a topic. Thus it should compare and relate different theories, findings, etc, rather than just summarize them individually. In addition, it should have a particular focus or theme to organize the review. It does not have to be an exhaustive account of everything published on the topic, but it should discuss all the significant academic literature and other relevant sources important for that focus.

This is meant to be a general guide to writing a literature review: ways to structure one, what to include, how it supplements other research. For more specific help on writing a review, and especially for help on finding the literature to review, sign up for a Personal Research Session .

The specific organization of a literature review depends on the type and purpose of the review, as well as on the specific field or topic being reviewed. But in general, it is a relatively brief but thorough exploration of past and current work on a topic. Rather than a chronological listing of previous work, though, literature reviews are usually organized thematically, such as different theoretical approaches, methodologies, or specific issues or concepts involved in the topic. A thematic organization makes it much easier to examine contrasting perspectives, theoretical approaches, methodologies, findings, etc, and to analyze the strengths and weaknesses of, and point out any gaps in, previous research. And this is the heart of what a literature review is about. A literature review may offer new interpretations, theoretical approaches, or other ideas; if it is part of a research proposal or report it should demonstrate the relationship of the proposed or reported research to others' work; but whatever else it does, it must provide a critical overview of the current state of research efforts. 

Literature reviews are common and very important in the sciences and social sciences. They are less common and have a less important role in the humanities, but they do have a place, especially stand-alone reviews.

Types of Literature Reviews

There are different types of literature reviews, and different purposes for writing a review, but the most common are:

• Stand-alone literature review articles . These provide an overview and analysis of the current state of research on a topic or question. The goal is to evaluate and compare previous research on a topic to provide an analysis of what is currently known, and also to reveal controversies, weaknesses, and gaps in current work, thus pointing to directions for future research. You can find examples published in any number of academic journals, but there is a series of Annual Reviews of *Subject* which are specifically devoted to literature review articles. Writing a stand-alone review is often an effective way to get a good handle on a topic and to develop ideas for your own research program. For example, contrasting theoretical approaches or conflicting interpretations of findings can be the basis of your research project: can you find evidence supporting one interpretation against another, or can you propose an alternative interpretation that overcomes their limitations?
• Part of a research proposal . This could be a proposal for a PhD dissertation, a senior thesis, or a class project. It could also be a submission for a grant. The literature review, by pointing out the current issues and questions concerning a topic, is a crucial part of demonstrating how your proposed research will contribute to the field, and thus of convincing your thesis committee to allow you to pursue the topic of your interest or a funding agency to pay for your research efforts.
• Part of a research report . When you finish your research and write your thesis or paper to present your findings, it should include a literature review to provide the context to which your work is a contribution. Your report, in addition to detailing the methods, results, etc. of your research, should show how your work relates to others' work.

A literature review for a research report is often a revision of the review for a research proposal, which can be a revision of a stand-alone review. Each revision should be a fairly extensive revision. With the increased knowledge of and experience in the topic as you proceed, your understanding of the topic will increase. Thus, you will be in a better position to analyze and critique the literature. In addition, your focus will change as you proceed in your research. Some areas of the literature you initially reviewed will be marginal or irrelevant for your eventual research, and you will need to explore other areas more thoroughly. 

Examples of Literature Reviews

See the series of Annual Reviews of *Subject* which are specifically devoted to literature review articles to find many examples of stand-alone literature reviews in the biomedical, physical, and social sciences. 

Research report articles vary in how they are organized, but a common general structure is to have sections such as:

• Abstract - Brief summary of the contents of the article
• Introduction - A explanation of the purpose of the study, a statement of the research question(s) the study intends to address
• Literature review - A critical assessment of the work done so far on this topic, to show how the current study relates to what has already been done
• Methods - How the study was carried out (e.g. instruments or equipment, procedures, methods to gather and analyze data)
• Results - What was found in the course of the study
• Discussion - What do the results mean
• Conclusion - State the conclusions and implications of the results, and discuss how it relates to the work reviewed in the literature review; also, point to directions for further work in the area

Here are some articles that illustrate variations on this theme. There is no need to read the entire articles (unless the contents interest you); just quickly browse through to see the sections, and see how each section is introduced and what is contained in them.

The Determinants of Undergraduate Grade Point Average: The Relative Importance of Family Background, High School Resources, and Peer Group Effects , in The Journal of Human Resources , v. 34 no. 2 (Spring 1999), p. 268-293.

This article has a standard breakdown of sections:

• Introduction
• Literature Review
• Some discussion sections

First Encounters of the Bureaucratic Kind: Early Freshman Experiences with a Campus Bureaucracy , in The Journal of Higher Education , v. 67 no. 6 (Nov-Dec 1996), p. 660-691.

This one does not have a section specifically labeled as a "literature review" or "review of the literature," but the first few sections cite a long list of other sources discussing previous research in the area before the authors present their own study they are reporting.

• Next: What Is the Literature >>
• Last Updated: Jan 11, 2024 9:48 AM
• URL: https://libguides.wesleyan.edu/litreview

• UConn Library
• Literature Review: The What, Why and How-to Guide
• Introduction

Literature Review: The What, Why and How-to Guide — Introduction

• Getting Started
• How to Pick a Topic
• Strategies to Find Sources
• Evaluating Sources & Lit. Reviews
• Tips for Writing Literature Reviews
• Writing Literature Review: Useful Sites
• Citation Resources
• Other Academic Writings

What are Literature Reviews?

So, what is a literature review? "A literature review is an account of what has been published on a topic by accredited scholars and researchers. In writing the literature review, your purpose is to convey to your reader what knowledge and ideas have been established on a topic, and what their strengths and weaknesses are. As a piece of writing, the literature review must be defined by a guiding concept (e.g., your research objective, the problem or issue you are discussing, or your argumentative thesis). It is not just a descriptive list of the material available, or a set of summaries." Taylor, D.  The literature review: A few tips on conducting it . University of Toronto Health Sciences Writing Centre.

Goals of Literature Reviews

What are the goals of creating a Literature Review?  A literature could be written to accomplish different aims:

• To develop a theory or evaluate an existing theory
• To summarize the historical or existing state of a research topic
• Identify a problem in a field of research 

Baumeister, R. F., & Leary, M. R. (1997). Writing narrative literature reviews .  Review of General Psychology , 1 (3), 311-320.

What kinds of sources require a Literature Review?

• A research paper assigned in a course
• A thesis or dissertation
• A grant proposal
• An article intended for publication in a journal

All these instances require you to collect what has been written about your research topic so that you can demonstrate how your own research sheds new light on the topic.

Types of Literature Reviews

What kinds of literature reviews are written?

Narrative review: The purpose of this type of review is to describe the current state of the research on a specific topic/research and to offer a critical analysis of the literature reviewed. Studies are grouped by research/theoretical categories, and themes and trends, strengths and weakness, and gaps are identified. The review ends with a conclusion section which summarizes the findings regarding the state of the research of the specific study, the gaps identify and if applicable, explains how the author's research will address gaps identify in the review and expand the knowledge on the topic reviewed.

• Example : Predictors and Outcomes of U.S. Quality Maternity Leave: A Review and Conceptual Framework:  10.1177/08948453211037398  

Systematic review : "The authors of a systematic review use a specific procedure to search the research literature, select the studies to include in their review, and critically evaluate the studies they find." (p. 139). Nelson, L. K. (2013). Research in Communication Sciences and Disorders . Plural Publishing.

• Example : The effect of leave policies on increasing fertility: a systematic review:  10.1057/s41599-022-01270-w

Meta-analysis : "Meta-analysis is a method of reviewing research findings in a quantitative fashion by transforming the data from individual studies into what is called an effect size and then pooling and analyzing this information. The basic goal in meta-analysis is to explain why different outcomes have occurred in different studies." (p. 197). Roberts, M. C., & Ilardi, S. S. (2003). Handbook of Research Methods in Clinical Psychology . Blackwell Publishing.

• Example : Employment Instability and Fertility in Europe: A Meta-Analysis:  10.1215/00703370-9164737

Meta-synthesis : "Qualitative meta-synthesis is a type of qualitative study that uses as data the findings from other qualitative studies linked by the same or related topic." (p.312). Zimmer, L. (2006). Qualitative meta-synthesis: A question of dialoguing with texts .  Journal of Advanced Nursing , 53 (3), 311-318.

• Example : Women’s perspectives on career successes and barriers: A qualitative meta-synthesis:  10.1177/05390184221113735

Literature Reviews in the Health Sciences

• UConn Health subject guide on systematic reviews Explanation of the different review types used in health sciences literature as well as tools to help you find the right review type
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Literature Review

• Getting Started
• Framing the Literature Review

Literature Review Process

• Mistakes to Avoid & Additional Help

The structure of a literature review should include the following :

• An overview of the subject, issue or theory under consideration, along with the objectives of the literature review,
• Division of works under review into themes or categories (e.g. works that support of a particular position, those against, and those offering alternative approaches entirely),
• An explanation of how each work is similar to and how it varies from the others,
• Conclusions as to which pieces are best considered in their argument, are most convincing of their opinions, and make the greatest contribution to the understanding and development of their area of research

The critical evaluation of each work should consider :

• Provenance  -- what are the author's credentials? Are the author's arguments supported by evidence (e.g. primary historical material, case studies, narratives, statistics, recent scientific findings)?
• Objectivity  -- is the author's perspective even-handed or prejudicial? Is contrary data considered or is certain pertinent information ignored to prove the author's point?
• Persuasiveness  -- which of the author's theses are most/least convincing?
• Value  -- are the author's arguments and conclusions convincing? Does the work ultimately contribute in any significant way to an understanding of the subject?

Development of the Literature Review

Four stages:.

• Introduce the reader to the importance of the topic being studied . The reader is oriented to the significance of the study and the research questions or hypotheses to follow.
• Places the problem into a particular context  that defines the parameters of what is to be investigated.
• Provides the framework for reporting the results  and indicates what is probably necessary to conduct the study and explain how the findings will present this information.
• Literature search -- finding materials relevant to the subject being explored.
• Evaluation of resources  -- determining which literature makes a significant contribution to the understanding of the topic.
• Analysis and interpretation -- discussing the findings and conclusions of pertinent literature.

Consider the following issues before writing the literature review:

Sources and expectations.  if your assignment is not very specific about what form your literature review should take, seek clarification from your professor by asking these questions:.

• Roughly how many sources should I include?
• What types of sources should I review (books, journal articles, websites)?
• Should I summarize, synthesize, or critique your sources by discussing a common theme or issue?
• Should I evaluate the sources?
• Should I provide subheadings and other background information, such as definitions and/or a history?

Find Models.   When reviewing the current literature, examine how authors in your discipline or area of interest have organized their literature reviews. Read not only for information, but also to get a sense of the types of themes you might want to look for in your own research review.

Narrow the topic.  the narrower your topic, the easier it will be to limit the number of sources you need to read in order to obtain a good survey of relevant resources., consider whether your sources are current and applicable.  s ome disciplines require that you use information that is as current as possible. this is very common in the sciences where research conducted only two years ago could be obsolete. however, when writing a review in the social sciences, a survey of the history of the literature may be what is needed because what is important is how perspectives have changed over the years or within a certain time period. try sorting through some other current bibliographies or literature reviews in the field to get a sense of what your discipline expects. you can also use this method to consider what is consider by scholars to be a "hot topic" and what is not., follow the bread crumb trail.  the bibliography or reference section of sources you read are excellent entry points for further exploration. you might find resourced listed in a bibliography that points you in the direction you wish to take your own research., ways to organize your literature review, chronologically:  .

If your review follows the chronological method, you could write about the materials according to when they were published or the time period they cover.

By Publication:  

Order your sources chronologically by publication date, only if the order demonstrates a more important trend. For instance, you could order a review of literature on environmental studies of brown fields if the progression revealed, for example, a change in the soil collection practices of the researchers who wrote and/or conducted the studies.

Conceptual Categories:

The literature review is organized around a topic or issue, rather than the progression of time. However, progression of time may still be an important factor in a thematic review. For example, a review of the Internet’s impact on American presidential politics could focus on the development of online political satire. While the study focuses on one topic, the Internet’s impact on American presidential politics, it will still be organized chronologically reflecting technological developments in media. The only difference here between a "chronological" and a "thematic" approach is what is emphasized the most.

Methodological:  

A methodological approach focuses on the methods utilized by the researcher.  A methodological scope will influence either the types of documents in the review or the way in which these documents are discussed.

Sections of Your Literature Review:  

Once you've decided on the organizational method for your literature review, the sections you need to include should be easy to figure out because they arise from your organizational strategy.

Here are examples of other sections you may need to include depending on the type of review you write:

• Current Situation : information necessary to understand the topic or focus of the literature review.
• History : the chronological progression of the field, the literature, or an idea that is necessary to understand the literature review, if the body of the literature review is not already a chronology.
• Selection Methods : the criteria you used to select (and perhaps exclude) sources in your literature review. For instance, you might explain that your review includes only peer-reviewed articles and journals.
• Standards : the way in which you present your information.
• Questions for Further Research : What questions about the field has the review sparked? How will you further your research as a result of the review?

Writing Your Literature Review

Once you've settled on how to organize your literature review, you're ready to write each section. When writing your review, keep in mind these issues.

Use Evidence:

A literature review in this sense is just like any other academic research paper. Your interpretation of the available sources must be backed up with evidence to show that what you are saying is valid.

Be Selective:  

Select only the most important points in each source to highlight in the review. The type of information you choose to mention should relate directly to the research problem, whether it is thematic, methodological, or chronological.

Use Quotes Sparingly:  

Some short quotes are okay if you want to emphasize a point, or if what the author said just cannot be rewritten in your own words. Sometimes you may need to quote certain terms that were coined by the author, not common knowledge, or taken directly from the study. Do not use extensive quotes as a substitute your own summary and interpretation of the literature.

Summarize and Synthesize:  

Remember to summarize and synthesize your sources within each paragraph as well as throughout the review. Recapitulate important features of a research study, but then synthesize it by rephrasing the study's significance and relating it to their own work.

Keep Your Own Voice:  

While the literature review presents others' ideas, your voice (the writer's) should remain front and center. For example, weave references to other sources into what you are writing but maintain your own voice by starting and ending the paragraph with your own ideas and wording.

Use Caution When Paraphrasing:  

When paraphrasing a source that is not your own, be sure to represent the author's information or opinions accurately and in your own words. Even when paraphrasing an author’s work, you still must provide a citation to that work.

• << Previous: Getting Started
• Next: Mistakes to Avoid & Additional Help >>
• Last Updated: Oct 3, 2023 2:44 PM
• URL: https://guides.franklin.edu/LITREVIEW

• University of Texas Libraries

Literature Reviews

• What is a literature review?
• Steps in the Literature Review Process
• Define your research question
• Determine inclusion and exclusion criteria
• Choose databases and search
• Review Results
• Synthesize Results
• Analyze Results
• Librarian Support

What is a Literature Review?

A literature or narrative review is a comprehensive review and analysis of the published literature on a specific topic or research question. The literature that is reviewed contains: books, articles, academic articles, conference proceedings, association papers, and dissertations. It contains the most pertinent studies and points to important past and current research and practices. It provides background and context, and shows how your research will contribute to the field. 

A literature review should: 

• Provide a comprehensive and updated review of the literature;
• Explain why this review has taken place;
• Articulate a position or hypothesis;
• Acknowledge and account for conflicting and corroborating points of view

From  S age Research Methods

Purpose of a Literature Review

A literature review can be written as an introduction to a study to:

• Demonstrate how a study fills a gap in research
• Compare a study with other research that's been done

Or it can be a separate work (a research article on its own) which:

• Organizes or describes a topic
• Describes variables within a particular issue/problem

Limitations of a Literature Review

Some of the limitations of a literature review are:

• It's a snapshot in time. Unlike other reviews, this one has beginning, a middle and an end. There may be future developments that could make your work less relevant.
• It may be too focused. Some niche studies may miss the bigger picture.
• It can be difficult to be comprehensive. There is no way to make sure all the literature on a topic was considered.
• It is easy to be biased if you stick to top tier journals. There may be other places where people are publishing exemplary research. Look to open access publications and conferences to reflect a more inclusive collection. Also, make sure to include opposing views (and not just supporting evidence).

Source: Grant, Maria J., and Andrew Booth. “A Typology of Reviews: An Analysis of 14 Review Types and Associated Methodologies.” Health Information & Libraries Journal, vol. 26, no. 2, June 2009, pp. 91–108. Wiley Online Library, doi:10.1111/j.1471-1842.2009.00848.x.

Meryl Brodsky : Communication and Information Studies

Hannah Chapman Tripp : Biology, Neuroscience

Carolyn Cunningham : Human Development & Family Sciences, Psychology, Sociology

Larayne Dallas : Engineering

Janelle Hedstrom : Special Education, Curriculum & Instruction, Ed Leadership & Policy ​

Susan Macicak : Linguistics

Imelda Vetter : Dell Medical School

For help in other subject areas, please see the guide to library specialists by subject .

Periodically, UT Libraries runs a workshop covering the basics and library support for literature reviews. While we try to offer these once per academic year, we find providing the recording to be helpful to community members who have missed the session. Following is the most recent recording of the workshop, Conducting a Literature Review. To view the recording, a UT login is required.

• October 26, 2022 recording
• Last Updated: Oct 26, 2022 2:49 PM
• URL: https://guides.lib.utexas.edu/literaturereviews

Reference management. Clean and simple.

What is a literature review? [with examples]

What is a literature review?

The purpose of a literature review, how to write a literature review, the format of a literature review, general formatting rules, the length of a literature review, literature review examples, frequently asked questions about literature reviews, related articles.

A literature review is an assessment of the sources in a chosen topic of research.

In a literature review, you’re expected to report on the existing scholarly conversation, without adding new contributions.

If you are currently writing one, you've come to the right place. In the following paragraphs, we will explain:

• the objective of a literature review
• how to write a literature review
• the basic format of a literature review

Tip: It’s not always mandatory to add a literature review in a paper. Theses and dissertations often include them, whereas research papers may not. Make sure to consult with your instructor for exact requirements.

The four main objectives of a literature review are:

• Studying the references of your research area
• Summarizing the main arguments
• Identifying current gaps, stances, and issues
• Presenting all of the above in a text

Ultimately, the main goal of a literature review is to provide the researcher with sufficient knowledge about the topic in question so that they can eventually make an intervention.

The format of a literature review is fairly standard. It includes an:

• introduction that briefly introduces the main topic
• body that includes the main discussion of the key arguments
• conclusion that highlights the gaps and issues of the literature

➡️ Take a look at our guide on how to write a literature review to learn more about how to structure a literature review.

First of all, a literature review should have its own labeled section. You should indicate clearly in the table of contents where the literature can be found, and you should label this section as “Literature Review.”

➡️ For more information on writing a thesis, visit our guide on how to structure a thesis .

There is no set amount of words for a literature review, so the length depends on the research. If you are working with a large amount of sources, it will be long. If your paper does not depend entirely on references, it will be short.

Take a look at these three theses featuring great literature reviews:

• School-Based Speech-Language Pathologist's Perceptions of Sensory Food Aversions in Children [ PDF , see page 20]
• Who's Writing What We Read: Authorship in Criminological Research [ PDF , see page 4]
• A Phenomenological Study of the Lived Experience of Online Instructors of Theological Reflection at Christian Institutions Accredited by the Association of Theological Schools [ PDF , see page 56]

Literature reviews are most commonly found in theses and dissertations. However, you find them in research papers as well.

There is no set amount of words for a literature review, so the length depends on the research. If you are working with a large amount of sources, then it will be long. If your paper does not depend entirely on references, then it will be short.

No. A literature review should have its own independent section. You should indicate clearly in the table of contents where the literature review can be found, and label this section as “Literature Review.”

The main goal of a literature review is to provide the researcher with sufficient knowledge about the topic in question so that they can eventually make an intervention.

Literature Reviews

What this handout is about.

This handout will explain what literature reviews are and offer insights into the form and construction of literature reviews in the humanities, social sciences, and sciences.

Introduction

OK. You’ve got to write a literature review. You dust off a novel and a book of poetry, settle down in your chair, and get ready to issue a “thumbs up” or “thumbs down” as you leaf through the pages. “Literature review” done. Right?

Wrong! The “literature” of a literature review refers to any collection of materials on a topic, not necessarily the great literary texts of the world. “Literature” could be anything from a set of government pamphlets on British colonial methods in Africa to scholarly articles on the treatment of a torn ACL. And a review does not necessarily mean that your reader wants you to give your personal opinion on whether or not you liked these sources.

What is a literature review, then?

A literature review discusses published information in a particular subject area, and sometimes information in a particular subject area within a certain time period.

A literature review can be just a simple summary of the sources, but it usually has an organizational pattern and combines both summary and synthesis. A summary is a recap of the important information of the source, but a synthesis is a re-organization, or a reshuffling, of that information. It might give a new interpretation of old material or combine new with old interpretations. Or it might trace the intellectual progression of the field, including major debates. And depending on the situation, the literature review may evaluate the sources and advise the reader on the most pertinent or relevant.

But how is a literature review different from an academic research paper?

The main focus of an academic research paper is to develop a new argument, and a research paper is likely to contain a literature review as one of its parts. In a research paper, you use the literature as a foundation and as support for a new insight that you contribute. The focus of a literature review, however, is to summarize and synthesize the arguments and ideas of others without adding new contributions.

Why do we write literature reviews?

Literature reviews provide you with a handy guide to a particular topic. If you have limited time to conduct research, literature reviews can give you an overview or act as a stepping stone. For professionals, they are useful reports that keep them up to date with what is current in the field. For scholars, the depth and breadth of the literature review emphasizes the credibility of the writer in his or her field. Literature reviews also provide a solid background for a research paper’s investigation. Comprehensive knowledge of the literature of the field is essential to most research papers.

Who writes these things, anyway?

Literature reviews are written occasionally in the humanities, but mostly in the sciences and social sciences; in experiment and lab reports, they constitute a section of the paper. Sometimes a literature review is written as a paper in itself.

Let’s get to it! What should I do before writing the literature review?

If your assignment is not very specific, seek clarification from your instructor:

• Roughly how many sources should you include?
• What types of sources (books, journal articles, websites)?
• Should you summarize, synthesize, or critique your sources by discussing a common theme or issue?
• Should you evaluate your sources?
• Should you provide subheadings and other background information, such as definitions and/or a history?

Find models

Look for other literature reviews in your area of interest or in the discipline and read them to get a sense of the types of themes you might want to look for in your own research or ways to organize your final review. You can simply put the word “review” in your search engine along with your other topic terms to find articles of this type on the Internet or in an electronic database. The bibliography or reference section of sources you’ve already read are also excellent entry points into your own research.

Narrow your topic

There are hundreds or even thousands of articles and books on most areas of study. The narrower your topic, the easier it will be to limit the number of sources you need to read in order to get a good survey of the material. Your instructor will probably not expect you to read everything that’s out there on the topic, but you’ll make your job easier if you first limit your scope.

Keep in mind that UNC Libraries have research guides and to databases relevant to many fields of study. You can reach out to the subject librarian for a consultation: https://library.unc.edu/support/consultations/ .

And don’t forget to tap into your professor’s (or other professors’) knowledge in the field. Ask your professor questions such as: “If you had to read only one book from the 90’s on topic X, what would it be?” Questions such as this help you to find and determine quickly the most seminal pieces in the field.

Consider whether your sources are current

Some disciplines require that you use information that is as current as possible. In the sciences, for instance, treatments for medical problems are constantly changing according to the latest studies. Information even two years old could be obsolete. However, if you are writing a review in the humanities, history, or social sciences, a survey of the history of the literature may be what is needed, because what is important is how perspectives have changed through the years or within a certain time period. Try sorting through some other current bibliographies or literature reviews in the field to get a sense of what your discipline expects. You can also use this method to consider what is currently of interest to scholars in this field and what is not.

Strategies for writing the literature review

Find a focus.

A literature review, like a term paper, is usually organized around ideas, not the sources themselves as an annotated bibliography would be organized. This means that you will not just simply list your sources and go into detail about each one of them, one at a time. No. As you read widely but selectively in your topic area, consider instead what themes or issues connect your sources together. Do they present one or different solutions? Is there an aspect of the field that is missing? How well do they present the material and do they portray it according to an appropriate theory? Do they reveal a trend in the field? A raging debate? Pick one of these themes to focus the organization of your review.

Convey it to your reader

A literature review may not have a traditional thesis statement (one that makes an argument), but you do need to tell readers what to expect. Try writing a simple statement that lets the reader know what is your main organizing principle. Here are a couple of examples:

The current trend in treatment for congestive heart failure combines surgery and medicine. More and more cultural studies scholars are accepting popular media as a subject worthy of academic consideration.

Consider organization

You’ve got a focus, and you’ve stated it clearly and directly. Now what is the most effective way of presenting the information? What are the most important topics, subtopics, etc., that your review needs to include? And in what order should you present them? Develop an organization for your review at both a global and local level:

First, cover the basic categories

Just like most academic papers, literature reviews also must contain at least three basic elements: an introduction or background information section; the body of the review containing the discussion of sources; and, finally, a conclusion and/or recommendations section to end the paper. The following provides a brief description of the content of each:

• Introduction: Gives a quick idea of the topic of the literature review, such as the central theme or organizational pattern.
• Body: Contains your discussion of sources and is organized either chronologically, thematically, or methodologically (see below for more information on each).
• Conclusions/Recommendations: Discuss what you have drawn from reviewing literature so far. Where might the discussion proceed?

Organizing the body

Once you have the basic categories in place, then you must consider how you will present the sources themselves within the body of your paper. Create an organizational method to focus this section even further.

To help you come up with an overall organizational framework for your review, consider the following scenario:

You’ve decided to focus your literature review on materials dealing with sperm whales. This is because you’ve just finished reading Moby Dick, and you wonder if that whale’s portrayal is really real. You start with some articles about the physiology of sperm whales in biology journals written in the 1980’s. But these articles refer to some British biological studies performed on whales in the early 18th century. So you check those out. Then you look up a book written in 1968 with information on how sperm whales have been portrayed in other forms of art, such as in Alaskan poetry, in French painting, or on whale bone, as the whale hunters in the late 19th century used to do. This makes you wonder about American whaling methods during the time portrayed in Moby Dick, so you find some academic articles published in the last five years on how accurately Herman Melville portrayed the whaling scene in his novel.

Now consider some typical ways of organizing the sources into a review:

• Chronological: If your review follows the chronological method, you could write about the materials above according to when they were published. For instance, first you would talk about the British biological studies of the 18th century, then about Moby Dick, published in 1851, then the book on sperm whales in other art (1968), and finally the biology articles (1980s) and the recent articles on American whaling of the 19th century. But there is relatively no continuity among subjects here. And notice that even though the sources on sperm whales in other art and on American whaling are written recently, they are about other subjects/objects that were created much earlier. Thus, the review loses its chronological focus.
• By publication: Order your sources by publication chronology, then, only if the order demonstrates a more important trend. For instance, you could order a review of literature on biological studies of sperm whales if the progression revealed a change in dissection practices of the researchers who wrote and/or conducted the studies.
• By trend: A better way to organize the above sources chronologically is to examine the sources under another trend, such as the history of whaling. Then your review would have subsections according to eras within this period. For instance, the review might examine whaling from pre-1600-1699, 1700-1799, and 1800-1899. Under this method, you would combine the recent studies on American whaling in the 19th century with Moby Dick itself in the 1800-1899 category, even though the authors wrote a century apart.
• Thematic: Thematic reviews of literature are organized around a topic or issue, rather than the progression of time. However, progression of time may still be an important factor in a thematic review. For instance, the sperm whale review could focus on the development of the harpoon for whale hunting. While the study focuses on one topic, harpoon technology, it will still be organized chronologically. The only difference here between a “chronological” and a “thematic” approach is what is emphasized the most: the development of the harpoon or the harpoon technology.But more authentic thematic reviews tend to break away from chronological order. For instance, a thematic review of material on sperm whales might examine how they are portrayed as “evil” in cultural documents. The subsections might include how they are personified, how their proportions are exaggerated, and their behaviors misunderstood. A review organized in this manner would shift between time periods within each section according to the point made.
• Methodological: A methodological approach differs from the two above in that the focusing factor usually does not have to do with the content of the material. Instead, it focuses on the “methods” of the researcher or writer. For the sperm whale project, one methodological approach would be to look at cultural differences between the portrayal of whales in American, British, and French art work. Or the review might focus on the economic impact of whaling on a community. A methodological scope will influence either the types of documents in the review or the way in which these documents are discussed. Once you’ve decided on the organizational method for the body of the review, the sections you need to include in the paper should be easy to figure out. They should arise out of your organizational strategy. In other words, a chronological review would have subsections for each vital time period. A thematic review would have subtopics based upon factors that relate to the theme or issue.

Sometimes, though, you might need to add additional sections that are necessary for your study, but do not fit in the organizational strategy of the body. What other sections you include in the body is up to you. Put in only what is necessary. Here are a few other sections you might want to consider:

• Current Situation: Information necessary to understand the topic or focus of the literature review.
• History: The chronological progression of the field, the literature, or an idea that is necessary to understand the literature review, if the body of the literature review is not already a chronology.
• Methods and/or Standards: The criteria you used to select the sources in your literature review or the way in which you present your information. For instance, you might explain that your review includes only peer-reviewed articles and journals.

Questions for Further Research: What questions about the field has the review sparked? How will you further your research as a result of the review?

Begin composing

Once you’ve settled on a general pattern of organization, you’re ready to write each section. There are a few guidelines you should follow during the writing stage as well. Here is a sample paragraph from a literature review about sexism and language to illuminate the following discussion:

However, other studies have shown that even gender-neutral antecedents are more likely to produce masculine images than feminine ones (Gastil, 1990). Hamilton (1988) asked students to complete sentences that required them to fill in pronouns that agreed with gender-neutral antecedents such as “writer,” “pedestrian,” and “persons.” The students were asked to describe any image they had when writing the sentence. Hamilton found that people imagined 3.3 men to each woman in the masculine “generic” condition and 1.5 men per woman in the unbiased condition. Thus, while ambient sexism accounted for some of the masculine bias, sexist language amplified the effect. (Source: Erika Falk and Jordan Mills, “Why Sexist Language Affects Persuasion: The Role of Homophily, Intended Audience, and Offense,” Women and Language19:2).

Use evidence

In the example above, the writers refer to several other sources when making their point. A literature review in this sense is just like any other academic research paper. Your interpretation of the available sources must be backed up with evidence to show that what you are saying is valid.

Be selective

Select only the most important points in each source to highlight in the review. The type of information you choose to mention should relate directly to the review’s focus, whether it is thematic, methodological, or chronological.

Use quotes sparingly

Falk and Mills do not use any direct quotes. That is because the survey nature of the literature review does not allow for in-depth discussion or detailed quotes from the text. Some short quotes here and there are okay, though, if you want to emphasize a point, or if what the author said just cannot be rewritten in your own words. Notice that Falk and Mills do quote certain terms that were coined by the author, not common knowledge, or taken directly from the study. But if you find yourself wanting to put in more quotes, check with your instructor.

Summarize and synthesize

Remember to summarize and synthesize your sources within each paragraph as well as throughout the review. The authors here recapitulate important features of Hamilton’s study, but then synthesize it by rephrasing the study’s significance and relating it to their own work.

Keep your own voice

While the literature review presents others’ ideas, your voice (the writer’s) should remain front and center. Notice that Falk and Mills weave references to other sources into their own text, but they still maintain their own voice by starting and ending the paragraph with their own ideas and their own words. The sources support what Falk and Mills are saying.

Use caution when paraphrasing

When paraphrasing a source that is not your own, be sure to represent the author’s information or opinions accurately and in your own words. In the preceding example, Falk and Mills either directly refer in the text to the author of their source, such as Hamilton, or they provide ample notation in the text when the ideas they are mentioning are not their own, for example, Gastil’s. For more information, please see our handout on plagiarism .

Revise, revise, revise

Draft in hand? Now you’re ready to revise. Spending a lot of time revising is a wise idea, because your main objective is to present the material, not the argument. So check over your review again to make sure it follows the assignment and/or your outline. Then, just as you would for most other academic forms of writing, rewrite or rework the language of your review so that you’ve presented your information in the most concise manner possible. Be sure to use terminology familiar to your audience; get rid of unnecessary jargon or slang. Finally, double check that you’ve documented your sources and formatted the review appropriately for your discipline. For tips on the revising and editing process, see our handout on revising drafts .

Works consulted

We consulted these works while writing this handout. This is not a comprehensive list of resources on the handout’s topic, and we encourage you to do your own research to find additional publications. Please do not use this list as a model for the format of your own reference list, as it may not match the citation style you are using. For guidance on formatting citations, please see the UNC Libraries citation tutorial . We revise these tips periodically and welcome feedback.

Anson, Chris M., and Robert A. Schwegler. 2010. The Longman Handbook for Writers and Readers , 6th ed. New York: Longman.

Jones, Robert, Patrick Bizzaro, and Cynthia Selfe. 1997. The Harcourt Brace Guide to Writing in the Disciplines . New York: Harcourt Brace.

Lamb, Sandra E. 1998. How to Write It: A Complete Guide to Everything You’ll Ever Write . Berkeley: Ten Speed Press.

Rosen, Leonard J., and Laurence Behrens. 2003. The Allyn & Bacon Handbook , 5th ed. New York: Longman.

Troyka, Lynn Quittman, and Doug Hesse. 2016. Simon and Schuster Handbook for Writers , 11th ed. London: Pearson.

You may reproduce it for non-commercial use if you use the entire handout and attribute the source: The Writing Center, University of North Carolina at Chapel Hill

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What is a literature review?

A literature review is an integrated analysis -- not just a summary-- of scholarly writings and other relevant evidence related directly to your research question.  That is, it represents a synthesis of the evidence that provides background information on your topic and shows a association between the evidence and your research question.

A literature review may be a stand alone work or the introduction to a larger research paper, depending on the assignment.  Rely heavily on the guidelines your instructor has given you.

Why is it important?

A literature review is important because it:

• Explains the background of research on a topic.
• Demonstrates why a topic is significant to a subject area.
• Discovers relationships between research studies/ideas.
• Identifies major themes, concepts, and researchers on a topic.
• Identifies critical gaps and points of disagreement.
• Discusses further research questions that logically come out of the previous studies.

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1. Choose a topic. Define your research question.

Your literature review should be guided by your central research question.  The literature represents background and research developments related to a specific research question, interpreted and analyzed by you in a synthesized way.

• Make sure your research question is not too broad or too narrow.  Is it manageable?
• Begin writing down terms that are related to your question. These will be useful for searches later.
• If you have the opportunity, discuss your topic with your professor and your class mates.

2. Decide on the scope of your review

How many studies do you need to look at? How comprehensive should it be? How many years should it cover? 

• This may depend on your assignment.  How many sources does the assignment require?

3. Select the databases you will use to conduct your searches.

Make a list of the databases you will search. 

Where to find databases:

• use the tabs on this guide
• Find other databases in the Nursing Information Resources web page
• More on the Medical Library web page
• ... and more on the Yale University Library web page

4. Conduct your searches to find the evidence. Keep track of your searches.

• Use the key words in your question, as well as synonyms for those words, as terms in your search. Use the database tutorials for help.
• Save the searches in the databases. This saves time when you want to redo, or modify, the searches. It is also helpful to use as a guide is the searches are not finding any useful results.
• Review the abstracts of research studies carefully. This will save you time.
• Use the bibliographies and references of research studies you find to locate others.
• Check with your professor, or a subject expert in the field, if you are missing any key works in the field.
• Ask your librarian for help at any time.
• Use a citation manager, such as EndNote as the repository for your citations. See the EndNote tutorials for help.

Review the literature

Some questions to help you analyze the research:

• What was the research question of the study you are reviewing? What were the authors trying to discover?
• Was the research funded by a source that could influence the findings?
• What were the research methodologies? Analyze its literature review, the samples and variables used, the results, and the conclusions.
• Does the research seem to be complete? Could it have been conducted more soundly? What further questions does it raise?
• If there are conflicting studies, why do you think that is?
• How are the authors viewed in the field? Has this study been cited? If so, how has it been analyzed?

Tips: 

• Review the abstracts carefully.  
• Keep careful notes so that you may track your thought processes during the research process.
• Create a matrix of the studies for easy analysis, and synthesis, across all of the studies.
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A literature review is a review and synthesis of existing research on a topic or research question. A literature review is meant to analyze the scholarly literature, make connections across writings and identify strengths, weaknesses, trends, and missing conversations. A literature review should address different aspects of a topic as it relates to your research question. A literature review goes beyond a description or summary of the literature you have read. 

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A literature review surveys prior research published in books, scholarly articles, and any other sources relevant to a particular issue, area of research, or theory, and by so doing, provides a description, summary, and critical evaluation of these works in relation to the research problem being investigated. Literature reviews are designed to provide an overview of sources you have used in researching a particular topic and to demonstrate to your readers how your research fits within existing scholarship about the topic.

Fink, Arlene. Conducting Research Literature Reviews: From the Internet to Paper . Fourth edition. Thousand Oaks, CA: SAGE, 2014.

Importance of a Good Literature Review

A literature review may consist of simply a summary of key sources, but in the social sciences, a literature review usually has an organizational pattern and combines both summary and synthesis, often within specific conceptual categories . A summary is a recap of the important information of the source, but a synthesis is a re-organization, or a reshuffling, of that information in a way that informs how you are planning to investigate a research problem. The analytical features of a literature review might:

• Give a new interpretation of old material or combine new with old interpretations,
• Trace the intellectual progression of the field, including major debates,
• Depending on the situation, evaluate the sources and advise the reader on the most pertinent or relevant research, or
• Usually in the conclusion of a literature review, identify where gaps exist in how a problem has been researched to date.

Given this, the purpose of a literature review is to:

• Place each work in the context of its contribution to understanding the research problem being studied.
• Describe the relationship of each work to the others under consideration.
• Identify new ways to interpret prior research.
• Reveal any gaps that exist in the literature.
• Resolve conflicts amongst seemingly contradictory previous studies.
• Identify areas of prior scholarship to prevent duplication of effort.
• Point the way in fulfilling a need for additional research.
• Locate your own research within the context of existing literature [very important].

Fink, Arlene. Conducting Research Literature Reviews: From the Internet to Paper. 2nd ed. Thousand Oaks, CA: Sage, 2005; Hart, Chris. Doing a Literature Review: Releasing the Social Science Research Imagination . Thousand Oaks, CA: Sage Publications, 1998; Jesson, Jill. Doing Your Literature Review: Traditional and Systematic Techniques . Los Angeles, CA: SAGE, 2011; Knopf, Jeffrey W. "Doing a Literature Review." PS: Political Science and Politics 39 (January 2006): 127-132; Ridley, Diana. The Literature Review: A Step-by-Step Guide for Students . 2nd ed. Los Angeles, CA: SAGE, 2012.

Types of Literature Reviews

It is important to think of knowledge in a given field as consisting of three layers. First, there are the primary studies that researchers conduct and publish. Second are the reviews of those studies that summarize and offer new interpretations built from and often extending beyond the primary studies. Third, there are the perceptions, conclusions, opinion, and interpretations that are shared informally among scholars that become part of the body of epistemological traditions within the field.

In composing a literature review, it is important to note that it is often this third layer of knowledge that is cited as "true" even though it often has only a loose relationship to the primary studies and secondary literature reviews. Given this, while literature reviews are designed to provide an overview and synthesis of pertinent sources you have explored, there are a number of approaches you could adopt depending upon the type of analysis underpinning your study.

Argumentative Review This form examines literature selectively in order to support or refute an argument, deeply embedded assumption, or philosophical problem already established in the literature. The purpose is to develop a body of literature that establishes a contrarian viewpoint. Given the value-laden nature of some social science research [e.g., educational reform; immigration control], argumentative approaches to analyzing the literature can be a legitimate and important form of discourse. However, note that they can also introduce problems of bias when they are used to make summary claims of the sort found in systematic reviews [see below].

Integrative Review Considered a form of research that reviews, critiques, and synthesizes representative literature on a topic in an integrated way such that new frameworks and perspectives on the topic are generated. The body of literature includes all studies that address related or identical hypotheses or research problems. A well-done integrative review meets the same standards as primary research in regard to clarity, rigor, and replication. This is the most common form of review in the social sciences.

Historical Review Few things rest in isolation from historical precedent. Historical literature reviews focus on examining research throughout a period of time, often starting with the first time an issue, concept, theory, phenomena emerged in the literature, then tracing its evolution within the scholarship of a discipline. The purpose is to place research in a historical context to show familiarity with state-of-the-art developments and to identify the likely directions for future research.

Methodological Review A review does not always focus on what someone said [findings], but how they came about saying what they say [method of analysis]. Reviewing methods of analysis provides a framework of understanding at different levels [i.e. those of theory, substantive fields, research approaches, and data collection and analysis techniques], how researchers draw upon a wide variety of knowledge ranging from the conceptual level to practical documents for use in fieldwork in the areas of ontological and epistemological consideration, quantitative and qualitative integration, sampling, interviewing, data collection, and data analysis. This approach helps highlight ethical issues which you should be aware of and consider as you go through your own study.

Systematic Review This form consists of an overview of existing evidence pertinent to a clearly formulated research question, which uses pre-specified and standardized methods to identify and critically appraise relevant research, and to collect, report, and analyze data from the studies that are included in the review. The goal is to deliberately document, critically evaluate, and summarize scientifically all of the research about a clearly defined research problem . Typically it focuses on a very specific empirical question, often posed in a cause-and-effect form, such as "To what extent does A contribute to B?" This type of literature review is primarily applied to examining prior research studies in clinical medicine and allied health fields, but it is increasingly being used in the social sciences.

Theoretical Review The purpose of this form is to examine the corpus of theory that has accumulated in regard to an issue, concept, theory, phenomena. The theoretical literature review helps to establish what theories already exist, the relationships between them, to what degree the existing theories have been investigated, and to develop new hypotheses to be tested. Often this form is used to help establish a lack of appropriate theories or reveal that current theories are inadequate for explaining new or emerging research problems. The unit of analysis can focus on a theoretical concept or a whole theory or framework.

NOTE: Most often the literature review will incorporate some combination of types. For example, a review that examines literature supporting or refuting an argument, assumption, or philosophical problem related to the research problem will also need to include writing supported by sources that establish the history of these arguments in the literature.

Baumeister, Roy F. and Mark R. Leary. "Writing Narrative Literature Reviews."  Review of General Psychology 1 (September 1997): 311-320; Mark R. Fink, Arlene. Conducting Research Literature Reviews: From the Internet to Paper . 2nd ed. Thousand Oaks, CA: Sage, 2005; Hart, Chris. Doing a Literature Review: Releasing the Social Science Research Imagination . Thousand Oaks, CA: Sage Publications, 1998; Kennedy, Mary M. "Defining a Literature." Educational Researcher 36 (April 2007): 139-147; Petticrew, Mark and Helen Roberts. Systematic Reviews in the Social Sciences: A Practical Guide . Malden, MA: Blackwell Publishers, 2006; Torracro, Richard. "Writing Integrative Literature Reviews: Guidelines and Examples." Human Resource Development Review 4 (September 2005): 356-367; Rocco, Tonette S. and Maria S. Plakhotnik. "Literature Reviews, Conceptual Frameworks, and Theoretical Frameworks: Terms, Functions, and Distinctions." Human Ressource Development Review 8 (March 2008): 120-130; Sutton, Anthea. Systematic Approaches to a Successful Literature Review . Los Angeles, CA: Sage Publications, 2016.

Structure and Writing Style

I.  Thinking About Your Literature Review

The structure of a literature review should include the following in support of understanding the research problem :

• An overview of the subject, issue, or theory under consideration, along with the objectives of the literature review,
• Division of works under review into themes or categories [e.g. works that support a particular position, those against, and those offering alternative approaches entirely],
• An explanation of how each work is similar to and how it varies from the others,
• Conclusions as to which pieces are best considered in their argument, are most convincing of their opinions, and make the greatest contribution to the understanding and development of their area of research.

The critical evaluation of each work should consider :

• Provenance -- what are the author's credentials? Are the author's arguments supported by evidence [e.g. primary historical material, case studies, narratives, statistics, recent scientific findings]?
• Methodology -- were the techniques used to identify, gather, and analyze the data appropriate to addressing the research problem? Was the sample size appropriate? Were the results effectively interpreted and reported?
• Objectivity -- is the author's perspective even-handed or prejudicial? Is contrary data considered or is certain pertinent information ignored to prove the author's point?
• Persuasiveness -- which of the author's theses are most convincing or least convincing?
• Validity -- are the author's arguments and conclusions convincing? Does the work ultimately contribute in any significant way to an understanding of the subject?

II.  Development of the Literature Review

Four Basic Stages of Writing 1.  Problem formulation -- which topic or field is being examined and what are its component issues? 2.  Literature search -- finding materials relevant to the subject being explored. 3.  Data evaluation -- determining which literature makes a significant contribution to the understanding of the topic. 4.  Analysis and interpretation -- discussing the findings and conclusions of pertinent literature.

Consider the following issues before writing the literature review: Clarify If your assignment is not specific about what form your literature review should take, seek clarification from your professor by asking these questions: 1.  Roughly how many sources would be appropriate to include? 2.  What types of sources should I review (books, journal articles, websites; scholarly versus popular sources)? 3.  Should I summarize, synthesize, or critique sources by discussing a common theme or issue? 4.  Should I evaluate the sources in any way beyond evaluating how they relate to understanding the research problem? 5.  Should I provide subheadings and other background information, such as definitions and/or a history? Find Models Use the exercise of reviewing the literature to examine how authors in your discipline or area of interest have composed their literature review sections. Read them to get a sense of the types of themes you might want to look for in your own research or to identify ways to organize your final review. The bibliography or reference section of sources you've already read, such as required readings in the course syllabus, are also excellent entry points into your own research. Narrow the Topic The narrower your topic, the easier it will be to limit the number of sources you need to read in order to obtain a good survey of relevant resources. Your professor will probably not expect you to read everything that's available about the topic, but you'll make the act of reviewing easier if you first limit scope of the research problem. A good strategy is to begin by searching the USC Libraries Catalog for recent books about the topic and review the table of contents for chapters that focuses on specific issues. You can also review the indexes of books to find references to specific issues that can serve as the focus of your research. For example, a book surveying the history of the Israeli-Palestinian conflict may include a chapter on the role Egypt has played in mediating the conflict, or look in the index for the pages where Egypt is mentioned in the text. Consider Whether Your Sources are Current Some disciplines require that you use information that is as current as possible. This is particularly true in disciplines in medicine and the sciences where research conducted becomes obsolete very quickly as new discoveries are made. However, when writing a review in the social sciences, a survey of the history of the literature may be required. In other words, a complete understanding the research problem requires you to deliberately examine how knowledge and perspectives have changed over time. Sort through other current bibliographies or literature reviews in the field to get a sense of what your discipline expects. You can also use this method to explore what is considered by scholars to be a "hot topic" and what is not.

III.  Ways to Organize Your Literature Review

Chronology of Events If your review follows the chronological method, you could write about the materials according to when they were published. This approach should only be followed if a clear path of research building on previous research can be identified and that these trends follow a clear chronological order of development. For example, a literature review that focuses on continuing research about the emergence of German economic power after the fall of the Soviet Union. By Publication Order your sources by publication chronology, then, only if the order demonstrates a more important trend. For instance, you could order a review of literature on environmental studies of brown fields if the progression revealed, for example, a change in the soil collection practices of the researchers who wrote and/or conducted the studies. Thematic [“conceptual categories”] A thematic literature review is the most common approach to summarizing prior research in the social and behavioral sciences. Thematic reviews are organized around a topic or issue, rather than the progression of time, although the progression of time may still be incorporated into a thematic review. For example, a review of the Internet’s impact on American presidential politics could focus on the development of online political satire. While the study focuses on one topic, the Internet’s impact on American presidential politics, it would still be organized chronologically reflecting technological developments in media. The difference in this example between a "chronological" and a "thematic" approach is what is emphasized the most: themes related to the role of the Internet in presidential politics. Note that more authentic thematic reviews tend to break away from chronological order. A review organized in this manner would shift between time periods within each section according to the point being made. Methodological A methodological approach focuses on the methods utilized by the researcher. For the Internet in American presidential politics project, one methodological approach would be to look at cultural differences between the portrayal of American presidents on American, British, and French websites. Or the review might focus on the fundraising impact of the Internet on a particular political party. A methodological scope will influence either the types of documents in the review or the way in which these documents are discussed.

Other Sections of Your Literature Review Once you've decided on the organizational method for your literature review, the sections you need to include in the paper should be easy to figure out because they arise from your organizational strategy. In other words, a chronological review would have subsections for each vital time period; a thematic review would have subtopics based upon factors that relate to the theme or issue. However, sometimes you may need to add additional sections that are necessary for your study, but do not fit in the organizational strategy of the body. What other sections you include in the body is up to you. However, only include what is necessary for the reader to locate your study within the larger scholarship about the research problem.

Here are examples of other sections, usually in the form of a single paragraph, you may need to include depending on the type of review you write:

• Current Situation : Information necessary to understand the current topic or focus of the literature review.
• Sources Used : Describes the methods and resources [e.g., databases] you used to identify the literature you reviewed.
• History : The chronological progression of the field, the research literature, or an idea that is necessary to understand the literature review, if the body of the literature review is not already a chronology.
• Selection Methods : Criteria you used to select (and perhaps exclude) sources in your literature review. For instance, you might explain that your review includes only peer-reviewed [i.e., scholarly] sources.
• Standards : Description of the way in which you present your information.
• Questions for Further Research : What questions about the field has the review sparked? How will you further your research as a result of the review?

IV.  Writing Your Literature Review

Once you've settled on how to organize your literature review, you're ready to write each section. When writing your review, keep in mind these issues.

Use Evidence A literature review section is, in this sense, just like any other academic research paper. Your interpretation of the available sources must be backed up with evidence [citations] that demonstrates that what you are saying is valid. Be Selective Select only the most important points in each source to highlight in the review. The type of information you choose to mention should relate directly to the research problem, whether it is thematic, methodological, or chronological. Related items that provide additional information, but that are not key to understanding the research problem, can be included in a list of further readings . Use Quotes Sparingly Some short quotes are appropriate if you want to emphasize a point, or if what an author stated cannot be easily paraphrased. Sometimes you may need to quote certain terminology that was coined by the author, is not common knowledge, or taken directly from the study. Do not use extensive quotes as a substitute for using your own words in reviewing the literature. Summarize and Synthesize Remember to summarize and synthesize your sources within each thematic paragraph as well as throughout the review. Recapitulate important features of a research study, but then synthesize it by rephrasing the study's significance and relating it to your own work and the work of others. Keep Your Own Voice While the literature review presents others' ideas, your voice [the writer's] should remain front and center. For example, weave references to other sources into what you are writing but maintain your own voice by starting and ending the paragraph with your own ideas and wording. Use Caution When Paraphrasing When paraphrasing a source that is not your own, be sure to represent the author's information or opinions accurately and in your own words. Even when paraphrasing an author’s work, you still must provide a citation to that work.

V.  Common Mistakes to Avoid

These are the most common mistakes made in reviewing social science research literature.

• Sources in your literature review do not clearly relate to the research problem;
• You do not take sufficient time to define and identify the most relevant sources to use in the literature review related to the research problem;
• Relies exclusively on secondary analytical sources rather than including relevant primary research studies or data;
• Uncritically accepts another researcher's findings and interpretations as valid, rather than examining critically all aspects of the research design and analysis;
• Does not describe the search procedures that were used in identifying the literature to review;
• Reports isolated statistical results rather than synthesizing them in chi-squared or meta-analytic methods; and,
• Only includes research that validates assumptions and does not consider contrary findings and alternative interpretations found in the literature.

Cook, Kathleen E. and Elise Murowchick. “Do Literature Review Skills Transfer from One Course to Another?” Psychology Learning and Teaching 13 (March 2014): 3-11; Fink, Arlene. Conducting Research Literature Reviews: From the Internet to Paper . 2nd ed. Thousand Oaks, CA: Sage, 2005; Hart, Chris. Doing a Literature Review: Releasing the Social Science Research Imagination . Thousand Oaks, CA: Sage Publications, 1998; Jesson, Jill. Doing Your Literature Review: Traditional and Systematic Techniques . London: SAGE, 2011; Literature Review Handout. Online Writing Center. Liberty University; Literature Reviews. The Writing Center. University of North Carolina; Onwuegbuzie, Anthony J. and Rebecca Frels. Seven Steps to a Comprehensive Literature Review: A Multimodal and Cultural Approach . Los Angeles, CA: SAGE, 2016; Ridley, Diana. The Literature Review: A Step-by-Step Guide for Students . 2nd ed. Los Angeles, CA: SAGE, 2012; Randolph, Justus J. “A Guide to Writing the Dissertation Literature Review." Practical Assessment, Research, and Evaluation. vol. 14, June 2009; Sutton, Anthea. Systematic Approaches to a Successful Literature Review . Los Angeles, CA: Sage Publications, 2016; Taylor, Dena. The Literature Review: A Few Tips On Conducting It. University College Writing Centre. University of Toronto; Writing a Literature Review. Academic Skills Centre. University of Canberra.

Writing Tip

Break Out of Your Disciplinary Box!

Thinking interdisciplinarily about a research problem can be a rewarding exercise in applying new ideas, theories, or concepts to an old problem. For example, what might cultural anthropologists say about the continuing conflict in the Middle East? In what ways might geographers view the need for better distribution of social service agencies in large cities than how social workers might study the issue? You don’t want to substitute a thorough review of core research literature in your discipline for studies conducted in other fields of study. However, particularly in the social sciences, thinking about research problems from multiple vectors is a key strategy for finding new solutions to a problem or gaining a new perspective. Consult with a librarian about identifying research databases in other disciplines; almost every field of study has at least one comprehensive database devoted to indexing its research literature.

Frodeman, Robert. The Oxford Handbook of Interdisciplinarity . New York: Oxford University Press, 2010.

Another Writing Tip

Don't Just Review for Content!

While conducting a review of the literature, maximize the time you devote to writing this part of your paper by thinking broadly about what you should be looking for and evaluating. Review not just what scholars are saying, but how are they saying it. Some questions to ask:

• How are they organizing their ideas?
• What methods have they used to study the problem?
• What theories have been used to explain, predict, or understand their research problem?
• What sources have they cited to support their conclusions?
• How have they used non-textual elements [e.g., charts, graphs, figures, etc.] to illustrate key points?

When you begin to write your literature review section, you'll be glad you dug deeper into how the research was designed and constructed because it establishes a means for developing more substantial analysis and interpretation of the research problem.

Hart, Chris. Doing a Literature Review: Releasing the Social Science Research Imagination . Thousand Oaks, CA: Sage Publications, 1 998.

Yet Another Writing Tip

When Do I Know I Can Stop Looking and Move On?

Here are several strategies you can utilize to assess whether you've thoroughly reviewed the literature:

• Look for repeating patterns in the research findings . If the same thing is being said, just by different people, then this likely demonstrates that the research problem has hit a conceptual dead end. At this point consider: Does your study extend current research?  Does it forge a new path? Or, does is merely add more of the same thing being said?
• Look at sources the authors cite to in their work . If you begin to see the same researchers cited again and again, then this is often an indication that no new ideas have been generated to address the research problem.
• Search Google Scholar to identify who has subsequently cited leading scholars already identified in your literature review [see next sub-tab]. This is called citation tracking and there are a number of sources that can help you identify who has cited whom, particularly scholars from outside of your discipline. Here again, if the same authors are being cited again and again, this may indicate no new literature has been written on the topic.

Onwuegbuzie, Anthony J. and Rebecca Frels. Seven Steps to a Comprehensive Literature Review: A Multimodal and Cultural Approach . Los Angeles, CA: Sage, 2016; Sutton, Anthea. Systematic Approaches to a Successful Literature Review . Los Angeles, CA: Sage Publications, 2016.

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• Last Updated: May 25, 2024 4:09 PM
• URL: https://libguides.usc.edu/writingguide

How do I Write a Literature Review?: #5 Writing the Review

• Step #1: Choosing a Topic
• Step #2: Finding Information
• Step #3: Evaluating Content
• Step #4: Synthesizing Content
• #5 Writing the Review
• Citing Your Sources

WRITING THE REVIEW 

You've done the research and now you're ready to put your findings down on paper. When preparing to write your review, first consider how will you organize your review.

The actual review generally has 5 components:

Abstract  -  An abstract is a summary of your literature review. It is made up of the following parts:

• A contextual sentence about your motivation behind your research topic
• Your thesis statement
• A descriptive statement about the types of literature used in the review
• Summarize your findings
• Conclusion(s) based upon your findings

Introduction :   Like a typical research paper introduction, provide the reader with a quick idea of the topic of the literature review:

• Define or identify the general topic, issue, or area of concern. This provides the reader with context for reviewing the literature.
• Identify related trends in what has already been published about the topic; or conflicts in theory, methodology, evidence, and conclusions; or gaps in research and scholarship; or a single problem or new perspective of immediate interest.
• Establish your reason (point of view) for reviewing the literature; explain the criteria to be used in analyzing and comparing literature and the organization of the review (sequence); and, when necessary, state why certain literature is or is not included (scope)  - 

Body :  The body of a literature review contains your discussion of sources and can be organized in 3 ways-

• Chronological -  by publication or by trend
• Thematic -  organized around a topic or issue, rather than the progression of time
• Methodical -  the focusing factor usually does not have to do with the content of the material. Instead, it focuses on the "methods" of the literature's researcher or writer that you are reviewing

You may also want to include a section on "questions for further research" and discuss what questions the review has sparked about the topic/field or offer suggestions for future studies/examinations that build on your current findings.

Conclusion :  In the conclusion, you should:

Conclude your paper by providing your reader with some perspective on the relationship between your literature review's specific topic and how it's related to it's parent discipline, scientific endeavor, or profession.

Bibliography :   Since a literature review is composed of pieces of research, it is very important that your correctly cite the literature you are reviewing, both in the reviews body as well as in a bibliography/works cited. To learn more about different citation styles, visit the " Citing Your Sources " tab.

• Writing a Literature Review: Wesleyan University
• Literature Review: Edith Cowan University
• << Previous: Step #4: Synthesizing Content
• Next: Citing Your Sources >>
• Last Updated: Aug 22, 2023 1:35 PM
• URL: https://libguides.eastern.edu/literature_reviews

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What Is A Literature Review?

A plain-language explainer (with examples).

By:  Derek Jansen (MBA) & Kerryn Warren (PhD) | June 2020 (Updated May 2023)

If you’re faced with writing a dissertation or thesis, chances are you’ve encountered the term “literature review” . If you’re on this page, you’re probably not 100% what the literature review is all about. The good news is that you’ve come to the right place.

Literature Review 101

• What (exactly) is a literature review
• What’s the purpose of the literature review chapter
• How to find high-quality resources
• How to structure your literature review chapter
• Example of an actual literature review

What is a literature review?

The word “literature review” can refer to two related things that are part of the broader literature review process. The first is the task of  reviewing the literature  – i.e. sourcing and reading through the existing research relating to your research topic. The second is the  actual chapter  that you write up in your dissertation, thesis or research project. Let’s look at each of them:

Reviewing the literature

The first step of any literature review is to hunt down and  read through the existing research  that’s relevant to your research topic. To do this, you’ll use a combination of tools (we’ll discuss some of these later) to find journal articles, books, ebooks, research reports, dissertations, theses and any other credible sources of information that relate to your topic. You’ll then  summarise and catalogue these  for easy reference when you write up your literature review chapter. 

The literature review chapter

The second step of the literature review is to write the actual literature review chapter (this is usually the second chapter in a typical dissertation or thesis structure ). At the simplest level, the literature review chapter is an  overview of the key literature  that’s relevant to your research topic. This chapter should provide a smooth-flowing discussion of what research has already been done, what is known, what is unknown and what is contested in relation to your research topic. So, you can think of it as an  integrated review of the state of knowledge  around your research topic. 

What’s the purpose of a literature review?

The literature review chapter has a few important functions within your dissertation, thesis or research project. Let’s take a look at these:

Purpose #1 – Demonstrate your topic knowledge

The first function of the literature review chapter is, quite simply, to show the reader (or marker) that you  know what you’re talking about . In other words, a good literature review chapter demonstrates that you’ve read the relevant existing research and understand what’s going on – who’s said what, what’s agreed upon, disagreed upon and so on. This needs to be  more than just a summary  of who said what – it needs to integrate the existing research to  show how it all fits together  and what’s missing (which leads us to purpose #2, next). 

Purpose #2 – Reveal the research gap that you’ll fill

The second function of the literature review chapter is to  show what’s currently missing  from the existing research, to lay the foundation for your own research topic. In other words, your literature review chapter needs to show that there are currently “missing pieces” in terms of the bigger puzzle, and that  your study will fill one of those research gaps . By doing this, you are showing that your research topic is original and will help contribute to the body of knowledge. In other words, the literature review helps justify your research topic.  

Purpose #3 – Lay the foundation for your conceptual framework

The third function of the literature review is to form the  basis for a conceptual framework . Not every research topic will necessarily have a conceptual framework, but if your topic does require one, it needs to be rooted in your literature review. 

For example, let’s say your research aims to identify the drivers of a certain outcome – the factors which contribute to burnout in office workers. In this case, you’d likely develop a conceptual framework which details the potential factors (e.g. long hours, excessive stress, etc), as well as the outcome (burnout). Those factors would need to emerge from the literature review chapter – they can’t just come from your gut! 

So, in this case, the literature review chapter would uncover each of the potential factors (based on previous studies about burnout), which would then be modelled into a framework. 

Purpose #4 – To inform your methodology

The fourth function of the literature review is to  inform the choice of methodology  for your own research. As we’ve  discussed on the Grad Coach blog , your choice of methodology will be heavily influenced by your research aims, objectives and questions . Given that you’ll be reviewing studies covering a topic close to yours, it makes sense that you could learn a lot from their (well-considered) methodologies.

So, when you’re reviewing the literature, you’ll need to  pay close attention to the research design , methodology and methods used in similar studies, and use these to inform your methodology. Quite often, you’ll be able to  “borrow” from previous studies . This is especially true for quantitative studies , as you can use previously tried and tested measures and scales. 

How do I find articles for my literature review?

Finding quality journal articles is essential to crafting a rock-solid literature review. As you probably already know, not all research is created equally, and so you need to make sure that your literature review is  built on credible research . 

We could write an entire post on how to find quality literature (actually, we have ), but a good starting point is Google Scholar . Google Scholar is essentially the academic equivalent of Google, using Google’s powerful search capabilities to find relevant journal articles and reports. It certainly doesn’t cover every possible resource, but it’s a very useful way to get started on your literature review journey, as it will very quickly give you a good indication of what the  most popular pieces of research  are in your field.

One downside of Google Scholar is that it’s merely a search engine – that is, it lists the articles, but oftentimes  it doesn’t host the articles . So you’ll often hit a paywall when clicking through to journal websites. 

Thankfully, your university should provide you with access to their library, so you can find the article titles using Google Scholar and then search for them by name in your university’s online library. Your university may also provide you with access to  ResearchGate , which is another great source for existing research. 

Remember, the correct search keywords will be super important to get the right information from the start. So, pay close attention to the keywords used in the journal articles you read and use those keywords to search for more articles. If you can’t find a spoon in the kitchen, you haven’t looked in the right drawer. 

Need a helping hand?

How should I structure my literature review?

Unfortunately, there’s no generic universal answer for this one. The structure of your literature review will depend largely on your topic area and your research aims and objectives.

You could potentially structure your literature review chapter according to theme, group, variables , chronologically or per concepts in your field of research. We explain the main approaches to structuring your literature review here . You can also download a copy of our free literature review template to help you establish an initial structure.

In general, it’s also a good idea to start wide (i.e. the big-picture-level) and then narrow down, ending your literature review close to your research questions . However, there’s no universal one “right way” to structure your literature review. The most important thing is not to discuss your sources one after the other like a list – as we touched on earlier, your literature review needs to synthesise the research , not summarise it .

Ultimately, you need to craft your literature review so that it conveys the most important information effectively – it needs to tell a logical story in a digestible way. It’s no use starting off with highly technical terms and then only explaining what these terms mean later. Always assume your reader is not a subject matter expert and hold their hand through a journe y of the literature while keeping the functions of the literature review chapter (which we discussed earlier) front of mind.

Example of a literature review

In the video below, we walk you through a high-quality literature review from a dissertation that earned full distinction. This will give you a clearer view of what a strong literature review looks like in practice and hopefully provide some inspiration for your own. 

Wrapping Up

In this post, we’ve (hopefully) answered the question, “ what is a literature review? “. We’ve also considered the purpose and functions of the literature review, as well as how to find literature and how to structure the literature review chapter. If you’re keen to learn more, check out the literature review section of the Grad Coach blog , as well as our detailed video post covering how to write a literature review . 

Psst… there’s more!

This post is an extract from our bestselling short course, Literature Review Bootcamp . If you want to work smart, you don't want to miss this .

You Might Also Like:

16 Comments

Thanks for this review. It narrates what’s not been taught as tutors are always in a early to finish their classes.

Thanks for the kind words, Becky. Good luck with your literature review 🙂

This website is amazing, it really helps break everything down. Thank you, I would have been lost without it.

This is review is amazing. I benefited from it a lot and hope others visiting this website will benefit too.

Timothy T. Chol [email protected]

Thank you very much for the guiding in literature review I learn and benefited a lot this make my journey smooth I’ll recommend this site to my friends

This was so useful. Thank you so much.

Hi, Concept was explained nicely by both of you. Thanks a lot for sharing it. It will surely help research scholars to start their Research Journey.

The review is really helpful to me especially during this period of covid-19 pandemic when most universities in my country only offer online classes. Great stuff

Great Brief Explanation, thanks

So helpful to me as a student

GradCoach is a fantastic site with brilliant and modern minds behind it.. I spent weeks decoding the substantial academic Jargon and grounding my initial steps on the research process, which could be shortened to a couple of days through the Gradcoach. Thanks again!

This is an amazing talk. I paved way for myself as a researcher. Thank you GradCoach!

Well-presented overview of the literature!

This was brilliant. So clear. Thank you

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Once you have completed your literature search , you can start thinking about creating a structure to best explain the literature and to link existing studies to your paper. Having a firm structure provides the foundation for laying out your discussions of the literature and/or the development of your research question(s) or hypothesis. Before that, though, you may still need to make some key decisions regarding what literature or texts should be included and excluded in your paper. This article highlights four essential considerations as you start drafting a structure for your literature review .

Comprehensiveness

There are two types of literature review : one is the literature review section within a paper and the other is a literature review synthesis paper that aims to provide a framework for future studies. For the first, a more focused review of only relevant studies would be more appropriate and useful. For the second type, however, you would usually be expected to provide a much more comprehensive review.

For a literature review section within a paper, a focused review that is more tightly related to your study will help you to build arguments more succinctly, and enable you to link existing studies to your own research more easily. If you find that the literature that is most relevant to your study still falls in large, broad categories, then breaking this section down into different, smaller subsections can be helpful for making sure the various ideas and themes are presented clearly and are easy to follow.

Level of detail

In the literature review, you should be aiming to clearly explain prior and current studies so you can better contextualise your own research within the field. However, the level of detail that you include in this section needs to be carefully considered. 

If several studies are key to your paper or sound similar to your study, you may need to compare and contrast them more closely in order to differentiate them from prior studies, create connections between them or to build on existing literature. 

In addition, if you need to draw from specific papers for your methodology or your theoretical framework , it is a good idea to go into slightly more detail and provide as much information as is reasonably possible, rather than assuming that the reader already knows about these studies.

However, too many detailed descriptions can be distracting and it is important to try to strike a balance between providing enough information for your reader to follow your argument without overwhelming them with too much detail. In some instances therefore, offering a summarised key message can work more effectively. 

In order to better gauge the level of detail needed, go through your writing several times to sharpen your focus, ask your colleagues for feedback or engage professional editing services to check that your structure and overall narrative are clear. 

Online sources and extended quotations

Sometimes, you may want to include online sources in your discussion of the literature. For example, government reports or reputable reports released by major organisations can be quite useful for helping you develop your narrative and arguments. These reports may also provide some initial evidence. However, if you do choose to use such studies, they should be engaged alongside other studies from different sources to make them more plausible. 

In addition, unless really necessary, try to avoid very long or extended quotations. A better practice is to paraphrase and/or summarise the key points that you are trying to make. Drawing from your notes can be useful here and will also help to avoid potential concerns about plagiarism . Using your own words to explain complex issues or to summarise long quotations can also make reading easier for the reader.

The literature review is supposed to comprise a summary of thoughts and findings in prior or existing studies related to the topic that you are addressing in your study. Accordingly, the discussion of these studies should be as objective as possible and should not include your personal opinions, comments or even article preferences. This will help you to describe what has already been done in the field more clearly and use this review as a basis for developing your own research.

Use the above four points to help you stay on track as you write. By being very clear about what your literature review will include or exclude, you will be able to provide an effective, focused overview of existing research, upon which you can build and structure your own study .

Read next (fourth) in series: How to refer to other studies or literature in the different sections of a research paper

Read previous (second) in series: How to structure and write your literature review

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Literature Reviews

• Types of reviews
• Getting started

Types of reviews and examples

Choosing a review type.

• 1. Define your research question
• 2. Plan your search
• 3. Search the literature
• 4. Organize your results
• 5. Synthesize your findings
• 6. Write the review
• Artificial intelligence (AI) tools
• Thompson Writing Studio This link opens in a new window
• Need to write a systematic review? This link opens in a new window

Contact a Librarian

Ask a Librarian

• Meta-analysis
• Systematized

Definition:

"A term used to describe a conventional overview of the literature, particularly when contrasted with a systematic review (Booth et al., 2012, p. 265).

Characteristics:

• Provides examination of recent or current literature on a wide range of subjects
• Varying levels of completeness / comprehensiveness, non-standardized methodology
• May or may not include comprehensive searching, quality assessment or critical appraisal

Mitchell, L. E., & Zajchowski, C. A. (2022). The history of air quality in Utah: A narrative review.  Sustainability ,  14 (15), 9653.  doi.org/10.3390/su14159653

Booth, A., Papaioannou, D., & Sutton, A. (2012). Systematic approaches to a successful literature review. London: SAGE Publications Ltd.

"An assessment of what is already known about a policy or practice issue...using systematic review methods to search and critically appraise existing research" (Grant & Booth, 2009, p. 100).

• Assessment of what is already known about an issue
• Similar to a systematic review but within a time-constrained setting
• Typically employs methodological shortcuts, increasing risk of introducing bias, includes basic level of quality assessment
• Best suited for issues needing quick decisions and solutions (i.e., policy recommendations)

Learn more about the method:

Khangura, S., Konnyu, K., Cushman, R., Grimshaw, J., & Moher, D. (2012). Evidence summaries: the evolution of a rapid review approach.  Systematic reviews, 1 (1), 1-9.  https://doi.org/10.1186/2046-4053-1-10

Virginia Commonwealth University Libraries. (2021). Rapid Review Protocol .

Quarmby, S., Santos, G., & Mathias, M. (2019). Air quality strategies and technologies: A rapid review of the international evidence.  Sustainability, 11 (10), 2757.  https://doi.org/10.3390/su11102757

Grant, M.J. & Booth, A. (2009). A typology of reviews: an analysis of the 14 review types and associated methodologies.  Health Information & Libraries Journal , 26(2), 91-108. https://www.doi.org/10.1111/j.1471-1842.2009.00848.x

Developed and refined by the Evidence for Policy and Practice Information and Co-ordinating Centre (EPPI-Centre), this review "map[s] out and categorize[s] existing literature on a particular topic, identifying gaps in research literature from which to commission further reviews and/or primary research" (Grant & Booth, 2009, p. 97).

Although mapping reviews are sometimes called scoping reviews, the key difference is that mapping reviews focus on a review question, rather than a topic

Mapping reviews are "best used where a clear target for a more focused evidence product has not yet been identified" (Booth, 2016, p. 14)

Mapping review searches are often quick and are intended to provide a broad overview

Mapping reviews can take different approaches in what types of literature is focused on in the search

Cooper I. D. (2016). What is a "mapping study?".  Journal of the Medical Library Association: JMLA ,  104 (1), 76–78. https://doi.org/10.3163/1536-5050.104.1.013

Miake-Lye, I. M., Hempel, S., Shanman, R., & Shekelle, P. G. (2016). What is an evidence map? A systematic review of published evidence maps and their definitions, methods, and products.  Systematic reviews, 5 (1), 1-21.  https://doi.org/10.1186/s13643-016-0204-x

Tainio, M., Andersen, Z. J., Nieuwenhuijsen, M. J., Hu, L., De Nazelle, A., An, R., ... & de Sá, T. H. (2021). Air pollution, physical activity and health: A mapping review of the evidence.  Environment international ,  147 , 105954.  https://doi.org/10.1016/j.envint.2020.105954

Booth, A. (2016). EVIDENT Guidance for Reviewing the Evidence: a compendium of methodological literature and websites . ResearchGate. https://doi.org/10.13140/RG.2.1.1562.9842 . 

Grant, M.J. & Booth, A. (2009). A typology of reviews: an analysis of the 14 review types and associated methodologies.  Health Information & Libraries Journal , 26(2), 91-108.  https://www.doi.org/10.1111/j.1471-1842.2009.00848.x

"A type of review that has as its primary objective the identification of the size and quality of research in a topic area in order to inform subsequent review" (Booth et al., 2012, p. 269).

• Main purpose is to map out and categorize existing literature, identify gaps in literature—great for informing policy-making
• Search comprehensiveness determined by time/scope constraints, could take longer than a systematic review
• No formal quality assessment or critical appraisal

Learn more about the methods :

Arksey, H., & O'Malley, L. (2005) Scoping studies: towards a methodological framework.  International Journal of Social Research Methodology ,  8 (1), 19-32.  https://doi.org/10.1080/1364557032000119616

Levac, D., Colquhoun, H., & O’Brien, K. K. (2010). Scoping studies: Advancing the methodology. Implementation Science: IS, 5, 69. https://doi.org/10.1186/1748-5908-5-69

Example : 

Rahman, A., Sarkar, A., Yadav, O. P., Achari, G., & Slobodnik, J. (2021). Potential human health risks due to environmental exposure to nano-and microplastics and knowledge gaps: A scoping review.  Science of the Total Environment, 757 , 143872.  https://doi.org/10.1016/j.scitotenv.2020.143872

A review that "[compiles] evidence from multiple...reviews into one accessible and usable document" (Grant & Booth, 2009, p. 103). While originally intended to be a compilation of Cochrane reviews, it now generally refers to any kind of evidence synthesis.

• Compiles evidence from multiple reviews into one document
• Often defines a broader question than is typical of a traditional systematic review

Choi, G. J., & Kang, H. (2022). The umbrella review: a useful strategy in the rain of evidence.  The Korean Journal of Pain ,  35 (2), 127–128.  https://doi.org/10.3344/kjp.2022.35.2.127

Aromataris, E., Fernandez, R., Godfrey, C. M., Holly, C., Khalil, H., & Tungpunkom, P. (2015). Summarizing systematic reviews: Methodological development, conduct and reporting of an umbrella review approach. International Journal of Evidence-Based Healthcare , 13(3), 132–140. https://doi.org/10.1097/XEB.0000000000000055

Rojas-Rueda, D., Morales-Zamora, E., Alsufyani, W. A., Herbst, C. H., Al Balawi, S. M., Alsukait, R., & Alomran, M. (2021). Environmental risk factors and health: An umbrella review of meta-analyses.  International Journal of Environmental Research and Public Dealth ,  18 (2), 704.  https://doi.org/10.3390/ijerph18020704

A meta-analysis is a "technique that statistically combines the results of quantitative studies to provide a more precise effect of the result" (Grant & Booth, 2009, p. 98).

• Statistical technique for combining results of quantitative studies to provide more precise effect of results
• Aims for exhaustive, comprehensive searching
• Quality assessment may determine inclusion/exclusion criteria
• May be conducted independently or as part of a systematic review

Berman, N. G., & Parker, R. A. (2002). Meta-analysis: Neither quick nor easy. BMC Medical Research Methodology , 2(1), 10. https://doi.org/10.1186/1471-2288-2-10

Hites R. A. (2004). Polybrominated diphenyl ethers in the environment and in people: a meta-analysis of concentrations.  Environmental Science & Technology ,  38 (4), 945–956.  https://doi.org/10.1021/es035082g

A systematic review "seeks to systematically search for, appraise, and [synthesize] research evidence, often adhering to the guidelines on the conduct of a review" provided by discipline-specific organizations, such as the Cochrane Collaboration (Grant & Booth, 2009, p. 102).

• Aims to compile and synthesize all known knowledge on a given topic
• Adheres to strict guidelines, protocols, and frameworks
• Time-intensive and often takes months to a year or more to complete
• The most commonly referred to type of evidence synthesis. Sometimes confused as a blanket term for other types of reviews

Gascon, M., Triguero-Mas, M., Martínez, D., Dadvand, P., Forns, J., Plasència, A., & Nieuwenhuijsen, M. J. (2015). Mental health benefits of long-term exposure to residential green and blue spaces: a systematic review.  International Journal of Environmental Research and Public Health ,  12 (4), 4354–4379.  https://doi.org/10.3390/ijerph120404354

"Systematized reviews attempt to include one or more elements of the systematic review process while stopping short of claiming that the resultant output is a systematic review" (Grant & Booth, 2009, p. 102). When a systematic review approach is adapted to produce a more manageable scope, while still retaining the rigor of a systematic review such as risk of bias assessment and the use of a protocol, this is often referred to as a  structured review  (Huelin et al., 2015).

• Typically conducted by postgraduate or graduate students
• Often assigned by instructors to students who don't have the resources to conduct a full systematic review

Salvo, G., Lashewicz, B. M., Doyle-Baker, P. K., & McCormack, G. R. (2018). Neighbourhood built environment influences on physical activity among adults: A systematized review of qualitative evidence.  International Journal of Environmental Research and Public Health ,  15 (5), 897.  https://doi.org/10.3390/ijerph15050897

Huelin, R., Iheanacho, I., Payne, K., & Sandman, K. (2015). What’s in a name? Systematic and non-systematic literature reviews, and why the distinction matters. https://www.evidera.com/resource/whats-in-a-name-systematic-and-non-systematic-literature-reviews-and-why-the-distinction-matters/

• Review Decision Tree - Cornell University For more information, check out Cornell's review methodology decision tree.
• LitR-Ex.com - Eight literature review methodologies Learn more about 8 different review types (incl. Systematic Reviews and Scoping Reviews) with practical tips about strengths and weaknesses of different methods.
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Rapid literature review: definition and methodology

Beata smela.

a Assignity, Cracow, Poland

Mondher Toumi

b Public Health Department, Aix-Marseille University, Marseille, France

Karolina Świerk

Clement francois, małgorzata biernikiewicz.

c Studio Slowa, Wroclaw, Poland

Emilie Clay

d Clever-Access, Paris, France

Laurent Boyer

Introduction: A rapid literature review (RLR) is an alternative to systematic literature review (SLR) that can speed up the analysis of newly published data. The objective was to identify and summarize available information regarding different approaches to defining RLR and the methodology applied to the conduct of such reviews.

Methods: The Medline and EMBASE databases, as well as the grey literature, were searched using the set of keywords and their combination related to the targeted and rapid review, as well as design, approach, and methodology. Of the 3,898 records retrieved, 12 articles were included.

Results: Specific definition of RLRs has only been developed in 2021. In terms of methodology, the RLR should be completed within shorter timeframes using simplified procedures in comparison to SLRs, while maintaining a similar level of transparency and minimizing bias. Inherent components of the RLR process should be a clear research question, search protocol, simplified process of study selection, data extraction, and quality assurance.

Conclusions: There is a lack of consensus on the formal definition of the RLR and the best approaches to perform it. The evidence-based supporting methods are evolving, and more work is needed to define the most robust approaches.

Introduction

A systematic literature review (SLR) summarizes the results of all available studies on a specific topic and provides a high level of evidence. Authors of the SLR have to follow an advanced plan that covers defining a priori information regarding the research question, sources they are going to search, inclusion criteria applied to choose studies answering the research question, and information regarding how they are going to summarize findings [ 1 ].

The rigor and transparency of SLRs make them the most reliable form of literature review [ 2 ], providing a comprehensive, objective summary of the evidence for a given topic [ 3 , 4 ]. On the other hand, the SLR process is usually very time-consuming and requires a lot of human resources. Taking into account a high increase of newly published data and a growing need to analyze information in the fastest possible way, rapid literature reviews (RLRs) often replace standard SLRs.

There are several guidelines on the methodology of RLRs [ 5–11 ]; however, only recently, one publication from 2021 attempted to construct a unified definition [ 11 ]. Generally, by RLRs, researchers understand evidence synthesis during which some of the components of the systematic approach are being used to facilitate answering a focused research question; however, scope restrictions and a narrower search strategy help to make the project manageable in a shorter time and to get the key conclusions faster [ 4 ].

The objective of this research was to collect and summarize available information on different approaches to the definition and methodology of RLRs. An RLR has been run to capture publications providing data that fit the project objective.

To find publications reporting information on the methodology of RLRs, searches were run in the Medline and EMBASE databases in November 2022. The following keywords were searched for in titles and abstracts: ‘targeted adj2 review’ OR ‘focused adj2 review’ OR ‘rapid adj2 review’, and ‘methodology’ OR ‘design’ OR ‘scheme’ OR ‘approach’. The grey literature was identified using Google Scholar with keywords including ‘targeted review methodology’ OR ‘focused review methodology’ OR ‘rapid review methodology’. Only publications in English were included, and the date of publication was restricted to year 2016 onward in order to identify the most up-to-date literature. The reference lists of each included article were searched manually to obtain the potentially eligible articles. Titles and abstracts of the retrieved records were first screened to exclude articles that were evidently irrelevant. The full texts of potentially relevant papers were further reviewed to examine their eligibility.

A pre-defined Excel grid was developed to extract the following information related to the methodology of RLR from guidelines:

• Definition,
• Research question and searches,
• Studies selection,
• Data extraction and quality assessment,
• Additional information.

There was no restriction on the study types to be analyzed; any study reporting on the methodology of RLRs could be included: reviews, practice guidelines, commentaries, and expert opinions on RLR relevant to healthcare policymakers or practitioners. The data extraction and evidence summary were conducted by one analyst and further examined by a senior analyst to ensure that relevant information was not omitted. Disagreements were resolved by discussion and consensus.

Studies selection

A total of 3,898 records (3,864 articles from a database search and 34 grey literature from Google Scholar) were retrieved. After removing duplicates, titles and abstracts of 3,813 articles were uploaded and screened. The full texts of 43 articles were analyzed resulting in 12 articles selected for this review, including 7 guidelines [ 5–11 ] on the methodology of RLRs, together with 2 papers summarizing the results of the Delphi consensus on the topic [ 12 , 13 ], and 3 publications analyzing and assessing different approaches to RLRs [ 4 , 14 , 15 ].

Overall, seven guidelines were identified: from the World Health Organization (WHO) [ 5 ], National Collaborating Centre for Methods and Tools (NCCMT) [ 7 ], the UK government [ 8 ], the Oxford Centre for Evidence Based Medicine [ 9 ], the Cochrane group [ 6 , 11 ], and one multi-national review [ 10 ]. Among the papers that did not describe the guidelines, Gordon et al. [ 4 ] proposed 12 tips for conducting a rapid review in the right settings and discussed why these reviews may be more beneficial in some circumstances. The objective of work conducted by Tricco et al. [ 13 ] and Pandor et al. [ 12 ] was to collect and compare perceptions of rapid reviews from stakeholders, including researchers, policymakers, industry, journal editors, and healthcare providers, and to reach a consensus outlining the domains to consider when deciding on approaches for RLRs. Haby et al. [ 14 ] run a rapid review of systematic reviews and primary studies to find out the best way to conduct an RLR in health policy and practice. In Tricco et al. (2022) [ 15 ], JBI position statement for RLRs is presented.

From all the seven identified guidelines information regarding definitions the authors used for RLRs, approach to the PICOS criteria and search strategy development, studies selection, data extractions, quality assessment, and reporting were extracted.

Cochrane Rapid Reviews Methods Group developed methods guidance based on scoping review of the underlying evidence, primary methods studies conducted, as well as surveys sent to Cochrane representative and discussion among those with expertise [ 11 ]. They analyzed over 300 RLRs or RLR method papers and based on the methodology of those studies, constructed a broad definition RLR, one that meets a minimum set of requirements identified in the thematic analysis: ‘ A rapid review is a form of knowledge synthesis that accelerates the process of conducting a traditional systematic review through streamlining or omitting a variety of methods to produce evidence in a resource-efficient manner .’ This interpretation aligns with more than 50% of RLRs identified in this study. The authors additionally provided several other definitions, depending on specific situations or requirements (e.g., when RLR is produced on stakeholder’s request). It was additionally underlined that RLRs should be driven by the need of timely evidence for decision-making purposes [ 11 ].

Rapid reviews vary in their objective, format, and methods used for evidence synthesis. This is a quite new area, and still no agreement on optimal methods can be found [ 5 ]. All of the definitions are highlighting that RLRs are completed within shorter timeframes than SLRs, and also lack of time is one of the main reasons they are conducted. It has been suggested that most rapid reviews are conducted within 12 weeks; however, some of the resources suggest time between a few weeks to no more than 6 months [ 5 , 6 ]. Some of the definitions are highlighting that RLRs follow the SLR process, but certain phases of the process are simplified or omitted to retrieve information in a time-saving way [ 6 , 7 ]. Different mechanisms are used to enhance the timeliness of reviews. They can be used independently or concurrently: increasing the intensity of work by intensifying the efforts of multiple analysts by parallelization of tasks, using review shortcuts whereby one or more systematic review steps may be reduced, automatizing review steps by using new technologies [ 5 ]. The UK government report [ 8 ] referred to two different RLRs: in the form of quick scoping reviews (QSR) or rapid evidence assessments (REA). While being less resource and time-consuming compared to standard SLRs, QSRs and REAs are designed to be similarly transparent and to minimize bias. QSRs can be applied to rather open-ended questions, e.g., ‘what do we know about something’ but both, QSRs and REAs, provide an understanding of the volume and characteristics of evidence on a specific topic, allowing answering questions by maximizing the use of existing data, and providing a clear picture of the adequacy of existing evidence [ 8 ].

Research questions and searches

The guidelines suggest creating a clear research question and search protocol at the beginning of the project. Additionally, to not duplicate RLRs, the Cochrane Rapid Reviews Methods Group encourages all people working on RLRs to consider registering their search protocol with PROSPERO, the international prospective register of reviews; however, so far they are not formally registered in most cases [ 5 , 6 ]. They also recommend involving key stakeholders (review users) to set and refine the review question, criteria, and outcomes, as well as consulting them through the entire process [ 11 ].

Regarding research questions, it is better to structure them in a neutral way rather than focus on a specific direction for the outcome. By doing so, the researcher is in a better position to identify all the relevant evidence [ 7 ]. Authors can add a second, supportive research question when needed [ 8 ]. It is encouraged to limit the number of interventions, comparators and outcomes, to focus on the ones that are most important for decision-making [ 11 ]. Useful could be also reviewing additional materials, e.g., SLRs on the topic, as well as conducting a quick literature search to better understand the topic before starting with RLRs [ 7 ]. In SLRs researchers usually do not need to care a lot about time spent on creating PICOS, they need to make sure that the scope is broad enough, and they cannot use many restrictions. When working on RLRs, a reviewer may spend more or less time defining each of the components of the study question, and the main step is making sure that PICOS addresses the needs of those who requested the rapid review, and at the same time, it is feasible within the required time frame [ 7 ]. Search protocol should contain an outline of how the following review steps are to be carried out, including selected search keywords and a full strategy, a list of data sources, precise inclusion and exclusion criteria, a strategy for data extraction and critical appraisal, and a plan of how the information will be synthesized [ 8 ].

In terms of searches running, in most cases, an exhaustive process will not be feasible. Researchers should make sure that the search is effective and efficient to produce results in a timely manner. Cochrane Rapid Reviews Methods Group recommends involving an information specialist and conducting peer review of at least one search strategy [ 11 ]. According to the rapid review guidebook by McMaster University [ 7 ], it is important that RLRs, especially those that support policy and program decisions, are being fed by the results of a body of literature, rather than single studies, when possible. It would result in more generalizable findings applied at the level of a population and serve more realistic findings for program decisions [ 7 ]. It is important to document the search strategy, together with a record of the date and any date limits of the search, so that it can easily be run again, modified, or updated. Furthermore, the information on the individual databases included in platform services should always be reported, as this depends on organizations’ subscriptions and must be included for transparency and repeatability [ 7 , 8 ]. Good solution for RLRs is narrowing the scope or searching a limited number of databases and other sources [ 7 ]. Often, the authors use the PubMed/MEDLINE, Cochrane Library, and Embase databases. In most reviews, two or more databases are searched, and common limits are language (usually restricted to English), date, study design, and geographical area. Some RLRs include searching of grey literature; however, contact with authors is rather uncommon [ 5 , 8 ]. According to the flexible framework for restricted systematic review published by the University of Oxford, the search should be run in at least one major scientific database such as PubMed, and one other source, e.g., Google Scholar [ 9 ]. Grey literature and unpublished evidence may be particularly needed and important for intervention questions. It is related to the fact that studies that do not report the effects of interventions are less likely to be published [ 8 ]. If there is any type of evidence that will not be considered by the RLRs, e.g., reviews or theoretical and conceptual studies, it should also be stated in the protocol together with justification [ 8 ]. Additionally, authors of a practical guide published by WHO suggest using a staged search to identify existing SLRs at the beginning, and then focusing on studies with other designs [ 5 ]. If a low number of citations have been retrieved, it is acceptable to expand searches, remove some of the limits, and add additional databases and sources [ 7 ].

Searching for RLRs is an iterative process, and revising the approach is usually needed [ 7 ]. Changes should be confirmed with stakeholders and should be tracked and reflected in the final report [ 5 ].

The next step in the rapid review is the selection of studies consisting of two phases: screening of titles and abstracts, and analysis of full texts. Prior to screening initiation, it is recommended to conduct a pilot exercise using the same 30–50 abstracts and 5–10 full-texts for the entire screening team in order to calibrate and test the review form [ 11 ]. In contrast to SLRs, it can be done by one reviewer with or without verification by a second one. If verification is performed, usually the second reviewer checks only a subset of records and compares them. Cochrane Group, in contrast, recommends a stricter approach: at least 20% of references should be double-screened at titles and abstracts stage, and while the rest of the references may be screened by one reviewer, the excluded items need to be re-examined by second reviewer; similar approach is used in full-text screening [ 11 ]. This helps to ensure that bias was reduced and that the PICOS criteria are applied in a relevant way [ 5 , 8 , 9 , 11 ]. During the analysis of titles and abstracts, there is no need to report reasons for exclusion; however, they should be tracked for all excluded full texts [ 7 ].

Data extraction and quality assessment

According to the WHO guide, the most common method for data extraction in RLRs is extraction done by a single reviewer with or without partial verification. The authors point out that a reasonable approach is to use a second reviewer to check a random sample of at least 10% of the extractions for accuracy. Dual performance is more necessary for the extraction of quantitative results than for descriptive study information. In contrast, Cochrane group recommends that second reviewer should check the correctness and completeness of all data [ 11 ]. When possible, extractions should be limited to key characteristics and outcomes of the study. The same approach to data extraction is also suggested for a quality assessment process within rapid reviews [ 5 , 9 , 11 ]. Authors of the guidebook from McMaster University highlight that data extraction should be done ideally by two reviewers independently and consensus on the discrepancies should always be reached [ 7 ]. The final decision on the approach to this important step of review should depend on the available time and should also reflect the complexity of the research question [ 9 ].

For screening, analysis of full texts, extractions, and quality assessments, researchers can use information technologies to support them by making these review steps more efficient [ 5 ].

Before data reporting, a reviewer should prepare a document with key message headings, executive summary, background related to the topic and status of the current knowledge, project question, synthesis of findings, conclusions, and recommendations. According to the McMaster University guidebook, a report should be structured in a 1:2:20 format, that is, one page for key messages, two pages for an executive summary, and a full report of up to 20 pages [ 7 ]. All the limitations of the RLRs should be analyzed, and conclusions should be drawn with caution [ 5 ]. The quality of the accumulated evidence and the strength of recommendations can be assessed using, e.g., the GRADE system [ 5 ]. When working on references quoting, researchers should remember to use a primary source, not secondary references [ 7 ]. It would be worth considering the support of some software tools to automate reporting steps. Additionally, any standardization of the process and the usage of templates can support report development and enhance the transparency of the review [ 5 ].

Ideally, all the review steps should be completed during RLRs; however, often some steps may need skipping or will not be completed as thoroughly as should because of time constraints. It is always crucial to decide which steps may be skipped, and which are the key ones, depending on the project [ 7 ]. Guidelines suggest that it may be helpful to invite researchers with experience in the operations of SLRs to participate in the rapid review development [ 5 , 9 ]. As some of the steps will be completed by one reviewer only, it is important to provide them with relevant training at the beginning of the process, as well as during the review, to minimize the risk of mistakes [ 5 ].

Additional information

Depending on the policy goal and available resources and deadlines, methodology of the RLRs may be modified. Wilson et al. [ 10 ] provided extensive guidelines for performing RLR within days (e.g., to inform urgent internal policy discussions and/or management decisions), weeks (e.g., to inform public debates), or months (e.g., to inform policy development cycles that have a longer timeline, but that cannot wait for a traditional full systematic review). These approaches vary in terms of data synthesis, types of considered evidence and project management considerations.

In shortest timeframes, focused questions and subquestions should be formulated, typically to conduct a policy analysis; the report should consist of tables along with a brief narrative summary. Evidence from SLRs is often considered, as well as key informant interviews may be conducted to identify additional literature and insights about the topic, while primary studies and other types of evidence are not typically feasible due to time restrictions. The review would be best conducted with 1–2 reviewers sharing the work, enabling rapid iterations of the review. As for RLRs with longer timeline (weeks), these may use a mix of policy, systems and political analysis. Structure of the review would be similar to shorter RLRs – tabular with short narrative summary, as the timeline does not allow for comprehensive synthesis of data. Besides SLRs, primary studies and other evidence may be feasible in this timeframe, if obtained using the targeted searches in the most relevant databases. The review team should be larger, and standardized procedures for reviewing of the results and data extraction should be applied. In contrast to previous timeframe, merit review process may be feasible. For both timeframes, brief consultations with small transdisciplinary team should be conducted at the beginning and in the final stage of the review to discuss important matters.

For RLRs spanning several months, more comprehensive methodology may be adapted in terms of data synthesis and types of evidence. However, authors advise that review may be best conducted with a small review team in order to allow for more in-depth interpretation and iteration.

Studies analyzing methodology

There have been two interesting publications summarizing the results of Delphi consensus on the RLR methodology identified and included in this review [ 12 , 13 ].

Tricco et al. [ 13 ] first conducted an international survey and scoping review to collect information on the possible approaches to the running of rapid reviews, based on which, they employed a modified Delphi method that included inputs from 113 stakeholders to explore the most optimized approach. Among the six most frequent rapid review approaches (not all detailed here) being evaluated, the approach that combines inclusion of published literature only, a search of more than one database and limitations by date and language, study selection by one analyst, data extraction, and quality assessment by one analyst and one verifier, was perceived as the most feasible approach (72%, 81/113 responses) with the potentially lowest risk of bias (12%, 12/103). The approach ranked as the first one when considering timelines assumes updating of the search from a previously published review, no additional limits on search, studies selection and data extraction done by one reviewer, and no quality assessment. Finally, based on the publication, the most comprehensive RLRs can be made by moving on with the following rules: searching more than one database and grey literature and using date restriction, and assigning one reviewer working on screening, data extraction, and risk of bias assessment ( Table 1 ). Pandor et al. [ 12 ] introduced a decision tool for SelecTing Approaches for Rapid Reviews (STARR) that were produced through the Delphi consensus of international experts through an iterative and rigorous process. Participants were asked to assess the importance of predefined items in four domains related to the rapid review process: interaction with commissioners, understanding the evidence base, data extraction and synthesis methods, and reporting of rapid review methods. All items assigned to four domains achieved > 70% of consensus, and in that way, the first consensus-driven tool has been created that supports authors of RLRs in planning and deciding on approaches.

Six most frequent approaches to RLRs (adapted from Tricco et al. [ 13 ]).

Haby et al. [ 14 ] run searches of 11 databases and two websites and developed a comprehensive overview of the methodology of RLRs. With five SLRs and one RCT being finally included, they identified the following approaches used in RLRs to make them faster than full SLRs: limiting the number and scope of questions, searching fewer databases, limited searching of grey literature, restrictions on language and date (e.g., English only, most recent publications), updating the existing SLRs, eliminating or limiting hand searches of reference lists, noniterative search strategies, eliminating consultation with experts, limiting dual study selection, data extraction and quality assessment, minimal data synthesis with short concise conclusions or recommendations. All the SLRs included in this review were consistent in stating that no agreed definition of rapid reviews is available, and there is still no final agreement on the best methodological rules to be followed.

Gordon et al. [ 4 ] explained the advantages of performing a focused review and provided 12 tips for its conduction. They define focused reviews as ‘a form of knowledge synthesis in which the components of the systematic process are applied to facilitate the analysis of a focused research question’. The first tip presented by the authors is related to deciding if a focused review is a right solution for the considered project. RLRs will suit emerging topics, approaches, or assessments where early synthesis can support doctors, policymakers, etc., but also can direct future research. The second, third, and fourth tips highlight the importance of running preliminary searches and considering narrowing the results by using reasonable constraints taking into account the local context, problems, efficiency perspectives, and available time. Further tips include creating a team of experienced reviewers working on the RLRs, thinking about the target journal from the beginning of work on the rapid review, registering the search protocol on the PROSPERO registry, and the need for contacting authors of papers when data available in publications are missing or incongruent. The last three tips are related to the choice of evidence synthesis method, using the visual presentation of data, and considering and describing all the limitations of the focused review.

Finally, a new publication by Tricco et al. from 2022, describing JBI position statement [ 15 ] underlined that for the time being, there is no specific tool for critical appraisal of the RLR’s methodological quality. Instead, reviewers may use available tools to assess the risk of bias or quality of SLRs, like ROBIS, the JBI critical appraisal tools, or the assessment of multiple systematic reviews (AMSTAR).

Inconsistency in the definitions and methodologies of RLR

Although RLR was broadly perceived as an approach to quicken the conduct of conventional SLR, there is a lack of consensus on the formal definition of the RLR, so as to the best approaches to perform it. Only in 2021, a study proposing unified definition was published; however, it is important to note that the most accurate definition was only matching slightly over 50% of papers analysed by the authors, which underlines the lack of homogeneity in the field [ 11 ]. The evidence-based supporting methods are evolving, and more evidence is needed to define the most robust approaches [ 5 ].

Diverse terms are used to describe the RLR, including ‘rapid review’, focused systematic review’, ‘quick scoping reviews’, and ‘rapid evidence assessments’. Although the general principles of conducting RLR are to accelerate the whole process, complexity was seen in the methodologies used for RLRs, as reflected in this study. Also, inconsistencies related to the scope of the questions, search strategies, inclusion criteria, study screening, full-text review, quality assessment, and evidence presentation were implied. All these factors may hamper decision-making about optimal methodologies for conducting rapid reviews, and as a result, the efficiency of RLR might be decreased. Additionally, researchers may tend to report the methodology of their reviews without a sufficient level of detail, making it difficult to appraise the quality and robustness of their work.

Advantages and weaknesses of RLR

Although RLR used simplified approaches for evidence synthesis compared with SLR, the methodologies for RLR should be replicable, rigorous, and transparent to the greatest extent [ 16 ]. When time and resources are limited, RLR could be a practical and efficient tool to provide the summary of evidence that is critical for making rapid clinical or policy-related decisions [ 5 ]. Focusing on specific questions that are of controversy or special interest could be powerful in reaffirming whether the existing recommendation statements are still appropriate [ 17 ].

The weakness of RLR should also be borne in mind, and the trade-off of using RLR should be carefully considered regarding the thoroughness of the search, breadth of a research question, and depth of analysis [ 18 ]. If allowed, SLR is preferred over RLR considering that some relevant studies might be omitted with narrowed search strategies and simplified screening process [ 14 ]. Additionally, omitting the quality assessment of included studies could result in an increased risk of bias, making the comprehensiveness of RLR compromised [ 13 ]. Furthermore, in situations that require high accuracy, for example, where a small relative difference in an intervention has great impacts, for the purpose of drafting clinical guidelines, or making licensing decisions, a comprehensive SLR may remain the priority [ 19 ]. Therefore, clear communications with policymakers are recommended to reach an agreement on whether an RLR is justified and whether the methodologies of RLR are acceptable to address the unanswered questions [ 18 ].

Disclosure statement

No potential conflict of interest was reported by the author(s).

• Open access
• Published: 21 May 2024

A modern way to teach and practice manual therapy

• Roger Kerry 1 ,
• Kenneth J. Young   ORCID: orcid.org/0000-0001-8837-7977 2 ,
• David W. Evans 3 ,
• Edward Lee 1 , 4 ,
• Vasileios Georgopoulos 1 , 5 ,
• Adam Meakins 6 ,
• Chris McCarthy 7 ,
• Chad Cook 8 ,
• Colette Ridehalgh 9 , 10 ,
• Steven Vogel 11 ,
• Amanda Banton 11 ,
• Cecilia Bergström 12 ,
• Anna Maria Mazzieri 13 ,
• Firas Mourad 14 , 15 &
• Nathan Hutting 16  

Chiropractic & Manual Therapies volume  32 , Article number:  17 ( 2024 ) Cite this article

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Musculoskeletal conditions are the leading contributor to global disability and health burden. Manual therapy (MT) interventions are commonly recommended in clinical guidelines and used in the management of musculoskeletal conditions. Traditional systems of manual therapy (TMT), including physiotherapy, osteopathy, chiropractic, and soft tissue therapy have been built on principles such as clinician-centred assessment , patho-anatomical reasoning, and technique specificity. These historical principles are not supported by current evidence. However, data from clinical trials support the clinical and cost effectiveness of manual therapy as an intervention for musculoskeletal conditions, when used as part of a package of care.

The purpose of this paper is to propose a modern evidence-guided framework for the teaching and practice of MT which avoids reference to and reliance on the outdated principles of TMT. This framework is based on three fundamental humanistic dimensions common in all aspects of healthcare: safety , comfort , and efficiency . These practical elements are contextualised by positive communication , a collaborative context , and person-centred care . The framework facilitates best-practice, reasoning, and communication and is exemplified here with two case studies.

A literature review stimulated by a new method of teaching manual therapy, reflecting contemporary evidence, being trialled at a United Kingdom education institute. A group of experienced, internationally-based academics, clinicians, and researchers from across the spectrum of manual therapy was convened. Perspectives were elicited through reviews of contemporary literature and discussions in an iterative process. Public presentations were made to multidisciplinary groups and feedback was incorporated. Consensus was achieved through repeated discussion of relevant elements.

Conclusions

Manual therapy interventions should include both passive and active, person-empowering interventions such as exercise, education, and lifestyle adaptations. These should be delivered in a contextualised healing environment with a well-developed person-practitioner therapeutic alliance. Teaching manual therapy should follow this model.

Musculoskeletal (MSK) conditions are leading contributors to the burden of global disability and healthcare [ 1 ]. Amongst other interventions, manual therapy (MT) has been recommended for the management of people with MSK conditions in multiple clinical guidelines, for example [ 2 , 3 ].

MT has been described as the deliberate application of externally generated force upon body tissue, typically via the hands, with therapeutic intent [ 4 ]. It includes touch-based interventions such as thrust manipulation, joint mobilisation, soft-tissue mobilisation, and neurodynamic movements [ 5 ]. For people with MSK conditions, this therapeutic intent is usually to reduce pain and improve movement, thus facilitating a return to function and improved quality of life [ 6 ]. Patient perceptions of MT are, however, vague and sit among wider expectations of treatment including education, self-efficacy and the role of exercise, and prognosis [ 7 ].

Although the teaching and practice of MT has invariably changed over time, its foundations arguably remain unaltered and set in biomedical and outdated principles. This paper sets out to review contemporary literature and propose a revised model to inform the teaching and practice of MT.

The aim of this paper is to stimulate debate about the future teaching and practice of manual therapy through the proposal of an evidence-informed re-conceptualised model of manual therapy. The new model dismisses traditional elements of manual therapy which are not supported by research evidence. In place, the model offers a structure based on common humanistic principles of healthcare.

Consenus methodology

We present the literature synthesis and proposed framework as a consensus document to motivate further professional discussion developed through a simple three-stage iterative process over a 5-year period. The consensus methodology was classed as educational development which did not require ethical approval. Stage 1: a change of teaching practice was adopted by some co-authors (VG, RK, EL) on undergraduate and postgraduate Physiotherapy programmes at a UK University in 2018. This was a result of standard institutional teaching practice development which includes consideration of evidence-informed teaching. Stage 2: Input from a broader spectrum of stakeholders was sought, so a group of experienced, internationally-based educators, clinicians, and researchers from across the spectrum of manual therapy was convened. Perspectives were elicited through discussions in an iterative process. Stage 3: Presentations were made by some of the co-authors (VG, RK, SV, KY) to multidisciplinary groups (UK, Europe, North America) and feedback via questions and discussions was incorporated into further co-author discussions on the development of the framework. Consensus was achieved through repeated discussion of relevant elements. Figure  1 summarises the consensus methodology.

Summary and timeline of iterative consensus process for development of framework (MT: Manual Therapy; UG: Undergraduate; PG: Postgraduate)

Clinical & cost effectiveness of manual therapy

Manual therapy has been suggested to be a valuable part of a multimodal approach to managing MSK pain and disability, for example [ 8 ]. The majority of recent systematic reviews of clinical trials report a beneficial effect of MT for a range of MSK conditions, with at least similar effect sizes to other recommended approaches, for example [ 9 ]. Some systematic reviews report inconclusive findings, for example [ 10 ], and a minority report effects that were no better than comparison or sham treatments, for example [ 11 ].

Potential benefits must always be weighed against potential harms, of course. Mild to moderate adverse events from MT (e.g. mild muscle soreness) are common and generally considered acceptable [ 12 ], whilst serious adverse events are very rare and their risk may be mitigated by good practice [ 13 ]. MT has been reported by people with MSK disorders as a preferential and effective treatment with accepted levels of post-treatment soreness [ 14 ].

MT is considered cost-effective [ 15 ] and the addition of MT to exercise packages has been shown to increase clinical and cost-effectiveness compared to exercise alone in several MSK conditions [ 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 ]. Further, manual therapy has been shown to be less costly and more beneficial than evidence-based advice to stay active [ 24 ].

In summary, MT is considered a useful evidence-based addition to care packages for people experiencing pain and disability associated with MSK conditions. As such, MT continues to be included in national and international clinical guidelines for a range of MSK conditions as part of multimodal care.

Principles of traditional manual therapy (TMT)

Manual therapy has been used within healthcare for centuries [ 4 ] with many branches of MT having appeared (and disappeared) over time [ 25 ]. In developed nations today, MT is most commonly utilised by the formalised professional groups of physiotherapy, osteopathy, chiropractic, as well as groups such as soft tissue therapists. All of these groups have a history that borrows heavily from traditional healers and bone-setters [ 26 ].

Although there are many elements of MT, three principles appear to have become ubiquitous within what we shall now refer to as ‘traditional manual therapy’ (TMT): clinician-centred assessment , patho-anatomical reasoning , and technique specificity [ 27 , 28 , 29 , 30 ]. These principles continue to influence the teaching and practice of manual therapy over recent years, for example [ 31 ].

However, they have become increasingly difficult to defend given a growing volume of empirical evidence to the contrary.

Traditional manual therapy (TMT) principles: origins and problems

Clinician-centred assessment.

TMT has long had an emphasis on what we shall refer to as clinician-centred assessments . Within this, we claim, is an assumption that clinical information is both highly accurate and diagnostically important, for example [ 32 ]. Clinician-centred assessments include, for example, routine imaging, the search for patho-anatomical 'lesions’ and asymmetries, and specialised palpation. Although the focus of this paper is on the ‘hands-on’ examples of client-centred assessment, the notion of imaging is presented below to expose some of the flaws in the underlying belief system for TMT.

The emphasis on clinician-centred assessments has probably been driven, in part, by a desire for objective diagnostic tests which align well with gold-standard imaging. Indeed, since the discovery of x-rays, radiological imaging been used as an assessment for spinal pain – and a justification for using spinal manipulation – particularly in the chiropractic profession [ 33 ]. Contrary to many TMT claims, X-ray imaging is not without risk [ 34 ]. Additionally, until relatively recently (with the advent of magnetic resonance imaging) it was not widely appreciated that patho-anatomical ‘lesions’ believed to explain MSK pain conditions were nearly as common in pain-free individuals as those with pain [ 35 ]. Accordingly, the rates of unnecessary treatments, including surgery, are known to increase when imaging is used routinely [ 36 ]. For patients with non-specific low back pain, for example, imaging does not improve outcomes and risks overdiagnosis and overtreatment [ 37 ]. Hence, despite being objective in nature, the value of imaging for many MSK pain conditions (particularly spinal pain) has reduced drastically with clinical guidelines across the globe recommending against routine imaging for MSK pain of non-traumatic origin [ 38 ]. Even so, the practice of routine imaging continues [ 39 ].

Hands-on interventions are inextricably related to hands-on assessment [ 40 ], and often associated with claims of ‘specialisation’ [ 41 ]. By this we mean where a great level of training and precision are claimed to be necessary for influencing the interpretation of assessment findings, treatment decisions, and/or treatment outcomes. Implicit within this claim is that therapists who are unable to achieve such precision are not able to perform MT to an acceptable level (and thereby are not able to provide benefit to patients).

There are numerous studies that cast doubt over claims of highly specialised palpation skills. Palpation of anatomical landmarks does not reach a clinically acceptable level of validity [ 42 ]. Specialised motion palpation does not appear to be a good method for differentiating people with or without low back pain [ 43 ]. Poor content validity of specialised motion tests have been reported, in line with a lack of acceptable reference standards [ 44 ]. Palpable sensations reported by therapists are unlikely to be due to tissue deformation [ 45 ]. Furthermore, the delivery of interventions based on specialised palpatory findings is no better than non-specialised palpation [ 46 ]. Generally poor reliability of motion palpation skills has been reported, for example [ 47 ] and appear to be independent of clinician experience or training, for example [ 48 ]. Notably, person-centred palpation—for pain and tenderness for example—has slightly higher reliability, but is still fair at best [ 49 ].

This does not mean that palpation is of no use at all though; just that effective manual therapy does not depend upon it. For example, expert therapists can display high levels of interrater reliability during specialised motion palpation [ 50 ]. Focused training can improve the interrater reliability of specialised skills [ 51 ]. However, the validity of the phenomenon remains poor. Given the weight of the evidence and consistency of data over recent decades, we suggest that the role of clinician-centred hands-on assessment is no longer central to contemporary manual therapy.

Patho-anatomical reasoning

The justification for selecting particular MT interventions has historically been based upon the patho-anatomical status of local peripheral tissue [ 52 , 53 , 54 , 55 ]. Patho-anatomical reasoning, we propose, is the framework that links clinician-centred assessments to the desire for highly specific delivery of MT interventionsKey to this is the relationship between a patho-anatomic diagnosis and the assumed mechanisms of action of the intervention employed.

Theories for the mechanisms of action of MT interventions are many. Some of the most prominent include reductions of disc herniations [ 56 ], re-positioning of a bone or joint [ 32 ], removal of intra-articular adhesions [ 57 ], changes in the biomechanical properties of soft tissues [ 58 ], central pain modulation [ 59 ], and biochemical changes [ 60 ]. These theories have been used to justify the choice of certain interventions: a matching of diagnosis (i.e., existence of a lesion) to the effect of treatment takes place. However, most of these mechanistic theories either lack evidence or have been directly contested [ 61 ].

The causal relationship between proposed tissue-based factors such as posture, ergonomic settings, etc. and painful experience has also been disputed [ 62 ]. Although local tissue stiffness has been observed in people with pain, this is typically associated with neuromuscular responses, rather than patho-anatomical changes at local tissue level [ 63 , 64 , 65 , 66 ]. Overall, although some local tissue adaptions have been identified in people with recurrent MSK pain, this is inconsistent and the evidence is currently of low quality [ 67 ] are generally limited to short-term follow-up measures [ 68 ].

Technique specificity

TMT techniques have been taught with an emphasis that a particular direction, ‘grade’ of joint movement, or deformation of tissue at a very specific location in a certain way, is required to achieve a successful treatment outcome.

One problem with a demand for technique specificity in manual therapy is that an intervention does not always result in the intended effect. For example, posteroanterior forces applied during spinal mobilization consistently induce sagittal rotation, as opposed to the assumed posteroanterior translation, for example [ 69 ]. Furthermore, irrespective of the MT intervention chosen, restricting movements to a particular spinal segment is difficult and a regional, non-specific motion is typically induced, for example [ 70 ].

To support technique specificity, comparative data must repeatedly and reproducibly show superiority of outcome from specific MT interventions over non-specific MT, which is consistently not observed [ 71 , 72 , 73 ]. Some studies have demonstrated localised effects of targeted interventions [ 74 ] but there appears to be no difference in outcome related to: the way in which techniques are delivered [ 75 ]; whether technique selection is random or clinician-selected [ 41 ]; or variations in the direction of force or targeted spinal level [ 76 ]. Conversely, there is evidence that non-specific technique application may improve outcomes [ 77 , 78 , 79 ]. Further, sham techniques produce comparable results to specialised approaches [ 11 ].

Passive movement and localised touch have been associated with significant analgesic responses [ 80 ]. These data indicate the presence of an analgesic mechanism. Unfortunately, mechanistic explanation for the therapeutic effects of MT upon pain and disability still remain largely in a ‘black box’ state [ 81 ]. Nevertheless, there are several plausible mechanisms of action to explain the analgesic action of MT interventions, including the activation of modulatory spinal and supraspinal responses [ 82 , 83 , 84 , 85 ]. In support of this, MT interventions have been associated with a variety of neurophysiological responses [ 61 ]. However, it must be acknowledged that these studies provide mechanistic evidence based on association, which is insufficient to make causal claims [ 86 ]. Importantly, none of these neurophysiological responses have been directly related to either the analgesic mechanisms or clinical outcome and may therefore be incidental.

There is evidence that MT does not provide analgesia in injured tissues [ 87 , 88 ]. Conversely, MT has been shown to decrease inflammatory biomarkers [ 89 , 90 , 91 , 92 , 93 ], although these changes have not been evaluated in the longer-term, nor associated with clinical outcomes.

A modern framework for manual therapy

We propose a new direction for the future of MT in which the teaching and practice of this core dimension of MSK care are no longer based on the traditional principles of clinician-centred assessment , patho-anatomical reasoning , and technique specificity .

In doing so, this framework places MT more explicitly as part of person-centred care and appeals to common principles of healthcare, best available evidence, and contemporary theory which avoids unnecessary and over-complicated explanations of observed effects. The framework is simple in terms of implementation and delivery and contextualised by common elements of best practice for healthcare, in line with regulated standard of practice, e.g., [ 94 , 95 , 96 , 97 ]. Our proposal simply illustrates the operationalisation of these common elements through manual therapy.

Too much emphasis has been given to clinician-centred assessments and this should be rebalanced with an increased use of patient-centred assessments, such as a thorough case history, the use of validated patient-reported outcome measures (PROMS), and real-time patient feedback during assessments.

The new framework considers fundamental and humanistic dimensions of touch-based therapies, such as non-specific neuromodulation, communication and sense-making, physical education, and contextual clinical effectiveness. This aligns to contemporary ideas regarding therapeutic alliance and a move towards genuinely holistic healthcare [ 98 , 99 ]. The framework needs to be “open” in order to represent and allow expression of the complexity of the therapeutic encounter. However, to prevent the exploitation of this openness the framework is underpinned by evidence, and any manual therapy approaches without plausible and measurable mechanisms are not supported.

To provide the best care, common healthcare elements such as the safety and comfort of the person seeking help and therapist must be considered, and care should be provided as efficiently as possible. Our framework embraces these dimensions and employs an integration of current evidence. It is transdisciplinary in nature and may be adopted by all MT professions. Figure  1 provides a graphical representation of the framework. It is acknowledged that all components overlap, relate, and influence each. There are two main components: the practical elements on the inside, comprised of safety, comfort, and efficiency, and the conceptual themes on the outer regions, consisting of communication, context, and person-centred care Fig. 2 .

Representation of a modern teaching and practice framework for manual therapy. The image is purposefully designed to be simple, and has been developed primarily to be used as a teaching aid. When displayed in a learning environment, learners and clinicians can quickly refer to the image to check their practice against each element. To keep the image clear, each element of the image is described in detail in the text below”

Practical elements

Safety for people seeking help is a primary concern for all healthcare providers, with the aims to “ prevent and reduce risks, errors and harm that occur to patients [sic] during provision of health care… and to deliver quality essential health services ” [ 100 ]. This, and the notion of safety more generally (including that of the therapist), should be central to way MT is taught and practised.

A fundamentally safe context should be created where there is an absence of any obvious danger or risk of harm to physical or mental health. Consideration should be given to ensuring that communication and consent processes are orientated towards the safety of both the person seeking help and the therapist. The therapist should pay attention to any sense of threat that could be present in the physical, emotional, cognitive and environmental domains of the clinical encounter, and use skilful communication to mitigate anxiety about the assessment or therapeutic process.

Safety should also be considered in the clinical context of the assessment and treatment approach, ensuring that relevant and meaningful safety screenings have been undertaken [ 67 , 101 ]. There remains a need for good, skilful practice and development of manually applied techniques, but this can be achieved without reference to the principles of TMT and without the dogma of a proprietary therapeutic approach.

Comfort suggests that both the person seeking help and the therapist are physically and emotionally content during the assessment and therapeutic process. For example, the person seeking help is agreeable with any necessary state of dress (sociocultural difference should be considered); the person is relaxed and untroubled in whatever position they are in, and is adequately supported whether sitting, standing or recumbent during assessment and treatment; the therapist is comfortable with their positioning and posture; any discomfort produced by the therapeutic process is negotiated and agreed. Any physical mobilisation or touch should be applied with respect to the feedback from the person in relation to their comfort, rather than a pre-determined force based on the notion of resistance. This process requires clinical phronesis, sensitivity, responsivity, dexterity, and embodied communication [ 102 ].

The therapeutic process should be undertaken in a well-organised, competent manner aiming to achieve maximum therapeutic benefit with minimum waste of effort, time, or expense. To enhance the efficiency dimension, the assessment and therapeutic process should be an integral part of a holistic educational and/or activity-based approach to the management of the people which might also address psychological, nutritional, or ergonomic aspects of care, while being aware of social determinants to health. Recommendations exist which serve as a useful guide for enhancing care and promoting self-management in an efficient way [ 103 ].

A principle of this new model of MT is that therapists should not lose sight of the goals they develop with the people they help and ensure that there is coherence between their management aims and their techniques. Therapists should aim to support a person’s self-efficacy and use active approaches to empower them in their recovery. The overall number of therapeutic applications should be made in the context of fostering therapeutic alliance and supporting people to make sense of their situation and symptoms. This should be informed by contemporary views of the effects of manual therapy, emphasising a “physical education process” to promote sense-making and self-efficacy in alliance with the people they aim to help.

Clinical interactions need to be reproducible under a person’s own volition, serving to enhance self-empowerment. For example, someone could be taught how to “self-mobilise” if a positive effect is found with a particular therapeutic application. This should be appropriately scaffolded with behavioural change principles and functional contextualism that promote autonomy and self-management, rather than inappropriate reliance on the therapist [ 103 , 104 ].

An important and emergent notion from the proposed model is to question what constitutes indications for MT given that the model excludes traditional factors which would have informed whether manual therapy is indicated or not for a particular person. The response to this sits within the efficiency and safety dimensions: MT can be beneficial as part of a multi-dimensional approach to management across a broad population of people with musculoskeletal dysfunction, with no evidence to suggest any clinician-centered or patho-anatomical finding influences outcomes. The choice of whether or not to include MT as part of a management strategy should therefore be a product of a lack of contraindications and shared-decision making.

This framework aligns with evidence-based propositions that effectiveness and efficiency in assessment, diagnosis, and outcomes are not reliant on the therapist’s skill set of specialised elements of TMT, but rather other factors—for example variations in pain phenotypes [ 5 ].

Conceptual themes

Communication.

Communication is the overriding critical dimension to the whole therapeutic process and should be aimed at addressing peoples’ fundamental needs to make sense of their symptoms and path to recovery. The delivery and uptake of the therapy should therefore be operationalised in a communication process that meaningfully represents shared-decision making and the best possible attempt to contextualise the therapy in positive and evidence-informed explanations of the process and desired effects [ 105 ].

Within a therapeutic encounter, practitioners must give the time to listen to peoples’ accounts and explanations of their symptoms, including their ideas about their cause [ 106 ]. The assessment and diagnostic process should be a shared endeavour, for example, the negotiation of symptom reproduction. This should be done in a manner that facilitates sense-making, and which simultaneously encourages people to move on from unhelpful beliefs about their symptoms [ 107 , 108 ], encouraging understanding of the uncertain nature of pain and injury. Person-centered communication requires attention to what we communicate and how we communicate across the entire clinical interaction including interview, examination, and management planning [ 109 ]. Therapists need to be open, reflective, aware and responsive to verbal and non-verbal cues, and demonstrate a balance between engaging with people (e.g. eye-gaze) and writing/typing notes during the interview [ 110 , 111 , 112 ].

People should be given the opportunity to discuss their understanding of the diagnosis and options for treatment and rehabilitation. The decision-making process is dialogical, in which alternative options to the offered therapy should also be discussed with the comparative risks and benefits of all available management options, including doing nothing [ 113 , 114 ].

The therapist must fully appreciate the potential consequences of touch without consent. Continual dialogue should ensure that all parties are moving towards mutually agreed goals. The context of the therapy should be explicitly communicated to give appropriate context for any particular intervention as part of a holistic, evidence-based approach [ 115 , 116 , 117 ]. Therapists should be aware that their own beliefs can affect the way they communicate with their people; in the same way, a person’s context affects how they communicate what they expect from their treatment [ 107 , 118 , 119 , 120 ]. The construction of contextual healing scenarios which support positive outcomes, whilst minimising nocebic effects, is critical to effective healthcare [ 121 , 122 , 123 ].

There is a growing academic interest in the nature, role, and purpose of social and affective touch, and any re-framing of MT should consider touch as a means of communication to develop and enhance cooperative communications and strengthen the therapeutic relationship [ 124 , 125 , 126 , 127 , 128 , 129 ]. It can be soothing for a person in pain to experience the caring touch of a professional therapist [ 130 ]; on the other hand, probing, diagnostic, and touch can be experienced as alienating [ 131 , 132 , 133 ]. Touch can alter a person’s sense of body ownership and their ability to recognise and process their emotions by modulating interoceptive precision [ 129 , 134 , 135 ], and intentional touch may be perceived differently from casual, unfocussed touch [ 136 , 137 ]. There is also a thesis that touch generates shared understanding and meaning [ 138 , 139 , 140 ]. This wider appreciation of touch should be embedded in modern MT communication.

The contextual quality of a person’s experience of the therapeutic encounter can affect satisfaction and clinical outcomes [ 141 , 142 , 143 , 144 , 145 ]. The context in which therapeutic care takes place should therefore be developed to enhance this experience. There could be very local, practical aspects of the context, such as the type of passive information available in the clinical space, e.g. replacing biomedical and pathological imagery and objects with positive, active artefacts; judicious and thoughtful organisation and use of treatment tables to discourage a sense of passivity and disempowerment; allocating a comfortable space where communication can take place; colour schemes and light sources which facilitate positivity; ensuring consistency through all clinical and administrative staff promoting encouraging and non-nocebic messages. Importantly, the way the therapist dresses influences peoples’ perception of their healthcare experience [ 146 , 147 ], and that in turn should be contextually and culturally sensitive [ 148 , 149 , 150 ].

Beyond the local clinical space is the broader social environment. The undertaking of MT should serve a role in a person’s engagement with their social environment. For example, someone returning home after engaging with their therapist and disseminating positive health messages within their home and social networks; people acting as advocates for self-empowered healthcare. Furthermore, early data have demonstrated that aligning treatment with the beliefs and values of culturally and linguistically diverse communities enhances peoples’ engagement with their healthcare [ 151 ].

Person-centred care

Here we borrow directly from one of the most established and clinically useful definitions of Person-Centered Medicine [ 152 ]:

“(Person-Centered Medicine is) an affordable biomedical and technological advance to be delivered to patients [sic] within a humanistic framework of care that recognises the importance of applying science in a manner that respects the patients [sic] as a whole person and takes full account of [their] values, preferences, aspirations, stories, cultural context, fears, worries and hopes and thus that recognises and responds to [their] emotional, social and spiritual necessities in addition to [their] physical needs” [ 152 ] , p219.

Person-centred care incorporates a person’s perspective as part of the therapeutic process. In practice, therapists need to communicate in a manner that creates adequate conversational space to elicit a person’s agenda (i.e. understanding, impact of pain, concerns, needs, and goals), which guides clinical interactions. This approach encourages greater partnership in management [ 109 , 153 , 154 ].

A roadmap outlining key actions to implement person-centeredness in clinical practice has been outlined in detail elsewhere [ 155 ]. This includes screening for serious pathology, health co-morbidities and psychosocial factors; adopting effective communication; providing positive health education; coaching and supporting people towards active self-management; and facilitating and managing co-care (when needed) [ 154 ].

It is critical and necessary now to make these features explicit and central to the revised model of MT proposed in this paper. We wish to identify common ground across all MT professions in order to achieve a trans-disciplinary understanding of the evidence supporting the use of MT.

We acknowledge that our arguments here are rooted in empiricism and deliberately based on available research data from within the health science disciplines. We also acknowledge that there is a wider debate about future directions in person-centred care arising from the current evolution of the evidence-based health care movement, which has pointed to the need to learn more about peoples’ lived experiences, to redefine the model of the therapeutic relationship. Although beyond the scope of this paper, a full exploration of modern health care provision involves reconsideration of the ethics and legal requirements of communication and shared decision-making [ 156 , 157 , 158 , 159 ]. The authors envision this paper as a stimulus for self-reflection, stakeholder discussions, and ultimately change that can positively impact outcomes for people who seek manual therapy interventions.

Manual therapy has long been part of MSK healthcare and, given that is likely to continue. Current evidence suggests that effectiveness does not rely on the traditional principles historically developed in any of the major manual therapies. Therefore, the continued teaching and practice based on the principles of clinician-centred palpation , patho-anatomical reasoning , and technique specificity are no longer justified and may well even limit the value of MT.

A revised and reconceptualised framework of MT, based on the humanistic domains of safety, comfort and efficiency and underpinned by the dimensions of communication, context and person-centred care will ensure an empowering, biopsychosocial, evidence-informed approach to MSK care. We propose that the future teaching and practice of MT in physiotherapy, osteopathy, chiropractic, and all associated hands-on professions working within the healthcare field should be based on this new framework.

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Energy expenditure during nutritional rehabilitation: a scoping review to investigate hypermetabolism in individuals with anorexia nervosa

• Kylie K. Reed 1 ,
• Ava E. Silverman 2 , 3 ,
• Afrouz Abbaspour 4 ,
• Kyle S. Burger 1 ,
• Cynthia M. Bulik 1 , 2 , 4   na1 &
• Ian M. Carroll 1   na1  

Journal of Eating Disorders volume  12 , Article number:  63 ( 2024 ) Cite this article

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Weight gain and nutritional rehabilitation are essential first steps to achieve medical stabilization in anorexia nervosa, and frequent resistance to weight gain requires patients to consume high kilocalorie loads. Adaptive hypometabolism is common when patients begin treatment, and rebound hypermetabolism is suspected to be a significant barrier to weight gain. The aim of this review was to summarize existing data describing metabolic changes in anorexia nervosa during weight restoration. The reported findings challenge current hypotheses of weight gain resistance and highlight key areas for future research.

Using scoping review guidelines, three databases were searched for studies investigating metabolic changes in anorexia nervosa before and after renourishment. Two reviewers systematically screened the titles and abstracts of 447 articles, and full-text versions of 106 studies were assessed for eligibility. A total of 36 studies were included for review. Data regarding the study description, sample population (including age, weight, BMI, duration of treatment, and caloric intake), and metabolic variable descriptions were extracted.

Female patients with anorexia nervosa from studies across 13 countries were included. Across the studies, average BMI increased from 13.7 kg/m 2 at admission to 17.57 kg/m 2 . Patients presented to treatment with clinically reduced energy expenditure levels. After varying levels of nutritional rehabilitation and weight restoration, measured energy expenditure increased significantly in 76% of the studies. Energy expenditure values at the second timepoint increased to the standard range for normal weight female teenagers and adults. Despite these increases, the studies do not indicate the presence of a hypermetabolic state during renourishment. Additionally, all studies including both measured and predicted energy expenditure reported that predicted energy expenditure overestimated measured values.

This study provides a detailed evaluation of the literature investigating energy expenditure and metabolic rate in patients with anorexia nervosa before and following a period of renourishment. The findings from this review identify important gaps in the current beliefs of energy expenditure in anorexia nervosa and highlight a need for further exploration of metabolic alterations during weight restoration.

Plain English Summary

Nutritional rehabilitation and weight restoration are two primary goals of anorexia nervosa treatment that pose significant physiological and psychological challenges for patients. Patients often require high caloric loads to continue an adequate weight gain trajectory, but the underlying cause of weight gain resistance remains unknown. We completed a scoping review of research into energy expenditure and metabolic rate during treatment. Our search identified 447 relevant articles from academic databases, and 106 were deemed eligible after screening. We extracted data, including sample characteristics, kilocalorie intake, energy expenditure, and treatment information, from 36 studies. When individuals arrived for treatment, their energy expenditure was lower than that of individuals without an eating disorder due to the prolonged state of nutrient deprivation. After varying amounts of time and kilocalorie intake, most studies reported significant increases in energy expenditure. However, energy expenditure after a period of renourishment did not indicate an overactive metabolism (i.e., “hypermetabolism”). Funders should consider supporting exploration of additional factors that may be functioning as barriers to weight gain during treatment, in pursuit of making treatment more efficient and long-lasting. Additionally, future research describing metabolism in anorexia nervosa should provide more consistent methodologies, robust statical testing, and comprehensive reporting of dietary intake.

Introduction

Anorexia nervosa (AN), a severe psychiatric disorder characterized by extreme weight dysregulation, carries one of the highest mortality rates of all psychiatric illnesses [ 1 , 2 ]. Affecting individuals of all ages, ancestries, and genders, AN has an estimated lifetime prevalence of up to 4% in females and 0.3% in males [ 3 ]. Within the AN diagnosis, patients may be classified as restricting or binge eating/purging type, and nearly 75% of patients with AN report a comorbid lifetime mood or anxiety disorder [ 2 , 4 ]. Somatic symptoms associated with AN, although varying with severity and stage of illness, affect nearly every organ system in the body due to starvation or binge eating and/or purging behaviors [ 5 ]. AN presentation involves a complex interplay between biological, psychological, genetic and environmental factors, and remediating the consequences of severe caloric restriction are only one component of the current treatment paradigm [ 6 ].

To achieve medical stabilization, weight gain and nutritional rehabilitation (also referred to as clinical refeeding, renourishment, or weight restoration) are the first and essential goals of treatment. The process of therapeutic renourishment can be both physically and psychologically uncomfortable and relapse is high [ 7 , 8 ]—highlighting the need for novel, safe, and effective therapeutic approaches. Full recovery is more common in adolescents than in adults [ 9 ], and on average, adult patients require 5–6 years of treatment until achieving remission [ 10 ]. Throughout the course of the illness, it is common for both adolescent and adult patients to undergo several cycles of therapeutic renourishment followed by loss of restored weight before achieving lasting recovery. One potential explanation for the lack of efficacy of current renourishment strategies is the need to consume a sustained high kilocalorie (kcal) diet, which is psychologically (due to fear of weight gain) and physically (due to discomfort, pain, and gastrointestinal complications) challenging to patients and can lead to premature discontinuation of treatment and jeopardize long-term recovery [ 11 , 12 ]. As metabolic output forms the basis for caloric intake prescription, meticulous monitoring of the metabolic profile in individuals receiving treatment for AN is crucial for achieving successful renourishment. Research to advance the nutritional component of AN treatment protocols, however, lacks an updated and comprehensive characterization of metabolic changes in patients with AN.

Metabolic adaptations in anorexia nervosa

Metabolism is a series of chemical reactions by which calories consumed are converted (catabolized) into usable energy for healthy body function. Metabolic rate is often measured by indirect calorimetry and predicted using calculations including the Harris-Benedict and Schebendach equations [ 13 ]. Previous work has highlighted that these equations may not accurately predict metabolic rate in AN [ 14 ], as classical energy expenditure estimation based on age, height, weight, and sex fails to consider the metabolic profile in a disease state [ 15 ]. For AN, therapeutic renourishment plans are developed on the foundation of metabolic requirements and tailored to each individual patient. The current standard of care varies widely across treatment facilities, with some recommendations starting at 10 kilocalorie (kcal)/kg/day with increases of 5 kcal/kg/day [ 16 ] and others starting at 30–40 kcal/kg/day with increases up to 70–100 kcal/kg/day to promote faster weight gain [ 17 ]. Recent studies have highlighted the efficacy of higher-calorie refeeding, both in restoring medical stability more quickly and reducing overall hospital charges per participant [ 18 ]. Importantly, patients with AN in a chronic state of starvation can experience significant decreases in metabolic rate to compensate for the lack of energy intake [ 19 ]. These hypo metabolic states are typically attributed to reduced protein turnover (i.e., reduced renewal and replacement of protein) and ATP supply pathways, providing the body with significant energy savings [ 20 ].

Adaptive hypometabolism prior to renourishment is common and well-documented [ 21 , 22 ]. Less clear is whether rebound hyper metabolism (either from a hypo- or normo-metabolic baseline) occurs as commonly during nutritional rehabilitation. When weight gain stalls during inpatient or residential treatment, two common hypotheses are typically considered: (i) the patient is using exercise or other methods to inhibit weight gain, or (ii) the patient’s metabolic rate has shifted to a hyper metabolic state [ 23 ]. Hypermetabolic states are characterized by increased physiological responses including heart rate, blood pressure, body temperature, and protein and lipid catabolism, leading to excessive resting energy expenditure [ 24 ]. Hypermetabolism has been well described in circumstances of both chronic and acute stress (e.g., trauma [ 25 ], severe burn injury [ 26 ], and COVID-19 [ 27 ]), so it is conceivable that physiological stress from AN progression, in addition to other common AN complications such as chronically elevated cortisol [ 28 ] and difficulty sleeping [ 29 ], may also contribute to increased cellular metabolism during treatment. Anecdotal reports posit that increases in metabolic rate may be an important barrier to weight gain and weight maintenance in AN [ 23 ], and limited evidence reports a shift towards hypermetabolism during AN treatment [ 30 , 31 ]. Proposed explanations for accelerated energy expenditure during nutritional rehabilitation include the occurrence of night sweats, irregular and/or elevated heart rate, and nervous system dysfunction [ 23 ].

As nutritional rehabilitation programs are centered around metabolic rate estimations, it is essential for providers to have an accurate depiction of the metabolic setting in each individual patient. Caloric initiation standards are based on basal metabolic rate (BMR); however, BMR is infrequently remeasured once renourishment begins, leaving dietetic teams to increase caloric load based on careful observation of weight gain, food intake, and physical activity on the unit [ 14 ]. Additionally, it is likely that studies investigating metabolism during AN treatment employ equations that were not developed for application to low body weight individuals [ 32 ]. These challenges highlight the need for comprehensive documentation of metabolic changes before, during, and after renourishment, rather than relying on a cross-sectional metabolic assessment upon hospital admission.

In an effort to consolidate and evaluate existing knowledge about metabolic changes during renourishment in individuals with AN, we conducted a scoping review of energy expenditure (EE) during nutritional rehabilitation. We anticipated finding consistent reports of moderate increases in energy expenditure after renourishment and aimed to aggregate existing knowledge on the commonly referred to “hypermetabolic state” that occurs during renourishment.

Search strategy

A scoping review search was performed in June and July 2023 through Covidence using PRISMA guidelines. Searches were conducted in PubMed, SCOPUS, and the Cumulated Index in Nursing and Allied Health Literature (CINHAL). Search terms included (“Energy Metabolism” [Mesh] OR “Energy Expenditure” OR “energy expenditures” OR “hypermetabolism” OR “hypermetabolic” OR “metabolic rate” OR “basal metabolism” OR “metabolic rates” OR “energy metabolism”) AND (“Anorexia Nervosa” [Mesh] OR “anorexia nervosa”). Medical Subject Headings (i.e., MeSH) assigned to files in PubMed were used to retrieve all records on the relevant subject (metabolism and AN) in a subjective manner, regardless of the vocabulary utilized by the author.

Inclusion and exclusion criteria

Studies and articles (including peer reviewed conference abstracts) published between 1980 and 2022 that investigated metabolic changes in patients with AN before (T1) and after (or during) renourishment (T2) were eligible for analysis. Relevant studies that reported any metabolic variable outcome, including resting energy expenditure (REE), total energy expenditure (TEE), basal metabolic rate (BMR), and resting metabolic rate (RMR) and recorded at least two time points (e.g., admission and discharge from treatment unit, baseline and follow-up from treatment, independent groups of active cases and recovered patients, etc.) were included. The following exclusion criteria were applied: (1) cross-sectional studies reporting only one metabolic timepoint; (2) case studies; (3) qualitative studies; (4) animal studies; (5) studies of individuals with other eating disorders; (6) presentations, dissertations, theses, book chapters, and other technical documentation.

Study selection and data extraction

A flowchart was created to document general article screening progress in accordance with PRISMA guidelines (Fig.  1 ). K.R. and A.S. used Covidence to systematically assess articles using titles, abstracts, and full text copies. After the initial search, 448 studies were imported for screening, one of which was a duplicate. Of the 447 studies screened, 334 studies were deemed irrelevant based on title and/or abstract screening according to inclusion and exclusion criteria. The remaining 106 full-text studies were assessed for eligibility, and 70 were excluded due to study design ( n  = 55) or outcomes ( n  = 15) not of relevance for this review. A total of 36 studies were included (Fig.  1 ).

PRISMA flowchart depicting article identification, screening, and inclusion

A Covidence-generated template was used to extract the following information: (1) Author and year of publication; (2) country where the study was conducted; (3) aim of the study; (4) inclusion and exclusion criteria; (5) population characteristics (including age, weight, BMI, duration of treatment, and caloric intake when available); (6) metabolic variable descriptions, numerical results, and correction factors. All study participants met diagnostic criteria for AN according to the DSM-III, DSM-IV, or DSM-5, depending on time of publication. Means and standard deviations were evaluated for each numeric variable when available. Metabolic variables (REE, TEE, RMR, and BMR) were standardized to kcal/day, and the longest duration from follow-up reported in each study was recorded for this review to maintain consistency throughout data extraction. Means of clinical characteristics and percent change in EE values from baseline to follow-up were calculated.

Study characteristics

The included studies evaluated female patients with AN in Australia ( n  = 2), Brazil ( n  = 1), Canada ( n  = 2), Czech Republic ( n  = 2), France ( n  = 4), Germany ( n  = 3), Israel ( n  = 2), Italy ( n  = 4), Japan ( n  = 2), Spain ( n  = 4), Sweden ( n  = 1), Switzerland ( n  = 1), and USA ( n  = 8) (Table  1 ). Studies were published between 1984 and 2020. A non-eating disorder (non-ED) control group was included in 55% of studies ( n  = 20). In addition to healthy female controls, three studies included “refed”, “rehabilitated”, or “recovered” patients with AN [ 33 , 34 , 35 ]; one study included a comparison group of weight-recovered females with an acute episode of AN in the last 10 years [ 36 ]; and one study included an additional comparison of “malnourished, dying patients” with other diseases [ 37 ]. Four of the studies [ 34 , 35 , 38 , 39 ] recruited from outpatient treatment facilities, whereas the majority of included patients with AN were receiving inpatient treatment. All studies included only female participants across both AN and control groups, and only data on patients with AN were extracted.

The studies reported varying renourishment protocols, and energy intake ranged from 753 [ 40 ] to 3264 [ 41 ] kcal at baseline (T1) and 1658 [ 42 ] to 3600 [ 43 ] kcal at follow-up (T2). With the exception of Pettersson 2016 (-19.67% change in kcal) [ 41 ] and Pauly 2000 (0.00% percent change in kcal) [ 42 ], studies reported a higher kcal intake at the second timepoint (ranging from + 11.82% [ 44 ] to + 217.76% [ 45 ]). When the first measurement was obtained, the study participants had an average BMI of 13.7 kg/m 2 . At the T2 measurement and an average of 67 days of renourishment, the patients gained significant weight, had an average BMI of 17.57 kg/m 2 . Of note, the mean BMI at T2 falls outside of the recommended range for BMI (18.5–25 kg/m 2 ).

Measured energy expenditure

Measured energy expenditure is reported in Table  2 . The energy expenditure measurement with the longest duration from baseline was extracted as the second timepoint (T2). Of the included studies, 76% ( n  = 28) reported statistically significant increases in energy expenditure from baseline (T1) to follow-up (T2) timepoints. In contrast, five studies reported no significant differences [ 36 , 46 , 47 , 48 ]. An additional four studies did not report numerical summaries of relevant statistical tests [ 43 , 49 , 50 , 51 ]. On average, the studies reported a 24.99% change in EE from baseline to follow-up. Cuerda Compés 2005 reported the smallest percent change of 5.18% [ 52 ], and the EE values reported in Obarzanek 1994 showed the largest percent change of 62.80% [ 53 ].

Seven of the included studies adjusted the measured EE for body weight, lean body mass, or fat-free mass. In four of those studies [ 33 , 38 , 54 , 55 ], the EE remained significantly lower at T1 than T2 even after the adjustment. In contrast, the remaining three studies [ 13 , 56 , 57 ] reported that the statistically significant difference diminished after accounting for body weight, lean body mass, or fat-free mass (FFM). One study showed that the ratio of REE to FFM significantly correlated with energy intake, anxiety, abdominal pain, and depressive mood [ 45 ]. The ratio also increased significantly with physical activity and cigarette smoking. A positive correlation between serum leptin levels and EE was reported in studies by Haas et al. [ 58 ] and Polito et al. [ 59 ]. However, no statistically significant correlation was found in a study published a few years earlier by Haas [ 44 ].

Twelve of the included studies [ 37 , 38 , 43 , 44 , 45 , 51 , 53 , 55 , 60 , 61 , 62 , 63 ] used multiple EE values across the renourishment period. Three of the studies [ 38 , 44 , 61 ] included EE measurements at the beginning, middle, and end of treatment, with no significant evidence of a hypermetabolic period during the middle of treatment compared to discharge. Furthermore, Haas 2005 reported that discharge REEs were still lower in AN than their non-ED controls [ 44 ]. Similarly, Obarzanek 1994 reported significant increases in RMR when patients were restudied during early refeeding [ 53 ]; RMR further increased during late refeeding to levels comparable to healthy volunteers but reverted to values lower than those of controls when the patients finished the target weight-stabilization. Vaisman 1991 and Vaisman 2004 reported gradual increases in REE (across either body weight percentages [ 63 ] or treatment duration [ 55 ]) persisted until stabilizing near discharge (8–10 weeks). Despite these increases, however, the mean REE failed to reach the “normal” range (90–110% of predicted REE) during hospitalization [ 55 ].

In contrast to gradual increases over time, Schebendach 1997, Rigaud 2000, and Pichard 1996 reported that the early weeks of refeeding (i.e., weeks 0–2) are the critical period for statistically significant increases in EE, as higher energy expenditure does not seem to persist in longer-term weight stable patients [ 37 , 51 , 62 ]. Additionally, Van Wymelbeke 2004 reported that the initial increase in REE during the first week of treatment represented 31% of the total REE increase over 2.5 months of refeeding [ 45 ]. Importantly, Krahn 1993 and Moukaddem 1997 reported EE results with detailed energy intake information [ 43 , 57 ]. As patients increased their energy intake to 3600 kcal/day (by 300 kcal/day increments starting at 1200 kcal/day at baseline), Krahn 1993 reported that observed differences in REE ranged from 467 to 1049 kcal/day, highlighting large variability in metabolic recovery [ 43 ]. Moukaddem 1997 reported an 8% increase in REE after 1 week of refeeding, with slight variations in estimations based on 300 kcal or 700 kcal experimental loads [ 57 ].

Predicted energy expenditure

Predicted energy expenditure results across two timepoints were extracted if raw values were reported (i.e., not only as percentages of measured EE; Table  3 ). For consistency within this review, only predictions using the Harris-Benedict equation ( n  = 6) (most widely used [ 64 ]) or Bioelectrical Impedance Analysis (BIA; n  = 1) were extracted. Five of the studies reported statistically significant changes between predicted EE values at baseline and follow up [ 13 , 36 , 44 , 52 , 60 ], and all studies that included raw predicted EE values reported the finding that predicted values overestimated measured EE in patients with AN. On average, the studies reported a 11.65% change in EE from baseline to follow-up, over 50% less than the average percent change in measured EE. Agüera 2015 reported the smallest percent change of 2.07% in patients with restricting AN [ 60 ], and DosReis 2020 reported the largest percent change of 53.36% [ 35 ]. Interestingly, Konrad 2007 reported that measured values of EE were 84% below values predicted with the Harris-Benedict Eq.  [ 38 ]. These findings are consistent with prior literature suggesting that REE is likely to be higher than predicted during refeeding [ 13 ] due to the failure of predictive equations to adequately account for altered body composition and/or hormonal status in females with AN.

Summary of findings

A comprehensive search revealed a complex relationship between metabolic trajectories and the renourishment process in AN, and the included studies reported consistently lower energy expenditure at the initiation of renourishment, compared with values reported in non-eating disorder controls. All studies highlighted subsequent increases in energy expenditure after differing durations of refeeding, with varying levels of statistical significance. The consistent report of moderate increases was not accompanied by reproducible reports of EE-associated clinical variables (e.g., BMI, FFM, or hormones) or a standard duration of refeeding needed to elicit these changes. Additionally, the studies, despite moderate increases, do not indicate evidence of energy expenditure that would indicate the presence of a hyper metabolic state, or energy expenditure > 110% of predicted REE [ 65 ]. This consensus definition of a hypermetabolic threshold relies heavily on studies of cancer cachexia and burn injuries, and the reliability of applying this numerical value in AN remains questionable due to frequent inaccuracies in predicted REE. Metabolic rates of the patients with AN at the second timepoint (either discharge from treatment, after a short period of refeeding, or recovered individuals) throughout all included studies fall within the normal range (total energy expenditure of 1910–2140 kcal/day for healthy female teenagers [ 66 ] and 1572–3687 kcal/day in healthy adults [ 67 ]). In summary, weight gain resistance in AN treatment does not seem to be fully explained by measures of metabolic rate and/or energy expenditure. Although there are increases in expenditure after initiation of renourishment, the data suggests that these increases are simply a normalization of expenditure out of the hypo metabolic disease state and do not indicate hyper metabolism-driven weight gain resistance.

Limitations of extant literature

Although metabolic adaptations before and after treatment were described, the existing data do not support formal conclusions about metabolic changes that may occur during refeeding. Only 33% of included studies ( n  = 12) reported more than two measurements, and many studies did not take the second energy expenditure measurement during the highest energy intake period but rather once the energy intake requirement declined prior to discharge. Moreover, the current literature does not report sufficient data to characterize differences between restricting and binge eating/purging AN subtypes, although one study reported BMR to be higher in the restricting subtype [ 60 ]. It is also likely that different measurement techniques for assessing and/or predicting metabolic rate may lead to vastly different estimates, creating an additional layer of difficulty when developing literature-based nutritional rehabilitation programs. Most included studies did not report effect sizes, making the associated clinical relevance hard to interpret. Additionally, metabolic changes in other eating disorders and/or other populations of patients with AN, such as males and/or patients presenting in larger bodies (i.e., atypical AN [ 68 ]), are not well described. This warrants future investigation, as males are typically considered to report higher variations in metabolic activity [ 69 ] and individuals with higher weights may have significantly different metabolic rates compared to lean individuals [ 70 , 71 , 72 ].

Additionally, there is large variability in both length of stay and weight change among the included studies. Three studies with both short (7 days) [ 42 , 57 ] and long (up to 11 months) [ 39 ] length of stay in the unit reported less than 1 unit change in BMI, which complicates the interpretation of these findings. Small weight changes may reflect changes in hydration status more than compartmental changes to body composition. When REE results from these reports are not considered, however, there is still no evidence of hypermetabolic spikes at discharge in the remaining studies. Variations in length of stay, weight change, and comparison groups highlight the need for more consistent characterization of metabolic changes during recovery.

Increasing scientific rigor

To gain a deeper understanding of the mechanistic basis of increases in energy expenditure in patients with AN during renourishment, it is imperative that the field fosters greater scientific rigor by seeking consistency across design, measurement, and analysis. The included studies discuss multiple hypotheses about why this hypermetabolic phenomenon may occur—such as shifts to bone formation [ 73 ], the continuation of protein synthesis in a resting state instead of just after meals [ 53 ], dietary induced thermogenesis spikes with greater amount and frequency of food [ 50 ]—but explanations for such a prompt rebound to or beyond typical metabolic rates remains elusive, leaving practitioners to adjust energy intake during this period without properly informed evidence-based guidance. Additionally, growing evidence from genetic studies uncovering both psychiatric and metabolic genetic underpinnings to AN [ 74 ] adds urgency to designing and conducting rigorous studies to more deeply understand metabolism in individuals with AN, both as a predisposing trait and additionally to understand changes in metabolism over time. As genetics explain ~ 40% of the variance in resting metabolic rate [ 75 ] and AN has twin-based heritability estimates of 50–60% [ 76 ], investigating the overlap between genetically influenced metabolic traits and AN phenotypes may provide meaningful insight.

Determining whether the purported hypermetabolic phase actually occurs is of considerable clinical importance. Tolerating increasingly high caloric prescriptions is physically and psychologically difficult for patients and can lead to marked gastrointestinal and emotional distress. Moreover, preventing the loss of therapeutically restored weight after discharge depends on accurate prediction of energy requirements to maintain or gain weight. If patients are not gaining weight with a prescribed caloric level and there is no evidence of hypermetabolism, then other reasons for the failure to gain weight must be explored.

Of relevance for refeeding, the primary role—among many—of the intestine is to harvest calories from the diet to sustain the body’s energy requirements. Prolonged caloric restriction can lead to a dysfunctional gut and potentially reduced calorie harvest from the diet [ 77 ]. Indeed, nutrient deprivation in individuals with AN could impact gut function and ultimately lead to a global reduction in the absorptive capacity of the gut, which may be misinterpreted as hypermetabolism during renourishment . Stated another way, although patients are being fed increasing numbers of calories, their guts may be unable to harvest and utilize those calories for weight restoration. Although renourishment, weight gain, and weight maintenance are major hurdles for recovery, scant information exists about the absorptive capacity of the gut, and its corresponding relationship with metabolism, in patients with AN. The very limited number of studies of intestinal epithelial alterations in AN reported disturbances in tissue architecture and a decrease in intestinal permeability [ 78 , 79 ], and it is logical to posit that the microbial ecosystem inhabiting the gastrointestinal tract may be an additional barrier [ 32 , 77 ]. As the body of research progresses, studies with consistent metabolic tracking may lead to investigation of the existence of a dysfunctional intestine in patients with AN, which may have significant implications for developing more effective and enduring renourishment strategies.

Recommendations

The clinical experience of hypermetabolism, albeit lacking robust empirical evidence, has a direct impact on renourishment protocols implemented by the clinical care team. If a patient is not making expected weight gain, all possible reasons should be explored in order to make informed clinical decisions. Although fear of weight gain may indeed lead patients to engage in treatment-interfering behaviors that inhibit weight gain, it should never automatically be assumed that this is the cause of a weight stall. Careful characterization of energy expenditure throughout the duration of treatment provides the best data for informed decision making among providers. Based on this review, considerable research is needed to enrich our understanding of metabolic factors and changes that are relevant to AN etiology, progression, treatment, and remission. As a start, we recommend the following:

Future research should harmonize methodologies and standardize reporting of results. Robust studies should include detailed dietary data (i.e., energy intake), subtype categorizations, and information about the duration of illness. In addition to significance testing, effect sizes should be reported as well as metrics that capture the extent to which results are clinically meaningful.

If physiological measurement via indirect calorimetry, doubly labeled water, or other methods is not available, studies utilizing predictive equations for energy expenditure should include subtype, body composition measures (fat free mass and fat mass through dual X-ray absorptiometry or bioelectrical impedance analysis [ 80 ]), and duration of illness in the equations for better predictive accuracy [ 15 ]. Recent findings from Bou Khalil et al. report that if FFM and FM measurements are not available, the Schebendach equation [ 81 ] will have the highest agreement with REE measured by indirect calorimetry [ 15 ]. Authors employing these methods should highlight shortcomings of these equations; for example, Cuerda 2007 reported that measured REE values did increase throughout hospitalization but still remained 10% lower than predicted values [ 13 ]. Treatment teams in the United States are frequently faced with the challenge of discharge prior to weight stabilization despite recent evidence that BMI at the end of treatment is a direct predictor of relapse [ 82 ]. In a climate of insurance thresholds that are based on percentages—such as discharge at 80% ideal body weight—it is imperative to acknowledge the implications of inaccurate expenditure predictions on weight stabilization and relapse risk. Although further research is needed to establish the most clinically relevant timepoints for energy expenditure assessment, we recommend energy expenditure estimations at admission, approximately two weeks into treatment, and prior to discharge to inform dietary prescriptions to support continued weight gain or weight maintenance. Although duration of inpatient stay is difficult to predict and varies due to many factors, a second measurement after a week or two of treatment will capture energy expenditure once fluid and electrolyte levels have stabilized. It is possible that persistent disruptions in homeostatic energy expenditure, in the presence of other indicators of active illness (such as lack of weight stabilization) may be important factors to consider prior to discharge at a certain percentage of ideal body weight.

 Funding for well-developed studies with a comprehensive characterization of energy expenditure over time, including multiple timepoints during renourishment, is imperative. Additionally, funding to investigate biological mechanisms that may be contributing to difficulties during treatment will greatly advance the field. Relevant biological avenues for exploration include: (i) the intestinal microbiota (including the development of microbiota directed complementary foods to be implemented during refeeding), (ii) genetics (with metabolic-, psychiatric- and nutri-genetic driven hypotheses), (iii) structural or physiological changes to the gut in AN, and (iv) other feeding and eating behaviors, such as time restricted eating, binge eating, and purging, that may play a role in the absorption or conversion of calories to tissue.

This scoping review provides an updated description of research examining variations in energy expenditure before and following a period of renourishment in patients with AN. After summarizing reports of measured and predicted EE, it is clear that patients currently ill with active AN present for treatment with slowed metabolic rates, and, after treatment, experience mild to moderate increases in metabolic rate. The commonly occurring and resolute resistance to weight gain, however, cannot be fully attributed to a hypermetabolic shift during renourishment. This review has highlighted many gaps for which further funding and research is essential, as there is an urgent need to explore metabolic abnormalities in AN. The reality faced by patients with AN is often a bleak one—with approximately one third of individuals with AN still not reaching recovery after 22 years of illness [ 83 ]. Decades of research into psychological and pharmacological interventions have left all those in the AN field—patients, caregivers, providers, and researchers alike—in need of more viable treatment options that provide a more promising future [ 84 ]. In a continued effort to shift the treatment paradigm, we propose that now is the time to finally understand the perplexing and remarkably resilient metabolic adaptions that occur in AN.

Data availability

No datasets were generated or analysed during the current study.

Abbreviations

anorexia nervosa

kilocalorie

adenosine triphosphate

basal metabolic rate

energy expenditure

resting energy expenditure

total energy expenditure

resting metabolic rate

Preferred Reporting Items for Systematic Reviews

Diagnostic and Statistical Manual of Mental Disorders

eating disorder

timepoint 1

timepoint 2

body mass index

fat free mass

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Acknowledgements

The authors would like to thank Jamie Conklin from the UNC-Chapel Hill Health Sciences Library for providing valuable support during article screening.

CMB is supported by NIMH (R56MH129437; R01MH120170; R01MH124871; R01MH119084; R01MH118278; R01 MH124871) and Swedish Research Council (Vetenskapsrådet, award: 538-2013-8864). IMC is supported by NIMH (R01MH105684) and the UNC CH Nutrition Obesity Research Center (NORC, P30-DK056350-21).

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Kylie K. Reed, Kyle S. Burger, Cynthia M. Bulik & Ian M. Carroll

Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA

Ava E. Silverman & Cynthia M. Bulik

Smith College, Northampton, MA, USA

Ava E. Silverman

Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden

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Reed, K.K., Silverman, A.E., Abbaspour, A. et al. Energy expenditure during nutritional rehabilitation: a scoping review to investigate hypermetabolism in individuals with anorexia nervosa. J Eat Disord 12 , 63 (2024). https://doi.org/10.1186/s40337-024-01019-7

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A systematic review and meta-analysis of the association between e-cigarette use among non-tobacco users and initiating smoking of combustible cigarettes

• Mimi M. Kim 1 ,
• Isabella Steffensen 1 ,
• Red Thaddeus D. Miguel 1 ,
• Tanja Babic 1 &
• Julien Carlone 1  

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Introduction

The rapid increase in e-cigarette use over the past decade has triggered an important public health question on the potential association between e-cigarette use and combustible cigarette smoking. Following AMSTAR 2 and PRISMA guidelines, this evidence synthesis sought to identify and characterize any associations between e-cigarette use among individuals not smoking cigarettes and initiation of cigarette smoking.

The protocol was registered on September 24, 2018 (PROSPERO 2018 CRD42018108540). Three databases were queried from January 01, 2007 to April 26, 2023. Search results were screened using the PICOS review method.

Among 55 included studies (40 “good” and 15 “fair”; evidence grade: “high”) that adjusted for gender, age, and race/ethnicity between groups, generally, there was a significant association between non-regular e-cigarette use and initiation of cigarette smoking, further supported by the meta-analytic results (AOR 3.71; 95% CI 2.86–4.81). However, smoking initiation was most often measured as ever/current cigarette smoking. Two studies (quality: 2 “good”) evaluated progression to regular cigarette smoking among individuals with regular use of e-cigarettes, and generally found no significant associations. One study (“good”) evaluated smoking initiation among individuals with regular use of e-cigarettes, finding an increasing probability of ever smoking cigarettes with increased e-cigarette use. Twelve studies (10 “good” and two “fair”) examining progression to regular smoking among individuals with non-regular use of e-cigarettes reported inconsistent findings.

Conclusions

Numerous methodological flaws in the body of literature limit the generalizability of these results to all individuals who are not smoking cigarettes with few studies measuring established/regular use/smoking of e-cigarettes and cigarettes. Further, studies did not control adequately for specific confounding variables representing common liabilities between e-cigarette use and cigarette smoking, nor did they account for sufficient follow-up durations. Collectively, these flaws limit the generalizability of findings to the question of an association between e-cigarette use and cigarette smoking initiation.

Implications

In order to support robust determinations regarding e-cigarette use and the initiation of—or progression to—cigarette smoking, future research should apply measures of e-cigarette and cigarette use in a manner consistent with examining true initiation (i.e., established and/or regular use, as opposed to ever or current use), increase follow-up durations to adequately evaluate progression to regular smoking, and sufficiently account for known or suspected confounding variables that would represent common liabilities between e-cigarette use and cigarette smoking.

Empirical evidence suggests e-cigarette aerosol does not contain most of the approximately 7000 chemicals present in cigarette smoke [ 1 , 2 ]. However, with the decline in cigarette smoking prevalence, there has been a parallel increasing prevalence in electronic cigarette (e-cigarette) use [ 3 , 4 , 5 , 6 ].

The potential association between e-cigarette use and cigarette smoking is an important public health issue [ 7 , 8 , 9 ]. Understanding the individual and population level impact of e-cigarettes requires an objective synthesis of the empirical evidence that informs on the potential association between e-cigarette use and subsequent cigarette smoking and the inherent risks to health presented by e-cigarettes themselves [ 2 ]. Among the public health concerns of the use of e-cigarettes is the question of youth who may transition from e-cigarettes to cigarette smoking [ 2 ]. Hence, an assessment of causality is central to understanding the public health effect of e-cigarettes.

The Common Liability model is an important consideration when assessing causality between e-cigarette and cigarette smoking, particularly among tobacco non-users [ 10 , 11 ]. Specifically, the common liability model posits that risks associated with using different substances can be explained by identifying common predisposing factors that also influence use behaviors [ 10 , 11 ]. According to this model, where risk-taking propensities and psychosocial processes can be factors that link patterns of multiple addictions, common liability can provide a parsimonious explanation of substance use and addiction co-occurrence [ 11 ]. Thus, narrowly focusing on the association between e-cigarette use and subsequent cigarette smoking without consideration of potential common liability factors limits an inference of causality [ 12 ].

The current systematic review and meta-analysis evaluated potential associations between e-cigarette use among tobacco non-users and cigarette smoking initiation, applying a level of methodological rigor not previously reported in other reviews. Based on a general understanding of the available published literature on e-cigarette use and cigarette smoking, a priori outcome measures included: age at initiation of smoking combustible cigarettes; percent who initiated smoking combustible cigarettes; and initiation and progression to regular smoking of combustible cigarettes. Study design was not limited in the inclusion criteria. While previous systematic reviews have examined the relationship between e-cigarette use and the onset of cigarette smoking in youth and young adults [ 3 , 13 , 14 , 15 , 16 , 17 ], as well as in the general population [ 18 , 19 ], this review specifically focused on initiation of and progression to regular cigarette smoking—an outcome measure unique to this systematic review. Furthermore, given the rapid rate of emerging evidence on e-cigarette use, this review provides an important timely evidence synthesis to previous reviews.

The methods and results reported here correspond to a larger systematic review addressing the key research question, “Are there any potential associations between e-cigarette use among non-tobacco users and intention to smoke combustible cigarettes or initiating smoking of combustible cigarettes?” The focus of the findings reported here is the identification and characterization of any potential associations between e-cigarette use among non-tobacco users and the initiation of cigarette smoking.

The review protocol was registered with PROSPERO (The International Prospective Register of Systematic Reviews) on September 24, 2018 (PROSPERO 2018 CRD42018108540; http://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD42018108540 ).

This review strictly followed standards of systematic review methodology (“high” overall rating by A MeaSurement Tool to Assess systematic Reviews [AMSTAR] 2) [ 20 ] and reporting (Preferred Reporting Items for Systematic Reviews and Meta-Analyses [PRISMA]) [ 21 ].

Terminology

Specific terminology in this review are fully reported in Supplemental Section 1 : Terminology.

Literature search methods

MEDLINE (Medical Literature Analysis and Retrieval System Online), EMBASE (Excerpta Medica Database), and PsycINFO were the database sources for the literature search. Applying search terms developed using medical subject headings (MeSH) and text words related to the associations between e-cigarette use and cigarette smoking intention and initiation, a full literature search was executed by an information specialist. Search dates were restricted to 2007 onwards due to the mass market introduction of e-cigarettes in the US [ 1 , 2 ] (Supplemental Section 2 : Literature Search Strategy).

The screening process was executed according to the PICOS (Population or participants and conditions of interest, Interventions or exposures, Comparisons or control groups, Outcomes of interest, and Study designs) review method (Supplemental Section 3 : Inclusion/Exclusion Criteria) [ 22 ]. The population of interest—tobacco non-users—without restriction by age. The interventions and controls were individuals using e-cigarettes and non-users, respectively. Outcome measures identified a priori included: age of initiation for cigarette smoking, initiation of cigarette smoking, and initiation and progression to regular cigarette smoking (not included in previously published systematic reviews [ 3 , 13 ]). Given the limited available evidence from randomized controlled trials (RCTs), this review was not limited by study design. The search strategy included: published peer-reviewed literature; theses and dissertations; government and industry documents; clinical trial registries (clinicaltrials.gov); gray literature in Google Scholar; consideration of reference lists across included studies; and content expert consultation. Studies were restricted to English-only publications.

Although the established/regular e-cigarette use provides the strongest evidence measure of sustained use behaviors, this review did not restrict use criteria. Additionally, studies were not restricted to those controlling for specific confounding variables that would represent common liabilities between e-cigarette use and cigarette smoking. The current review focused on studies that adjusted for at least the confounders of age, gender, and race/ethnicity.

Evidence synthesis

Two reviewers independently screened articles based on the inclusion/exclusion criteria at the title/abstract level and then, full-text for studies not excluded based on the title/abstract alone. Data extraction was first conducted by one reviewer and then checked by a second reviewer. Across all levels of review and data extraction, discrepancies were resolved through discussion between the two reviewers and included a third team member when adjudication was necessary. All data were extracted and recorded in the DistillerSR platform (Evidence Partners, Ottawa, Canada) [ 23 ].

Estimates of the difference between individuals using e-cigarettes and individuals who are not using e-cigarettes are presented with the best measures of precision (i.e., 95% confidence intervals [CIs]) and/or statistical significance (i.e., p value) reported in the included studies. Reporting references to “significant” and/or “significantly” are only used to indicate statistical significance (i.e., p  < 0.05 and/or CI excludes 1.0). The DerSimonian–Laird method was used to conduct random-effects meta-analyses where included studies were weighted by the inverse of the sum of within-study variance plus between-study variance [ 24 ]. The Cochran’s Q statistic assessed heterogeneity across pooled studies which was then quantified using the inconsistency index (I 2 ).

Study authors were contacted to obtain missing data. All meta-analytic data were analyzed through Review Manager version 5.3 [ 25 ], in Windows 10 Pro version 22H2.

Sensitivity analyses

Data permitting, sensitivity analyses were planned to include stratification of results (or removal of data inputs) from: studies that did not adjust for meso- and macro-level variables in addition to age, race/ethnicity, and gender; studies that did not define e-cigarette use or regular cigarette smoking; and studies with a questionable definition of e-cigarette use and/or regular cigarette smoking. Additionally, data permitting, stratification by age group, and a sensitivity analysis of age, was planned. A sub-group analysis for the meta-analysis based on the country where the study was implemented, and a sensitivity analysis excluding studies graded as “Fair,” was likewise planned.

Assessment of confounding

This review applied the Socio-Ecological Model as defined by McLeroy et al. [ 26 ] to guide consideration of the interrelationships between individuals and their social (micro-), physical (meso-), and policy (macro-) environments (further detail reported in Supplemental Section 4 : Conceptual Framework).

Evaluation of confounding factors was followed according to Cochrane guidelines for systematic reviews [ 27 ]; specifically, during protocol writing, a list of potential confounding factors was identified a priori based on evidence and expert opinion from members of the research team and external advisors; and during the systematic review process, the variables that individual study authors considered were recorded for additional post hoc consideration.

Outcomes and related psychometrics

Recognizing that not all the outcome measures are equally valid and reliable, this review examined the Contextual Question (CQ): “Have measures used to examine initiation and progression to regular cigarette smoking been psychometrically assessed as reliable and valid?” Specific criteria were applied to assess reliability and validity across the outcome measures [ 28 ] (full reporting in Supplemental Section 5 : Contextual Questions).

Study quality assessment

Two reviewers independently appraised study quality using the Downs and Black checklist. Individual studies were graded as either “excellent,” “good,” “fair,” or “poor” [ 29 ] (Full reporting in Supplemental Section 6 : Study Quality Assessment). A funnel plot was planned to test for the risk of publication bias if 10 or more studies provided estimates pooled in the meta-analysis.

Strength of evidence evaluation

Strength of evidence (SOE) was assessed for studies that controlled for age, gender, and race/ethnicity and those that did not control for key confounders. The overall SOE was graded as “high,” “moderate,” “low,” or “insufficient” using the Agency for Healthcare Research and Quality (AHRQ) Evidence Based Practice (EPC) grading system [ 30 ] (full reporting in Supplemental Section 7 : Strength of Evidence).

Consideration of industry funding bias

The potential impact of funding bias on results and conclusions has been a topic addressed in the evidence base [ 31 , 32 , 33 ]. As indicated in the conflict-of-interest disclosure for this review, and given the recent increase of peer-reviewed systematic reviews and meta-analyses, this topic with potential industry and public health impact may have a heightened importance as a methodological issue. To specifically address any potential concerns of funding bias in this reported evidence synthesis, this review was executed with the highest standards of the systematic review methodology including: a priori protocol registration (PROSPERO 2018 CRD42018108540; http://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD42018108540 ); strict adherence to the PICOS throughout the execution of this review; a transparent and replicable search strategy executed by an information specialist with corresponding literature research results (Supplemental Section 8 : Literature Search Output, Studies Reviewed at the Full-Text Level); full reporting of excluded studies including reason for exclusion (Supplemental Section 9 : List of Excluded Studies); full reporting details on quantitative methods; and the expected details, per AMSTAR-2 and PRISMA guidelines, to disseminate a fully transparent and replicable evidence synthesis. Overall, the methodological rigor of this review with fully transparent and replicable reporting can also serve as a measure to minimize publication bias with systematic reviews.

The initial database search (January 1, 2007 to August 31, 2018) yielded 2526 articles, with four additional articles identified through other sources [ 3 , 34 , 35 , 36 ], resulting in 2530 articles. The first updated literature search (January 1, 2018 to August 30, 2019) yielded 1525 articles with 307 duplicate articles due to applied overlapping timeframes between the two searches. This overlapping timeframe conducted searches from the first of the year; therefore, overlapping search timeframes were unavoidable. Additionally, two articles were identified through other sources [ 37 , 38 ], resulting in 1220 unique articled retrieved. A second updated literature search for the timeframe of January 1, 2019 to October 7, 2020 yielded 2211 articles, of which 595 were duplicate articles with the previous database search, resulting in 1616 unique articles retrieved. A third updated search for the January 1, 2020 to November 24, 2021 timeframe yielded 3245 articles, of which 935 were duplicate articles with the previous database search, resulting in 2310 unique articles retrieved. Finally, a fourth updated search for the January 1, 2021 to April 26, 2023 period yielded 3925 articles, of which 1420 were duplicate articles with the previous database search, resulting in 2505 unique articles retrieved.

A cumulative total of 10,175 articles were retrieved from the specified databases, with an additional six additional articles identified from other sources (total: 10,181). Of the 10,181 potentially relevant articles, 9186 were excluded at the title/abstract level, resulting in 995 articles eligible for review at full-text level (Supplemental Section 8 : Literature Search Output, Studies Reviewed at the Full-Text Level). Subsequently, a further 873 articles were excluded (Supplemental Section 9 : List of Excluded Studies), resulting in 122 studies eligible for inclusion in the larger systematic review (Supplemental Section 10 : List of Included Studies). Inter-rater reliability at Level 2 screening was considered substantial or near perfect agreement [ 39 ] across all literature searches with a weighted overall kappa ranging from 0.72 to 0.95 (refer to Fig.  1 for each level of screening).

PRISMA flowchart

Of the 122 studies identified in the systematic review, 99 studies reported on cigarette smoking initiation or progression and were eligible for the qualitative and quantitative evidence. Of these 99 studies, 55 reported results that were adjusted for gender, age, and race/ethnicity between groups. For each included study, data were extracted on: study characteristics (Supplemental Section 11 : Study and Sample Characteristics, Adjusted Studies), demographic and baseline characteristics (Supplemental Section 12 : Demographic and Baseline Characteristics, Adjusted Studies), and study outcomes (Supplemental Section 13 : Evidence Tables, Adjusted Studies). Studies reporting unadjusted results are presented in Supplemental Section 14 (Study and Sample Characteristics, Unadjusted Studies), Supplemental Section 15 (Study and Sample Characteristics, Unadjusted Studies), and Supplemental Section 16 (Evidence Tables, Unadjusted Studies), but are not included in the qualitative or quantitative synthesis of evidence.

The highest number of studies (10 studies) were published in both 2020 [ 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 ] and 2018 [ 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 ]; followed by 7 studies in each of 2021 [ 60 , 61 , 62 , 63 , 64 , 65 , 66 ], 2019 [ 37 , 67 , 68 , 69 , 70 , 71 , 72 ], and 2017 [ 34 , 36 , 73 , 74 , 75 , 76 , 77 ]; six studies in 2022 [ 78 , 79 , 80 , 81 , 82 , 83 ]; three studies in each of 2023 [ 84 , 85 , 86 ] and 2015 [ 87 , 88 , 89 ]; and two studies in 2016 [ 90 , 91 ]. Studies were predominantly longitudinal in design and were from registered surveys. Of the 55 included studies, 41 were conducted in the US [ 36 , 40 , 41 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 51 , 52 , 53 , 54 , 56 , 58 , 59 , 62 , 63 , 64 , 65 , 67 , 68 , 69 , 70 , 71 , 72 , 75 , 76 , 77 , 78 , 79 , 81 , 82 , 83 , 86 , 87 , 88 , 89 , 90 , 91 ], five in the UK [ 34 , 37 , 61 , 66 , 85 ], two in Canada [ 60 , 73 ], one study in each of Mexico [ 74 ], Netherlands [ 57 ], Netherlands and Belgium [ 84 ], Romania [ 55 ], South Korea [ 42 ], Switzerland [ 50 ], and Thailand [ 80 ]. In terms of the study population, four studies defined their study population as “adults” [ 40 , 48 , 69 , 72 ], one study stratified their results by youth and adult populations [ 43 ]; three studies defined their participants as 12 years or older [ 59 , 81 , 86 ]. For the remaining 47 studies that defined participants, respondents were categorized as “youth,” “adolescents,” or “young adults” (participants defined as “students” were between grade 6 and college level) [ 34 , 36 , 37 , 41 , 42 , 44 , 45 , 46 , 47 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 70 , 71 , 73 , 74 , 75 , 76 , 77 , 78 , 79 , 80 , 82 , 83 , 84 , 85 , 87 , 88 , 89 , 90 , 91 ].

In addition to age, sex, and race/ethnicity, most studies included further adjustments with varying combinations of other micro, meso, and macro covariates. However, none of the studies sufficiently adjusted for potential confounding variables that would represent common liabilities between e-cigarette use and cigarette smoking [ 92 ]—meaning that a bias for those predisposing elements would exist among individuals using e-cigarettes that would likely be unadjusted for in the included studies.

Initiation of cigarette smoking was evaluated by the largest number of included studies (49 adjusted studies) [ 34 , 36 , 37 , 41 , 42 , 43 , 44 , 46 , 47 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 66 , 67 , 68 , 70 , 71 , 72 , 73 , 74 , 76 , 77 , 78 , 79 , 80 , 81 , 82 , 83 , 84 , 85 , 86 , 87 , 88 , 89 , 90 , 91 ], followed by initiation and progression to regular cigarette smoking (12 adjusted studies) [ 37 , 40 , 45 , 48 , 54 , 61 , 65 , 66 , 69 , 72 , 73 , 86 ]. One adjusted study examined the potential relationship between e-cigarette use and age of initiation for cigarette smoking [ 75 ].

The reliability and validity of each outcome measure were evaluated according to the CQ with a comprehensive but not systematic review of the literature. The objective in doing so was to provide fuller context for the interpretation of findings from the evidence synthesis. All measures were single-item measures related to the initiation and/or progression of cigarette smoking. All three measures of initiation were supported by empirical data regarding their reliability and/or validity, and therefore qualified as “acceptable”—including initiation of cigarette smoking, age of initiation for cigarette smoking, and initiation and progression to regular cigarette smoking (full reporting in Supplemental Section 5 : Contextual Questions).

Quality appraisal for each included study was conducted by two reviewers according to the Downs and Black checklist [ 29 ]. Forty (73%) were rated “good” quality [ 34 , 37 , 40 , 41 , 44 , 45 , 46 , 47 , 48 , 49 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 64 , 65 , 66 , 67 , 68 , 72 , 73 , 74 , 75 , 76 , 77 , 78 , 84 , 86 , 87 , 88 , 90 , 91 ], 15 (27%) were rated “fair,” [ 36 , 42 , 43 , 50 , 63 , 69 , 70 , 71 , 79 , 80 , 81 , 82 , 83 , 85 , 89 ] and no studies were rated “excellent” or “poor” (Supplemental Section 6 : Study Quality Assessment). Publication bias was assessed using funnel plots, and no publication bias was detected.

The overall SOE among the adjusted data regarding the association between e-cigarette use and age of initiation of cigarette smoking was graded “moderate”; the body of evidence specific to e-cigarette use and initiation of cigarette smoking was graded “high”; and the body of evidence specific to initiation and progression to regular cigarette smoking was graded “moderate.” The SOE domain score table and the SOE and CQ ratings summary table for both the adjusted and unadjusted data are presented in Supplemental Section 7 : Strength of Evidence.

Definitions of e-cigarette use by outcome measure

Among the 55 included studies, one evaluated age of cigarette smoking initiation [ 75 ], 42 evaluated initiation of cigarette smoking [ 34 , 36 , 41 , 42 , 43 , 44 , 46 , 47 , 49 , 50 , 51 , 52 , 53 , 55 , 56 , 57 , 58 , 59 , 60 , 62 , 63 , 64 , 67 , 68 , 70 , 71 , 74 , 76 , 77 , 78 , 79 , 80 , 81 , 82 , 83 , 84 , 85 , 87 , 88 , 89 , 90 , 91 ], five evaluated progression to regular smoking [ 40 , 45 , 48 , 65 , 69 ], and seven studies evaluated both initiation of cigarette smoking and progression to regular smoking [ 37 , 54 , 61 , 66 , 72 , 73 , 86 ].

Among the 49 studies that examined initiation of cigarette smoking, only one evaluated the association between regular e-cigarette use and initiation of cigarette smoking. Wills et al. [ 77 ] defined e-cigarette use on a frequency scale (1–2 times ever use, 3–4 times ever use, yearly/monthly, and weekly/daily), with the initiation of cigarette smoking defined as having “ever smoked a whole cigarette”. For the remaining studies that examined initiation of cigarette smoking among individuals with non-regular use of e-cigarettes, ever use was the most common measure of both e-cigarette use (39 studies) [ 34 , 37 , 42 , 43 , 44 , 46 , 47 , 49 , 52 , 54 , 55 , 56 , 57 , 59 , 61 , 63 , 64 , 67 , 68 , 70 , 71 , 72 , 74 , 76 , 77 , 78 , 79 , 80 , 81 , 84 , 85 , 86 , 87 , 88 , 89 , 90 , 93 ] and cigarette use (33 studies) [ 34 , 37 , 42 , 43 , 44 , 46 , 47 , 49 , 52 , 55 , 56 , 57 , 58 , 61 , 63 , 64 , 66 , 67 , 68 , 70 , 71 , 72 , 73 , 74 , 76 , 77 , 78 , 79 , 80 , 84 , 87 , 89 , 91 ], with current or past 30-day use being the second most common measure (16 studies for e-cigarette use [ 36 , 41 , 52 , 53 , 54 , 58 , 60 , 62 , 67 , 72 , 73 , 78 , 79 , 80 , 86 , 91 ] and 23 studies for cigarette use [ 36 , 41 , 43 , 47 , 52 , 53 , 54 , 58 , 59 , 60 , 62 , 63 , 64 , 68 , 74 , 76 , 78 , 79 , 80 , 81 , 85 , 90 , 93 ]). The most commonly evaluated relationship for these two tobacco use behaviors was between ever use of e-cigarettes and ever use of cigarettes (30 studies) [ 34 , 37 , 42 , 43 , 44 , 46 , 47 , 49 , 52 , 55 , 56 , 57 , 61 , 63 , 64 , 66 , 67 , 68 , 70 , 71 , 72 , 74 , 76 , 77 , 78 , 79 , 80 , 84 , 87 , 88 ]. Ever use of e-cigarettes and current use of cigarettes was the second most commonly evaluated relationship (17 studies) [ 43 , 47 , 52 , 54 , 59 , 63 , 64 , 68 , 74 , 76 , 78 , 79 , 80 , 81 , 85 , 90 , 93 ], followed by current use of e-cigarettes and current use of cigarettes (11 studies) [ 36 , 41 , 52 , 53 , 54 , 58 , 60 , 62 , 78 , 79 , 80 ].

Twelve studies examined the association between e-cigarette use and initiation of and progression to regular cigarette smoking [ 37 , 45 , 48 , 54 , 61 , 65 , 66 , 69 , 72 , 73 , 86 , 94 ]. All of these 12 studies evaluated the association between non-regular e-cigarette use and progression to regular cigarette smoking. Additionally, two of the 12 studies also evaluated the association between regular e-cigarette use and progression to regular cigarette smoking [ 40 , 48 ]. Azagba et al. [ 94 ] defined e-cigarette use as either every day (current daily use and having ever used fairly regularly), some day (current use and having ever used fairly regularly), or experimental (current use and never having used fairly regularly), with progression to regular cigarette smoking defined as transitioning from either current non-established to current-established cigarette smoking, current non-established to current daily-established cigarette smoking, or current-established to current daily-established cigarette smoking [ 40 ]. Among individuals with established (having ever used fairly regularly) e-cigarette use, Wei et al. [ 48 ] evaluated transitions from non-current, non-established cigarette smoking to either exclusive current-established cigarette smoking or current-established dual use of cigarettes and e-cigarettes.

For the 12 studies that used definitions of non-regular e-cigarette use, e-cigarette use was defined as follows: current or past-30-day use in two studies [ 45 , 73 ]; e-cigarette experimentation, defined as non-established use (less than 100 times during lifetime) in one study [ 69 ]; and ever use of e-cigarettes in four studies [ 37 , 61 , 65 , 66 ]. Three studies applied multiple definitions of non-regular e-cigarette use: Chaffee et al. [ 54 ] included ever, past 30-day, and former e-cigarette use; Sun et al. [ 86 ] included ever and past 30-day use, while McMillen et al. [ 72 ] included ever and past 30-day e-cigarette use. Two studies that evaluated regular e-cigarette use also evaluated non-regular use defined as experimental use [ 40 , 48 ].

In the one study that evaluated age of initiation of cigarette smoking, e-cigarette use was defined as current use [ 75 ].

Qualitative synthesis of best available evidence

Fifty-five studies adjusted for three main confounders (gender, age, and race/ethnicity) between groups, and were analyzed in the qualitative review and quantitative syntheses reported below. Results for each outcome measure in the qualitative analysis were stratified by regular versus non-regular e-cigarette use.

Adjusted data for age of initiation, initiation of cigarette smoking, and progression to regular smoking are provided in Supplemental Section 13 : Evidence Tables, Adjusted Studies. Unadjusted data for age of initiation of cigarette smoking, initiation of cigarette smoking, and initiation and progression to regular cigarette smoking are provided in Supplemental Section 16 : Evidence Tables, Unadjusted Studies; however, unadjusted data are not included in qualitative analysis.

Age of initiation of cigarette smoking (regular e-cigarette use)

No studies provided adjusted analyses of age of initiation of cigarette smoking among individuals with regular use of e-cigarettes.

Age of initiation of cigarette smoking (non-regular e-cigarette use: 1 study)

One adjusted study was identified that investigated the association between non-regular e-cigarette use and age of initiation of cigarette smoking [ 75 ] (Summary characteristics of this study are provided in Table  1 ). In a cross-sectional analysis, McCabe et al. [ 75 ] reported that the adjusted odds of smoking the first cigarette at an earlier age (Grade 8 or below) were significantly higher among individuals using e-cigarettes (current [past-30-day]) versus individuals who are not using e-cigarettes (adjusted odds ratio [AOR] 4.12, 95% CI 2.56–6.62). Further, the odds of an earlier age of onset of daily cigarette smoking (before 8th grade level) were not significantly different between individuals currently using e-cigarettes (past-30-day) and individuals who are not using e-cigarettes (AOR 1.67, 95% CI 0.385–7.25) [ 75 ].

Initiation of cigarette smoking (regular e-cigarette use: 1 study)

One adjusted study was identified that investigated the association between regular e-cigarette use and odds of initiation of cigarette smoking among individuals not smoking cigarettes at baseline[ 77 ] (Summary characteristics of this study are provided in Table  2 ).

In their study of 1070 individuals who never smoked cigarettes at baseline, Wills et al. [ 77 ] examined the association between e-cigarette use and initiation of cigarette smoking by stratifying the probability of smoking onset by frequency of e-cigarette use at baseline, including a measure of regular (weekly/daily) e-cigarette use. Compared with individuals who are not using e-cigarettes, all individuals who have used e-cigarettes had significantly higher adjusted odds of initiating cigarette smoking: individuals who ever used e-cigarettes (1–2 times): AOR 2.88 (95% CI 1.96–4.22); individuals who ever used e-cigarettes (3–4 times): AOR 2.29 (95% CI 1.35–3.87); weekly/daily users: AOR 4.09 (95% CI 2.43–6.88); and yearly/monthly users: AOR 4.17 (95% CI 2.03–8.57).

Initiation of cigarette smoking (non-regular e-cigarette use: 49 studies)

Forty-nine adjusted studies examined the association between non-regular e-cigarette use and initiation of cigarette smoking among individuals not smoking cigarettes at baseline [ 34 , 36 , 37 , 41 , 42 , 43 , 44 , 46 , 47 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 66 , 67 , 68 , 70 , 71 , 72 , 73 , 74 , 76 , 77 , 78 , 79 , 80 , 81 , 82 , 83 , 84 , 85 , 86 , 87 , 88 , 89 , 90 , 91 ]. Summary characteristics of these 49 studies are provided in Table  3 .

As discussed in the search results of the meta-analysis, 12 studies met the inclusion criteria of the meta-analysis [ 34 , 43 , 52 , 56 , 59 , 63 , 66 , 76 , 77 , 80 , 81 , 84 ]. These studies are included in Table  3 , but are not discussed in qualitative synthesis. For a variety of reasons, 37 studies did not meet the criteria to be included in the quantitative synthesis (Supplemental Section 17 : Meta-Analytic Results); however, these studies contained information important to the research question and are described below.

Twenty-four studies—15 prospective cohort studies [ 37 , 46 , 49 , 55 , 58 , 61 , 62 , 68 , 70 , 71 , 73 , 83 , 87 , 89 , 90 ], eight longitudinal panel studies [ 41 , 47 , 50 , 53 , 72 , 82 , 86 , 88 ], and one retrospective cohort study [ 67 ]—all reported statistically significant AORs, showing a higher likelihood of individuals who have used e-cigarettes (non-regular use: ever, ever in the past 12 months, and current) initiating smoking compared with individuals who are not using e-cigarettes. Their AORs ranged from 1.75 (95% CI 1.10–2.77) in a prospective cohort of Grade 9 individuals who never smoked cigarettes at baseline reporting any cigarette use at follow-up (either 6 or 12 months) [ 87 ] to 8.3 (95% CI 1.2–58.6) in a prospective cohort of 16–26 year old non-susceptible individuals who never smoked a cigarette reporting ever cigarette use (at least one puff) at 18-month follow-up [ 89 ].

Four studies calculated the adjusted relative risk (ARR) of individuals who have used e-cigarettes (ever and current [past-30-day]) smoking cigarettes compared with individuals who are not using e-cigarettes [ 36 , 64 , 74 , 78 ]. Lozano et al. [ 74 ] found a statistically significantly higher risk for trying smoking (ARR 1.40, 95% CI 1.22–1.60), however, no significant difference was reported for current smoking (≥ 1 cigarette in the past 30 days; ARR 1.43, 95% CI 0.94–2.16). Miech et al. [ 36 ] also found a statistically significantly higher risk for current smoking (ARR 4.78, 95% CI 1.91–11.96).

Keller-Hamilton et al. [ 64 ] reported that individuals who have used e-cigarettes at baseline were more than twice as likely to report ever (ARR 2.71, 95% CI 1.89–3.87) and current (i.e., past 30 day) smoking (ARR 2.20, 95% CI 1.33–3.64) at follow-up compared to individuals who are not using e-cigarettes. Similar results were reported in a propensity score-matched analysis (ever cigarette use ARR 2.22; 95% CI 0.90–5.47; past 30-day cigarette use ARR 1.25; 95% CI 0.41–3.82). Using data from Waves 1–5 of the PATH study, Harlow et al. [ 78 ] showed that, among baseline never-smokers, ever e-cigarette use at Wave 2 was associated with a higher likelihood of ever smoking at Waves 3, 4, and 5 (ARR 2.7, 95% CI 2.4–3.0). This association was present for all sub-categories of e-cigarette ever-use, namely former use (ARR 2.5, 95% CI 2.2–2.9), current (i.e., past 30-day) use (ARR 3.5, 95% CI 2.9–4.1), use of tobacco-flavored (ARR 2.5, 95% CI 1.8–3.5), and nontobacco-flavored (ARR 2.8, 95% CI 2.5–3.1) e-cigarettes. In a marginal structural model that accounted for time-dependent confounding, ever e-cigarette use was similarly associated with a higher likelihood of ever smoking at follow-up waves (ARR 2.4, 95% CI 2.1–2.7), regardless of the sub-category of ever use (former use ARR 2.2, 95% CI 2.0–2.5; current use ARR 3.1, 95% CI 2.6–3.7), or e-cigarette flavor (tobacco flavored ARR 2.4, 95% CI 1.7–3.3; nontobacco flavored ARR 2.4, 95% CI 2.2–2.7) [ 78 ]. The study also reported that the likelihood of being an individual who currently smoked (i.e., past 30-day) at Waves 3–5 was higher among individuals who have ever used e-cigarettes at baseline (ARR 2.9, 95% CI 2.5–3.3), quit e-cigarette use (ARR 2.6, 95% CI 2.2–3.1), currently used (ARR 3.8, 95% CI 3.1–4.6), used tobacco-flavored (ARR 2.6, 95% CI 1.7–3.9), and non-tobacco-flavored (ARR 3.0, 95% CI 2.6–3.4) e-cigarettes [ 78 ]. Similarly, in the marginal structural model, the likelihood of past 30-day cigarette use at Waves 3–5 was associated with ever (ARR 2.5, 95% CI 2.2–2.9), former (ARR 2.3, 95% CI 1.9–2.7), current (ARR 3.4, 95% CI 2.8–4.2), tobacco-flavored (ARR 2.3, 95% CI 1.5–3.5), and nontobacco-flavored (ARR 2.6, 95% CI 2.2–3.0) [ 78 ] e-cigarette use.

A study by Aleyan et al. [ 60 ] calculated regression coefficients to estimate the association between past 30-day e-cigarette use at Wave 1 and initiation of cigarette smoking at Wave 3. Past-30-day e-cigarette use at Wave 1 was significantly associated with past 30-day cigarette smoking (β = 1.06; SE = 0.28; 95% CI 0.52–1.60; p  < 0.001), and dual use at Wave 3 (β = 1.31; SE = 0.24; 95% CI 0.84–1.79; p  < 0.001). Further, the association between past 30-day e-cigarette use at Wave 1 and cigarette smoking at Wave 3 remained significant after adjustment for having one or more friends who smoked at Wave 1.

Kintz et al. [ 44 ] calculated a phi-coefficient for the relationship between ever use of e-cigs at baseline and subsequent cigarette initiation (self-reported first use) at follow-up, and found that baseline ever e-cigarette use was significantly associated with cigarette smoking initiation at follow-up (phi coefficient = 0.141, p  < 0.001).

Two studies applied a multistate Markov model to evaluate the probability of transitioning to cigarette smoking [ 42 , 85 ]. A study by Kang et al. [ 42 ] applied a multistate Markov model to show that individuals who have ever used e-cigarettes at baseline had a 9.52% (95% CI 6.57–13.85) probability of transitioning to dual e-cigarette and cigarette use, whereas individuals who are not using e-cigarettes at baseline had a 1.39% (95% CI 1.29–1.49) probability of transitioning to exclusive cigarette use. Parnham et al. [ 85 ] examined transition probabilities between e-cigarette use and smoking in UK adolescents and young adults. In an analysis that adjusted for age, wave of data collection, sex, ethnicity, and tertiles of household income, adjusted probability of transition from ever e-cigarette use to smoking ranged from 14% (95% CI 13–16) in Year 1 to 27% (95% CI 25–29) in Year 5, while the probability of transitioning from e-cigarette never use to smoking ranged from 2% (95% CI 2–2) to 10% (95% CI 9–10) [ 85 ].

The study by Loukas et al. [ 79 ] reported hazard ratios for the association between past 30-day and ever e-cigarette use and transition from never to current cigarette smoking. After adjusting for covariates, both past 30-day (HR 2.69, 95% CI 1.95–3.72) and ever (HR 2.16, 95% CI 1.79–2.62) e-cigarette use were associated with a higher likelihood of transition to smoking.

Conner et al. [ 61 ] evaluated cigarette smoking initiation (ever use) among individuals who have used e-cigarettes “early” and “late”, defined as reporting ever e-cigarette use at either Wave 3 (early) or Wave 4 (late), respectively. The authors found that the adjusted odds of individuals using e-cigarettes early, compared to individuals who never used e-cigarettes, initiating cigarette smoking was statistically significant both at Wave 4 (AOR 1.39, 95% CI 1.29–1.50) and at Wave 5 (AOR 3.55, 95% CI 2.82–4.49). Similarly, individuals using e-cigarettes late were significantly more likely to initiate cigarette smoking at Wave 5 compared to individuals who have never used e-cigarettes (AOR 2.87, 95% CI 2.33–3.53) [ 61 ].

Chaffee et al. [ 54 ] calculated the AORs for initiating smoking in three different groups of individuals who have used e-cigarettes (versus individuals who have not used e-cigarettes) and found the following: a non-significant AOR of 1.57 (95% CI 0.99–2.49) for individuals who have ever used e-cigarettes and have smoked at least 100 + cigarettes; a non-significant AOR of 1.69 (95% CI 0.93–3.05) for individuals who have used e-cigarettes in the past-30-days who have smoked at least 100 cigarettes; a non-significant AOR for individuals who have smoked at least 100 cigarettes but have quit e-cigarette use (AOR 1.55, 95% CI 0.94–2.56); a non-significant AOR for individuals who have ever used e-cigarettes and smoked a cigarette in the past 30 days (AOR 1.32, 95% CI 0.99–1.76); a significant AOR for individuals who have used e-cigarettes in the past 30 days and smoked a cigarette in the past 30 days (AOR 1.64, 95% CI 1.12–2.41); and, a non-significant AOR for individuals who quit e-cigarette use and smoked in the past 30 days (AOR 1.20, 95% CI 0.86–1.68) [ 54 ].

In additional to their overall analysis, Owotomo et al. [ 46 ] reported AORs for cigarette smoking initiation among subgroups of adolescents according to their baseline cigarette smoking intentions. Overall, the authors found ever e-cigarette use to be significantly associated with ever cigarette smoking (AOR 2.58, 95% CI 1.73–3.85). The association remained significant in a subgroup analysis of adolescents with no baseline intention to smoke (AOR 4.62, 95% CI 2.87–7.42); however, among the subgroup of adolescents with baseline cigarette smoking intentions, the association between ever e-cigarette use and cigarette smoking initiation was nonsignificant (AOR 1.57, 95% CI 0.94–2.63). The AOR for the interaction between smoking intention and ever e-cigarette use with regards to smoking initiation was statistically significant (AOR 0.34, 95% CI 0.18–0.64), suggesting the association between e cigarette use and ever cigarette smoking was dependent on previous smoking intention status.

Three of the 37 studies not included in the meta-analysis evaluated initiation of cigarette smoking and either susceptibility or propensity to smoke cigarettes among individuals using e-cigarettes versus individuals who are not using e-cigarettes [ 52 , 57 , 91 ]. Barrington-Trimis et al. [ 52 ] evaluated the association between susceptibility and initiation of cigarette smoking in either individuals who have ever used e-cigarettes or individuals who are not using e-cigarettes and found a statistically significant difference between the two groups. The authors found that among individuals who are not using e-cigarettes, susceptibility to cigarette use was associated with over three times the odds of subsequent initiation of cigarette smoking compared with non-susceptible individuals who are not using e-cigarettes (AOR 3.47, 95% CI 2.38–5.07); however, only a small, non-statistically significant association was observed between susceptible and non-susceptible individuals who have ever used e-cigarettes and initiation of cigarette smoking (AOR 1.57, 95% CI 0.80–3.05) [ 52 ]. Thus, susceptibility only statistically significantly affected the subsequent initiation of cigarette smoking in individuals who are not using e-cigarettes ( p interaction  = 0.04).

Findings from a 2016 study by Wills et al. indicated that the effect of e-cigarette for cigarette smoking onset decreased as propensity increased—the AOR for smoking onset for individuals currently using e-cigarettes (past-30-day) versus individuals who are not using e-cigarettes was 2.23 (95% CI 1.57–3.17) for those in the bottom 10th percentile for propensity to smoke, and 1.32 (95% CI 1.19–1.47) for those in the top 10th percentile for propensity to smoke [ 91 ].

In a 2018 study, Treur et al. provided AORs for low-propensity- and high-propensity-to-smoke groups for ever e-cigarette versus individuals who are not using e-cigarettes, both with and without nicotine [ 57 ]. The investigators found that, for e-cigarettes containing nicotine, the AOR for initiating conventional smoking was 7.80 (95% CI 1.90–32.04) in the low-propensity-to-smoke group, and 2.89 (95% CI 1.47–5.68) in the high-propensity-to-smoke group; for e-cigarettes containing no nicotine, the AOR for initiating conventional smoking was 6.07 (95% CI 2.18–16.90) in the low-propensity-to-smoke group, and 3.30 (95% CI 2.33–4.67) in the high-propensity-to-smoke group.

Treur et al. also compared the effects of e-cigarette use with nicotine and e-cigarette use without nicotine in individuals using e-cigarettes versus individuals who have never used e-cigarettes [ 57 ]. The study reported an AOR for initiation of 5.36 (95% CI 2.73–10.52) for individuals who ever used e-cigarettes without nicotine compared with individuals who are not using e-cigarettes, and an AOR of 11.90 (95% CI 3.36–42.11) for individuals who ever used e-cigarettes with nicotine compared with individuals not using e-cigarettes.

Three studies evaluated initiation in susceptible subgroups [ 34 , 68 , 90 ], two of which were included in the meta-analysis for initiation of cigarette smoking [ 34 , 90 ]. The association between ever e-cigarette use and susceptibility to smoking was evaluated in a 2016 prospective cohort study by Barrington-Trimis et al. [ 90 ]. The study found that ever e-cigarette use had less of an effect in individuals classified as being susceptible to smoking, as demonstrated by a lower odds of initiation of cigarette smoking in that group (AOR 2.12, 95% CI 0.79–5.74), compared with individuals using e-cigarettes initially classified as non-susceptible to smoking (AOR 9.69, 95% CI 4.02–23.4) ( p interaction  = 0.025) [ 90 ]. Interestingly, the effect of e-cigarette use in the susceptible group on initiation of cigarette smoking was not statistically significant.

Berry et al. [ 68 ] reported similar outcomes, both in terms of ever and current cigarette use. In terms of ever cigarette use, the authors demonstrated lower odds of initiation among individuals who had used e-cigarettes in the past versus individuals who are not using e-cigarettes (AOR 3.51, 95% CI 2.52–4.89) among individuals classified as intermediate/high risk for smoking, compared with those classified as low risk (AOR 8.57, 95% CI 3.87–18.97). Similarly, in terms of current cigarette use, odds of initiation were lower among individuals classified as intermediate/high risk (AOR 2.16, 95% CI 1.23–3.79) compared with those classified as low risk (AOR 10.36, 95% CI 3.11–34.54). In both cases, this indicates that e-cigarette use had less of an effect on initiation among those individuals considered intermediate/high risk.

Best et al. [ 34 ], also included in the meta-analysis, found that there was an interaction between susceptibility to smoking and ever e-cigarette use with regards to initiation of cigarette smoking (AOR for e-cigarette use and susceptibility interaction of 0.42, 95% CI 0.19–0.94). In other words, there would be greater interaction between e-cigarette use and non-susceptible populations compared with susceptible populations in terms of initiation of cigarette smoking. It is worth noting that although Best et al. refer in their study to susceptibility and not the intent, the questions that respondents answered, i.e., “Do you think you will smoke cigarettes or hand-rolled cigarettes at any time during the next year” and “If one of your friends offered you a cigarette or hand-rolled cigarettes (roll-ups), would you smoke it?” were questions that measured intent.

Lastly, one study by Barrington-Trimis et al. [ 51 , 52 ] investigating initiation of cigarette smoking, with analyses of switching and dual-use, found that the adjusted odds of reporting dual use (at follow-up) among individuals who had ever used e-cigarettes exclusively at baseline (versus individuals who had never used e-cigarettes at baseline) were higher than the odds of reporting switching from baseline exclusive e-cigarette use to exclusive cigarette smoking at follow-up (AOR 7.16, 95% CI 4.47–11.5 vs. AOR 2.67, 95% CI 1.53–4.65, respectively). In another analysis, the authors also found that the odds of reporting dual use among current (past 30-day) e-cigarette users (versus non-current users) were similarly higher than the odds of reporting switching from exclusive e-cigarette use to exclusive cigarette smoking (AOR 8.86, 95% CI 5.08–15.4 vs. AOR 3.84, 95% CI 1.80–8.19, respectively [ 52 ].

Initiation of and progression to regular cigarette smoking (regular e-cigarette use: 2 studies)

Two adjusted studies were identified that provided adjusted analyses of initiation of and progression to regular cigarette smoking in individuals with regular use of e-cigarettes [ 40 , 48 ]. Summary characteristics of these two studies are provided in Table  4 .

Azagba et al. [ 40 ] defined regular e-cigarette use as either every day or someday use. In terms of the transition from experimental to some-day cigarette smoking, no significant association was found between individuals using e-cigarettes every day and individuals who have never used e-cigarettes (AOR 1.31, 95% CI 0.20–8.58), nor between individuals using e-cigarettes some day and individuals who have never used e-cigarettes (AOR 0.48, 95% CI 0.13–1.78). Similarly, no significant associations were found between individuals using e-cigarettes every day and individuals who have never used e-cigarettes (AOR 0.58, 95% CI 0.09–3.93) and individuals using e-cigarettes some day and individuals who have never used e-cigarettes (AOR 1.14, 95% CI 0.42–3.05) in terms of the transition from experimental to daily cigarette smoking. Likewise, in terms of the transition from some-day to daily cigarette smoking, no significant association was found between individuals using e-cigarettes every day and individuals who have never used e-cigarettes (AOR 1.89, 95% CI 0.98–3.66), nor between individuals using e-cigarettes some day and individuals who have never used e-cigarettes (AOR 1.41, 95% CI 0.84–2.39).

Wei et al. [ 48 ] evaluated transitions from non-current, non-established cigarette smoking to either exclusive current-established cigarette smoking or current-established dual use of cigarettes and e-cigarettes, among baseline individuals using e-cigarettes exclusively. The authors found that individuals who have established e-cigarette use were significantly less likely to transition to exclusive current-established cigarette smoking than individuals who have non-established e-cigarette use (AOR 0.13, 95% CI 0.02–0.87); however, no significant association was found between e-cigarette use (established versus non-established) and transitioning to dual use of cigarettes and e-cigarettes (AOR 0.53, 95% CI 0.05–6.25).

Initiation of and progression to regular cigarette smoking (non-regular e-cigarette use: 11 studies)

Eleven adjusted studies examined the potential association between e-cigarette use and initiation and progression to regular cigarette smoking among individuals with non-regular use of e-cigarettes [ 37 , 40 , 45 , 54 , 61 , 65 , 66 , 69 , 72 , 73 , 86 ]. Study characteristics for the 11 included studies are presented in Table  5 .

Sun et al. [ 86 ] used data from Waves 3–5 of the PATH study to investigate the association between e-cigarette use and the progression into regular cigarette smoking—defined as past 12-month use at Wave 4 with established use and at least 20 days use in the past 30 days at Wave 5. The authors show that the association between ever e-cigarette user and progression into regular smoking is non-significant with baseline e-cigarette ever-users having a lower risk of progressing into established regular smoking 0.13% (95% CI − 0.31 to 0.58) versus 0.17% (95% CI − 0.30 to 0.64) for baseline e-cigarette never-users (ARD − 0.03, 95% CI − 0.33 to 0.27; AOR 0.80, 95% CI 0.10–6.49). Similarly, e-cigarette current use was not associated with progression into established regular smoking as evidenced by the absolute risk of 0.47% (95% CI − 1.46 to 2.39) for individuals currently using e-cigs versus 0.15% (95% CI − 0.27 to 0.58) for e-cig non-users (ARD 0.31, 95% CI − 1.36 to 1.99; AOR 3.14, 95% CI 0.13–74.96) [ 86 ].

In addition to applying measures of regular e-cigarette use described previously, Azagba et al. [ 40 ] also applied a non-regular definition of experimental e-cigarette use. Consistent with their findings from their analyses of regular e-cigarette use, no significant associations were found between experimental and e-cigarette never-users in terms of: transitioning from experimental to someday cigarette smoking (AOR 0.98, 95% CI 0.44–2.20); transitioning from experimental to daily cigarette smoking (AOR 0.59, 95% CI 0.26–1.31); and transitioning from some day to daily cigarette smoking (AOR 1.03, 95% CI 0.61–1.75) [ 40 ].

A longitudinal panel study by McMillen et al. [ 72 ] reported inconsistent findings, depending on the measure of e-cigarette use applied. When evaluating ever e-cigarette use (versus e-cigarette non-use), no significant association with progression to current established cigarette smoking was found (AOR 2.5, 95% CI 0.6–10.9); however, current e-cigarette users were found to be significantly more likely to progress to current established cigarette smoking compared to individuals who are not using e-cigarettes (AOR 8.0, 95% CI 2.8–22.7). Another longitudinal panel study by Pierce et al. [ 65 ] evaluated rate of progression to daily cigarette smoking at Wave 4 among ever (but not daily) tobacco product users at Wave 3 of the PATH survey. The authors found that the adjusted risk difference between individuals who have ever used e-cigarettes versus e-cigarette never-users for progression to daily cigarette smoking was 7% (95% CI 6–9%) higher for individuals using e-cigarettes, although statistical significance was not assessed [ 65 ].

Findings from a prospective cohort study by Chaffee et al. [ 54 ] suggested the AOR of progressing to regular smoking (i.e., smoked ≥ 100 cigarettes and smoked in the past 30 days) was statistically significantly higher in individuals who have ever used e-cigarettes compared with individuals who are not using e-cigarettes (AOR 1.80, 95% CI 1.04–3.12); however, no such association was shown for past-30-day e-cigarette users (AOR 1.76, 95% CI 0.92–3.37). A second prospective cohort study by Hammond et al. [ 73 ] reported that progression to regular cigarette smoking was statistically significantly higher in past-30-day e-cigarette users compared with individuals who are not using e-cigarettes (AOR 1.79, 95% CI 1.41–2.28), while findings from a third prospective cohort study by Conner et al. [ 37 ] suggested statistically significantly higher odds of progressing to regular smoking (≥ 1 cigarette per week) at 2 years among individuals who have ever used e-cigarettes compared with individuals who are not using e-cigarettes (AOR 1.27, 95% CI 1.17–1.39). A fourth prospective cohort study, also by Conner et al. [ 61 ], reported statistically significantly higher odds of regular smoking (defined as smoking at least 1 cigarette per week) at Wave 5 among adolescents who first reported e-cigarette use at 13–14 years old (i.e., early users; AOR 1.25, 95% CI 1.16–1.34), and those who first reported e-cigarette use at 14–15 years (i.e., late users; AOR 1.12, 95% CI 1.08–1.16). The final prospective cohort study by Staff et al. [ 66 ] reported that the adjusted odds of reporting frequent smoking by age 17 were significantly higher for individuals using e-cigarettes compared with individuals who are not using e-cigarettes at baseline (AOR 2.91, 95% CI 1.56–5.4). The odds of frequent smoking remained significantly higher for individuals using e-cigarettes when the samples were matched on risk factors using propensity score matching.

Osibogun et al. [ 45 ] evaluated progression to regular cigarette smoking at both 1 and 2 years from baseline, finding that progression at 1 year was significantly associated with e-cigarette use (AOR 5.0, 95% CI 1.9–12.8). However, progression at 2 years was not significantly associated with e-cigarette use (AOR 3.4, 95% CI 1.0–11.5) [ 45 ].

The one cross-sectional study by Friedman et al. [ 69 ] reported statistically significantly lower odds of current established (≥ 100-lifetime cigarettes and past-30-day use) (AOR 0.22 95% CI 0.10–0.50) or daily (AOR 0.22 95% CI 0.06–0.77) cigarette use among individuals who experimented exclusively with e-cigarettes (experimenting before the age of 18 years) compared with individuals who did not experiment with e-cigarettes. Findings from this study also suggested statistically significantly higher odds of reporting current established cigarette smoking among individuals who first experimented with e-cigarettes and then with cigarettes, compared with individuals who did not experiment with e-cigarettes (AOR 1.89 95% CI 1.09–3.27); however, no significant difference in the odds of daily smoking was shown (AOR 0.73 95% CI NR).

Quantitative synthesis of best available evidence

Meta-analyses were performed by calculating pooled ORs from studies presenting AORs on initiation of cigarette smoking among naïve (individuals who never smoked cigarettes) cigarette smokers who either ever used or never used e-cigarettes. A meta-analysis evaluating the association between regular e-cigarette use and initiation of cigarette smoking was not possible, given that only one study reported adjusted outcomes for this association. Additionally, a meta-analysis evaluating e-cigarette use and initiation and progression to regular smoking was not possible, due to differences in definitions of e-cigarette use and/or outcome measures between studies (full results in Supplemental Section 17 : Meta-Analytic Results; all relevant code is publicly available [DOI: https://doi.org/10.5281/zenodo.10927677 ]).

Twelve studies met all the inclusion criteria and were included in the meta-analysis for initiation of cigarette smoking [ 34 , 43 , 52 , 56 , 59 , 63 , 66 , 76 , 77 , 80 , 81 , 84 ]. All 12 studies included individuals who never smoked cigarettes who were evaluated for initiation of cigarette smoking (minimum inclusion criteria = 1 puff). The studies compared an e-cigarette use group (regardless of frequency, volume, and duration) to a control group of e-cigarette never-users. The results from each study controlled for age, gender, race/ethnicity, and other covariates. All studies were longitudinal in design and had a combined analytic sample of 57,730 respondents.

For the 12 studies, the AORs ranged from 1.35 to 7.41. Pooling their results, the overall OR was 3.71 (95% CI 2.86–4.81). The test for the overall effect of the model was noted to be statistically significant ( p  < 0.00001). Heterogeneity tests revealed an I 2 of 76% and a X 2 of 45.18 ( p  < 0.00001) (Fig.  2 ). An assessment of publication bias—via the development of a funnel plot—was generally symmetrical, suggesting an absence of publication bias (Fig.  3 ).

Meta-analysis of odds of initiation of cigarette smoking among individuals who never smoked cigarettes who used e-cigarettes

Funnel plot for publication bias

Additionally, a sensitivity analysis excluding studies with a “Fair” quality rating was conducted—resulting in the exclusion of four studies [ 43 , 63 , 80 , 81 ]. Results of the eight studies with “Good” rating, presented a pooled OR of 3.96 (95% CI 3.10–5.07), with an I 2 of 60% and a X 2 of 17.64 ( p  < 0.00001) (Fig.  4 ).

Sensitivity analysis of odds of initiation of cigarette smoking among individuals who never smoked cigarettes who used e-cigarettes—excluding studies rated as “fair” quality

A sub-group analysis was conducted based on the country where the study was implemented (US-based or outside the US). The sub-group analysis stratified the results of eight studies conducted in the US [ 43 , 52 , 56 , 59 , 63 , 76 , 77 , 81 ] and four studies conducted outside of the US [ 34 , 66 , 80 , 84 ]. In the eight US studies, AORs ranged from 1.35 to 7.41, and the pooled overall OR was 3.63 (95% CI 2.54–5.18). The test for overall effect revealed that the results were significant ( p  < 0.00001), while heterogeneity was noted with I 2 of 79% and X 2 of 32.77 ( p  < 0.0001). In the studies outside the US the AORs ranged from 2.42 to 5.09 and the pooled OR was 3.94 (95% CI 2.62–5.95), with a significant test for overall effect ( p  < 0.00001), and I 2 of 70% and X 2 of 9.96 ( p  < 0.00001). The test for subgroup difference presented an I 2 of 0% and X 2 of 0.09 ( p  = 0.76) (Fig.  5 ).

Sub-group meta-analysis of odds of initiation of cigarette smoking among individuals who never smoked cigarettes who used e-cigarettes from studies conducted in the US and outside the US

As with the main analysis, a sensitivity analysis of the subgroup analysis based on country was performed, excluding studies graded as “Fair” quality, which resulting in the exclusion of three US-based studies [ 43 , 63 , 81 ], and one study from outside the US [ 80 ]. Pooled results from the remaining five US studies revealed a statistically significant pooled OR of 4.01 (95% CI 2.95–5.47; p  < 0.00001) with an I 2 of 47% and a X 2 of 7.54 ( p  = 0.11). In the remaining studies outside the US the AORs ranged from 2.42 to 5.09 and the pooled OR was 3.83 (95% CI 2.29–5.07), with a significant test for overall effect ( p  < 0.00001), and I 2 of 80% and X 2 of 9.94 ( p  < 0.00001). The test for subgroup difference presented an I 2 of 0% and X 2 of 0.02 ( p  = 0.88) (Fig.  6 ).

Sub-group meta-analysis of odds of initiation of cigarette smoking among individuals who never smoked cigarettes who used e-cigarettes from studies conducted in the US and outside the US—excluding studies rated as “fair” quality

The current systematic review identified a number of “good” quality studies (according to the Downs and Black quality metrics [ 29 ]) that evaluated the association between e-cigarette use and initiation of cigarette smoking, and initiation of and progression to regular cigarette smoking. Over half of the included studies controlled for age, gender, and race/ethnicity and reported adjusted results to provide a higher level of evidence. This review focused on such studies in the quantitative and qualitative synthesis of results.

A meta-analysis of 12 studies evaluating initiation of cigarette smoking indicated an increased odds (3.7 times higher) for individuals who have ever used e-cigarettes compared with individuals who are not using e-cigarettes and no indication of publication bias among the studies was observed [ 34 , 43 , 51 , 56 , 59 , 63 , 66 , 76 , 77 , 80 , 81 , 84 ]. These findings are consistent with previously-conducted meta-analyses, all of which reported increased odds of initiation associated with e-cigarettes: O’Brien et al. [ 16 ] reported 4.06 times higher odds among teenagers; Soneji et al. [ 13 ] reported 3.5 times higher odds among a study population of adolescents and young adults; Chan et al. [ 14 ] and Khouja et al. [ 15 ] both reported 2.9 times higher odds, in populations of youth and youth-young adults, respectively; and Baenziger et al. [ 18 ] and Adermark et al. [ 19 ] reported 3.2 and 3.3 times higher odds, respectively, in samples from the general population.

Only one study, also included in the meta-analysis, reported on initiation of cigarette smoking in individuals with regular use of e-cigarettes, providing outcome data for initiation of cigarette smoking based on the frequency of e-cigarette use at baseline (from 1–2 uses/day to everyday use) [ 77 ]. Wills et al. [ 77 ] found an upward trend for the probability of initiation of cigarette smoking and increased e-cigarette use. Thirty-seven adjusted studies not included in the meta-analysis showed a similar trend, with a higher probability or incidence of initiation of cigarette smoking in the e-cigarette user group [ 36 , 37 , 41 , 42 , 44 , 46 , 47 , 49 , 50 , 52 , 53 , 54 , 55 , 57 , 58 , 60 , 61 , 62 , 64 , 67 , 68 , 70 , 71 , 72 , 73 , 74 , 78 , 79 , 82 , 83 , 85 , 86 , 87 , 88 , 89 , 90 , 91 ]. These studies had similar definitions for e-cigarette use, with any or ever use at baseline, any e-cigarette use in the past 12 months, or any use in the past 30 days. All but one of these studies defined cigarette use as any cigarette use at follow-up, while the remaining study evaluated regular smoking, although definition of regular smoking was not provided.

Six studies compared initiation of cigarette smoking with e-cigarette use between study groups that were susceptible or not susceptible to cigarette smoking [ 34 , 52 , 57 , 68 , 90 , 91 ]. E-cigarette use was either not associated with an increase in smoking initiation in individuals using e-cigarettes susceptible to cigarette smoking [ 52 , 90 ], or the effect of e-cigarette use on initiation of cigarette smoking was less in individuals using e-cigarettes susceptible to cigarette smoking [ 34 , 57 , 68 , 91 ].

The limited data from one study evaluating e-cigarettes with or without nicotine pointed to a higher probability of initiating cigarette smoking with nicotine-containing e-cigarettes [ 57 ]. With regards to “switching” or “dual-use” following initiation of cigarette smoking, two studies found that the odds of reporting dual use among exclusive e-cigarette ever users (versus never users) were higher than the odds of reporting switching from exclusive e-cigarette use to exclusive current cigarette smoking [ 52 , 80 ]. In both studies, analyses of current (past 30-day) e-cigarette users reported similarly higher odds of dual-use compared with switching.

Twelve adjusted studies evaluated initiation of and progression to regular cigarette smoking for individuals using e-cigarettes versus individuals who are not using e-cigarettes [ 37 , 40 , 45 , 48 , 54 , 61 , 65 , 66 , 69 , 72 , 73 , 86 ], two of which applied measures of regular e-cigarette use [ 40 , 48 ]. Both studies generally found no significant associations between regular e-cigarette use and progression to regular cigarette smoking; however, one result suggested that established e-cigarette users were significantly less likely to transition to exclusive cigarette smoking than non-established e-cigarette users [ 48 ]. In terms of studies applying definitions of non-regular e-cigarette use, based on the variability in the results, and variations in the definition of a “regular” cigarette smoker, the current data regarding initiation of and progression to regular cigarette smoking does not support drawing conclusions. This is illustrated in the study by Friedman et al. [ 69 ], which reported statistically lower odds of both current established and daily cigarette use among individuals who experimented exclusively with e-cigarettes(non-established use prior to the age of 18 years old) compared with individuals who did not experiment with e-cigarettes. Conversely, this study also found statistically significantly higher odds of current established cigarette use among individuals who experimented with e-cigarettes first, then with cigarettes, compared with individuals who did not experiment with e-cigarettes; however, no significant difference in the odds of daily smoking was found between e-cigarette-then-cigarette experimenters compared with individuals who did not experiment with e-cigarettes.

Finally, only one adjusted study evaluated age of initiation of cigarette smoking [ 75 ]. Notably, although McCabe et al. [ 75 ] reported a significantly lower age among current e-cigarette users, age of regular (daily) cigarette smoking was not significantly different between current and non-current e-cigarette users.

The current systematic review exhibited three major strengths. Firstly, its comprehensive search methodology yielded a large number of studies for review. Secondly, the current review had a clearly defined PICOS, which assured the identification of the strongest evidence relevant to the research question. Thirdly, guidelines for this review ensured that only demographically adjusted and methodologically consistent studies were included in the quantitative syntheses. Finally, the strict adherence to AMSTAR-2 and PRISMA guidelines ensured the transparency and replicability of this review while minimizing any risk of various forms of bias (e.g. individual study design; industry sponsorship) to provide an unbiased and comprehensive synthesis of this evidence base. Collectively, these strengths support the robustness of this review in terms of comprehensiveness and methodological rigor.

Although the meta-analysis indicated a higher odds for initiation of cigarette smoking among individuals using e-cigarettes—a result generally supported by the studies included in the qualitative synthesis—interpretation of the results is limited for many critical reasons. Specifically, the definition of e-cigarette use was not restricted to regular use. While doing so would have provided the strongest evidence on potential associations with the initiation of cigarette smoking, such a restriction would have yielded too few studies. Instead, the review was broadened to include any measure of e-cigarette use, with most studies measuring ever or current (past-30-day) use. Also, few studies examined initiation and/or progression to regular cigarette smoking, instead applying definitions of cigarette smoking that were more consistent with temporary experimentation and not true initiation, such as ever or current (past-30-day) smoking. Further, included studies were not restricted by specific confounding variables representing common liabilities between e-cigarette use and cigarette smoking, as this would have critically reduced the number of included studies in this review. The common-liability model considers the sequencing of drug use initiation, addiction, and addiction severity and posits that there are common sources of variation in the risk for specific addictions [ 11 ]. This model is critical for consideration given the empirical mixed signals that support or contradict the gateway hypothesis. However, the limited number of studies controlling for confounding variables related to common liability highlights the need for more robust studies to effectively measure the causal relationship between e-cigarette use and the initiation of cigarette smoking.

The majority of studies looked at how an e-cigarette-using population, individuals who never smoked cigarettes at baseline, developed cigarette smoking practices at follow-up. Though this information is indeed fundamental, it is equally important to understand the concepts of switching and dual-use. There are two possible trajectories that lead to an outcome of cigarette smoking among individuals using e-cigarettes. Between the baseline and follow-up surveys, (1) the e-cigarette user could begin cigarette smoking simultaneous with his/her e-cigarette use (dual use); or, (2) the e-cigarette user could eventually stop using the e-cigarette and after some time start smoking cigarettes (switchers). Information regarding whether individuals switched or dual used was limited, with only one adjusted study presenting specific data regarding single or dual use [ 52 ].

Further, 49 of 55 included studies reported on “youth”, “adolescent” and/or “young adult” populations, limiting the utility of the conclusions, as studies in youth and/or young adults are not necessarily translatable to older adults. Indeed, there is evidence that cigarette and e-cigarette smoking behaviors differ in different age groups. For example, one study determined that young adults (18–29 years of age) were more likely to be occasional smokers and reported lower daily consumption compared with older individuals who smoke cigarettes (30 years of age or older) [ 95 ]. Moreover, different age groups may vary in terms of their perceptions of and willingness to take risks, views of smoking addiction, perception of relative cigarette and e-cigarette health risks and/or benefits, and responses to behavioral interventions [ 96 ], which may differentially influence smoking behaviors and inherently, smoking cessation.

Finally, the duration of follow-up for the available studies was generally limited with most studies limited to 12 months in duration. This introduces the potentially limitation to observe whether cigarette smoking behavior actually persisted after initiation, i.e., true initiation and not simply temporary experimentation [ 2 ]. This may explain why so few of the included studies evaluated progression to regular cigarette smoking.

In conclusion, more robust studies are required to determine whether there is an association between e-cigarette use and initiation of cigarette smoking and progression to regular smoking. Based on findings from this review, the available studies neither sufficiently measure e-cigarette use—or cigarette smoking—in a manner consistent with examining causality, nor sufficiently account for known or suspected confounding variables to support robust determinations regarding e-cigarette use and cigarette smoking behaviors. Thus, the utility of the evidence base for policymakers, healthcare providers, and researchers is limited.

Availability of data and materials

All data and materials considered in this review are publicly available.

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Acknowledgements

The authors would like to acknowledge Thera-Business (Ontario CANADA) for providing their systematic review expertise to all study activities across all levels of the updated review process. The authors would also like to thank Dr. Geoffrey Curtin, a retired employee of RAI Services Company, for his scientific contributions during the conceptualization of this review.

All study activities were executed by providers external to RAI Services Company (Thera-Business), who were financially compensated for services according to contractual terms with RAI Services Company. RAI Services Company is a wholly owned subsidiary of Reynolds American Inc., whose operating companies manufacture and market tobacco products. The conception, analysis, and writing for this manuscript was a collaboration between Thera-Business and RAI Services Company.

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Kim, M.M., Steffensen, I., Miguel, R.T.D. et al. A systematic review and meta-analysis of the association between e-cigarette use among non-tobacco users and initiating smoking of combustible cigarettes. Harm Reduct J 21 , 99 (2024). https://doi.org/10.1186/s12954-024-01013-x

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The current landscape of data reporting for outbreaks is ad hoc and inconsistent. Public health authorities have discretion to determine when, where, how, and what outbreak data to report. This uneven information flow hampers response efforts by decreasing the accountability and transparency needed to build public trust in the public health response. We performed a systematic literature review using the PubMed, EMBASE, MedLine Plus, and Google Scholar databases to identify existing guidelines that address timing, methodology and content of outbreak reporting. Our search strategy produced 46 manuscripts for initial screening to determine eligibility, after which we performed a full-text review of those selected for comprehensive evaluation. We identified four manuscripts that discuss minimum standards and expectations for outbreak reports. Included manuscripts highlight the absence of and the consequent need for minimum standards for what information should be reported to the public during outbreaks. Together, they suggest that the ideal outbreak report should contain information on disease severity, epidemic size and geographic extent, daily and total case count, demographics, transmissibility, signs and symptoms, probable disease transmission and exposure pathways, countermeasure status, and sources of uncertainty. This systematic review of existing guidelines is part of a larger effort to develop consensus guidelines for the public reporting of outbreak data.

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The Center for Health Security received funding from the Open Philanthropy Project: https://www.openphilanthropy.org/ The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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