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If basking young mate down the pub about FAPE in hands, one, they probably say.

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No one agrees if it's safer on nuts, so you might as well smoke anyway.

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Now, what Jemmy needs is a Cochrane review. All the facts have been checked at least twice.

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They find there's a lot that the experts agree on.

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I'd give you a different by. Hi, I'm declared insane.

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And I'm Jamie Hartman Boyce. We're both researchers based at the University of Oxford, where we work with the Cochrane Tobacco Addiction Group.

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Welcome to this edition of Let's Talk E-cigarettes. This podcast is a companion to a research project being carried out at the University of Oxford,

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where every month we search the e-cigarettes literature to find new studies.

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We then use these studies to update our Cochrane systematic review of e-cigarettes for smoking cessation.

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This is called a living systematic review. In each episode of this podcast,

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we start by going through the studies we found that month and then go into more detail about a particular study or topic related to e-cigarettes.

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So we'll start by describing what we found on our search on the 1st of March.

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In a nutshell, this month we also searched conference abstracts from the annual meeting of the Society for Research on Nicotine and Tobacco.

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We found four new studies, five new ongoing studies and five papers linked to studies already include in our review offers.

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Two new included. Studies came from that conference.

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And it's important to be aware of when we think about conference, some stress that they have limited detail and often from unpublished research.

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And so these results could be subject to change.

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So the lead author of the first of these abstracts was Thomas Hage, Brandon of the Moffitt Cancer Centre USA, and the study was government funded.

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It's a large, randomised controlled trial of almost 3000 people carried out in users of conventional cigarettes and e-cigarettes.

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People were assigned to one of three groups. So the first group received no treatment.

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The Sankaran group received generic smoking cessation self-help booklets and the third group were

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provided with smoking cessation self-help booklets that were specifically targeted at your users.

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Participants were followed up for two years,

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and the initial findings reported suggest high abstinence rates in people who received the intervention targeted at jewel users.

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Then no treatment with quit rates achieved by those receiving the generic self-help falling somewhere between the two.

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The lead author of the second abstract was Caroline Cobb from Virginia Commonwealth University in the US.

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Her team report on another randomised controlled trial of 520 people that was also government funded.

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Participants were all current smokers who were interested in reducing their smoking but not quitting.

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People were randomised to four different study groups,

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so they either got an electronic cigarette that contains zero milligrams per millilitre of nicotine liquid,

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eight milligrams per millilitre, 36 milligrams per millilitre, or a cigarette shaped plastic tube for six months.

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The results in this abstract focus only on predictors of people's withdrawal from the trial,

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which isn't something that we're looking at in our review. However, we'll be looking out for results.

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Looking at the effect and safety of the different approaches.

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The third abstract we found was also from the Society for Research on Nicotine and Tobacco Conference,

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and it was led by Christopher Russell at the Centre for Substance Abuse Research in Glasgow, Scotland.

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It was a randomised controlled trial of over 400 adults who smoked,

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and they were randomised to nicotine replacement therapy or two apart a cigarette product for three months.

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Within the people randomised to the party's cigarette product,

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they were split into those with pod devices containing either nicotine, salt, illiquid pods or freebase nicotine iPods.

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They reported twenty one point three percent of people had quit in the nicotine replacement therapy group at six months,

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compared to thirty point three percent in the nicotine salt pod group and twenty four point three percent in the Freebase Nicotine Pod Group.

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The abstract indicates that funding came from the cigarette industry. The fourth is also a conference abstract,

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but this one was published back in 2015 and we found it because we are screening

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a new systematic review to see if it included studies that we've missed.

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It was led by Joel Isaan Hoffer at the Baylor College of Medicine in Texas, and it was a really small study.

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It also looked at nicotine replacement therapy versus e-cigarettes.

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And here it was provided for three weeks to veterans who met the criteria for tobacco use disorder.

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They measured a range of short term outcomes. And the one of interest for our review is carbon monoxide.

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They reported that carbon monoxide was significantly reduced from baseline in both groups, but they don't give comparisons between groups.

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And these are preliminary findings. So very limited details were available and this was funded by the Veterans Affairs Medical Centre.

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This month, Jamie spoke to Professor Caitlin Notley from the University of East Anglia,

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who is a co-author of the Cochrane Electronic Cigarettes Living Review that has lots of other research in this area.

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Cochrane Review focuses on quantitative data,

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which means it looks at numbers such as how many people quit smoking or how many of experienced adverse effects.

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However, in e-cigarettes research, qualitative research methods also have a really important role to play.

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Obscure science term definition.

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By quantitative methods, we mean the types of methods that are often used to answer questions about experience, meaning and perspective.

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So an example of this might be interviews with people who have switched from smoking to vaping.

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Caitlin is experienced in carry out this type of research and she talked to Jamie about it in this month's deep dive.

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Really excited to have Caitlin here to talk to us about her research.

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So to start off with Caitlin, can you tell me a bit about yourself and what got you into doing research on e-cigarettes in the first place?

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Sure. Well, I'm a social scientist by background, and I came to this field of study through an interest in researching substance misuse primarily.

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So I I guess I have a strong grounding in the principles of harm reduction.

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I worked as a post doc on a study looking at supervised consumption for opiate maintenance therapy, actually leading the process evaluation study.

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Alongside that trial, obscure science term definition.

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The Centre for Disease Control defines a process evaluation as a way of determining whether programme activities have been implemented as intended.

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So that means looking at, if any, sort of activity.

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For example, a health care intervention has been delivered to the right people at the right time in the right way.

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So really interested in the views and experiences of people who were supervised,

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consuming their opiate maintenance therapy very much from their perspective that using a substitute medication

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to reduce the harm from illicit heroin was the way that treatment services were going at the time.

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And then following a period of maternity leave,

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I was lucky enough to secure a postdoctoral fellowship funded by the Society for the Study of Addiction,

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focussed on the topic of smoking relapse prevention.

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So at the time at the UEA, we had an HCA funded trial looking at the effectiveness of a relapse prevention intervention.

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And I again led a process evaluation study alongside.

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This is the first part of my fellowship programme of work. And then I undertook a qualitative, systematic review and some qualitative work,

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really trying to understand the phenomenon of smoking relapse for pregnant women who'd quit smoking during pregnancy.

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And what we found was it was incredibly common for pregnant women to find it quite easy to quit smoking.

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But actually, the rates of relapse immediately after pregnancy were incredibly high.

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Around about 75 percent of women who quit smoking in pregnancy would eventually relapse in the 12 months following pregnancy.

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So the programme of work was really trying to understand what was going on there.

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And during that time, e-cigarettes just kind of came to the fore.

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They really took off as a consumer phenomenon. It seemed that people were just deciding to use e-cigarettes.

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And as a research community, we really didn't know much about them. And coming from this background in substance misuse,

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I immediately saw there's huge potential for e-cigarettes to be a harm reduction tool to help people stop smoking.

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And then linking in with the the idea of relapse prevention,

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something that was attractive and being used by people helping them to switch quite easily might also be really important in helping people to stay.

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Quit from smoking in the long term is an attractive substitution, if you like, for tobacco.

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Brilliant. Thank you. I think there are a lot of links between harm reduction used in other areas and some of the earmarks, doctors and others.

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And I'm starting to think about it coming into play on smoking.

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So you clearly have a really impressive track record and tobacco addiction and

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cigarette research and those two particular areas which you've now touched upon.

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I'd like to delve into a bit more today, if we can.

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The first of those is, is your interest in relapse prevention, and the second is your interest in some more vulnerable populations.

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So to start with, can you tell us a bit more about relapse prevention?

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So what does that mean in the context of smoking? Says part of my post-doctoral fellowship.

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I explored the reasons for relapsing to smoking amongst pregnant and postpartum women and being a social scientist.

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I was really interested in that kind of whole range of reasons that women might relapse back to smoking really,

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as well as the sort of physical addiction to nicotine through smoking,

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that it was clear that as a strong psychological dependence to smoking a very strong social element.

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Of course, most women learnt to smoke as part of a kind of social exchange and being part of a group of smokers,

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incredibly important to many people, very strong cultural links.

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So for people born in a. Culture where it's the norm to continue to smoke,

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it's incredibly difficult to move away from and particular interest of mine is the idea of social identity.

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So for women who quit smoking during pregnancy, often the tobacco smoking has been a core part of their identity as a young woman.

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And for many women,

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kind of going back to smoking after having a baby seemed to be about regaining a sense of themselves as they saw themselves before they became a mum.

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Obviously, many young women sort of struggled to become a mum and to kind of take on that new identity as a mother.

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And for some, going back to smoking was kind of something for themselves, if you like.

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So they're really important kind of social,

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psychological dimensions that seem to be really important in terms of relapses are a complex psychosocial phenomenon.

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But really, interestingly,

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at the time before e-cigarettes and smoking cessation treatment seemed to me to focus just on one aspect of tobacco addiction.

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So nicotine replacement therapy, for example, focussed on their physical dependence to nicotine,

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but didn't really help people with their social and psychological aspects of the addiction.

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And behavioural support was really helpful for many people trying to quit smoking,

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but focus particularly on the psychological aspects of tobacco addiction without really addressing the kind of social and cultural aspects.

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So no treatment for helping people quit smoking seemed to attend to all the dimensions

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of tobacco addiction that really made it such a difficult addiction to overcome.

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And, of course, relapse is incredibly common.

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So the average smoker we knew tended to try to quit smoking around seven times before they actually succeeded.

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Clearly, there's a lot going on in relapse and a lot of kind of a multi-dimensional need for support.

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And so I guess seeing relapses are kind of relapsing.

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Remitting condition that needed ongoing support was the kind of angle that I started to come from when exploring the phenomenon.

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Particularly for women, as I said, kind of relapsing back to smoking seemed to be about regaining a sense of

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themselves that perhaps they had lost during pregnancy when they'd quit smoking.

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So when e-cigarettes came along, it seemed that they were an exciting kind of alternative,

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a way that people might kind of deal with all the aspects of tobacco addiction that previous treatments hadn't been out to address.

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So, of course, e-cigarettes mostly contain nicotine to deal with any physical addiction,

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but also it seemed that they had a psychological element to it.

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You know, people could use them in a habitual way, just as they previously perhaps might have used to tobacco,

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and they could substitute the hand to mouth action of smoking that perhaps they'd become very dependent on.

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Socially vaping seemed to offer a sort of group identity that some people found helpful to engage with and in an identity sense as well.

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E-cigarettes seemed to perhaps offer an alternative identity that people could switch to.

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So, you know, becoming a vapour instead of seeing themselves as a smoker.

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And also something really important, I think that's often missed in the medical literature when we're talking about treatments for smoking cessation,

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is that people seem to really enjoy using e-cigarettes. There was a pleasurable aspect to them in their own right.

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So for the first time, perhaps there was a treatment available for smoking cessation that people might actually not find difficult or painful.

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They might actually enjoy vaping in its own right. And this really led me to think that, you know,

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something that's pleasurable but also helps people overcome their tobacco addiction could mean that they could be supported to actually

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stay quit from smoking in the long term because the pleasurable alternative might be something that they want to carry on using.

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Thank you for talking to a relapse prevention. And I think that point you made about e-cigarettes being a relatively exciting

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development in the field because of their pretty unique ability to touch on behavioural,

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social and pharmacological aspects of cigarette addiction. Is is a really important one and one that maybe doesn't get spoken about all that much.

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But what I also wanted to touch on is that I know that in 2019 you were involved in a systematic review

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looking at the use of e-cigarettes for smoking cessation or reduction in vulnerable populations.

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So I was hoping you might be able to tarsal a little bit more about that review

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and what you found and and also how how do we define vulnerable populations?

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Why are we interested in these specific groups?

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In what way do we think maybe interventions will be different in those groups than they might be another populations?

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So, yeah, in the review, your you mentioned was led by a friend and colleague of mine, Dr Sara Gentry,

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who published in Nicotine in Tobacco Research asking whether e-cigarettes might be

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an effective aid for smoking cessation or reduction amongst vulnerable populations.

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So first off, defining vulnerability. Obviously, it's incredibly complex to define what we mean by a vulnerable group.

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And we have to be really careful not to stigmatise groups that might already already be very marginalised.

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So for this review in particular, we focussed on green groups experiencing multiple disadvantage and health inequity.

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So groups such as those who might be misusing other substances,

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those with serious mental illness groups experiencing homelessness or involved with the clinic,

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the criminal justice system, and all of these groups were particularly vulnerable to smoking related harm.

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So amongst all of those groups, prevalence of smoking remains over 70 percent of those populations incredibly high,

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obviously, compared to that major smoking now in the general population, which is currently just less than 15 percent.

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So we were really, really interested in focussing on these groups because despite the challenges in their lives,

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we know that smoking tobacco, that's most likely to cause these groups severe disease and ultimately premature death.

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So the findings of that review. Well, it was a mixed methods review because the literature in the field is extremely varied.

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There were there was a lack of files looking specifically at vulnerable populations.

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So we didn't have studies that we were able to combine in our meta analysis like we might do with the Cochrane Review.

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We included nine studies in total. Five from the US, none actually undertaken in the UK.

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Five of the studies were quantitative studies. As I said, no trials.

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And for qualitative studies. So a primary outcome was focussed on smoking cessation.

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The way in which smoking cessation was measured in these studies really varied.

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Often not biochemically validated, and the outcome was collected anywhere between four weeks and 18 months.

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Follow up so you can see very for rate and the cessation outcome then varied

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between nought percent and fourteen point three percent for these populations.

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Severely importantly, across the studies, we didn't find any adverse events, particularly being reported,

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which is obviously an exciting finding when you look at a cessation intervention and the qualitative studies,

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a qualitative findings, I guess, were really what was very interesting with this review.

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We were interested in what the barriers and facilitators to switching to e-cigarettes or other cessation methods might be for these populations.

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And we found some very specific barriers.

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And facilitators say, for example, being able to access supplies for these populations could be very difficult.

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Affordability of products was something that was a big barrier to use.

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But we did find some facilitators, for example, acceptance of our harm reduction approach.

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So seemed to be an increased acceptance of switching to reduced harm product and also seeing

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vaping e-cigarettes as a more socially acceptable than perhaps other groups might have seen them.

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And then really interestingly, across the studies as a whole, we did find us statistically significant level of smoking reduction.

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So although our cessation outcome wasn't great, we did say that people who had switched to e-cigarettes were at managed to reduce their smoking.

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And quite positively, we saw that as perhaps being on a pathway towards eventual cessation.

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But obviously, due to the low quality of included studies, we were unable to really assess the effectiveness of e-cigarettes for vulnerable groups.

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Although evidence from one moderate quality study did show that e-cigarettes might be at least as effective as nicotine replacement studies.

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And as I said, the thematic synthesis, the qualitative synthesis that we undertook showed that e-cigarettes really did have a

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potential to attend to the whole range of aspects of smoking addiction for vulnerable groups.

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So they might be a pleasurable alternative to tobacco smoking. They might promote social connectedness that might be important for these groups.

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But really importantly, we found that vulnerable populations particularly were in need of additional support to access these alternatives to smoking,

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to help them to become more more affordable and to support them to maintain ongoing use.

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So that's something I think we find across e-cigarettes.

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Research, particularly in the qualitative literature, is that people need support not just to switch in the short term,

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but to troubleshoot problems that they might have along the way,

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say that they are able to maintain that switch and not relapse back to tobacco making grey.

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And I think, you know, that reviews conducted back in 2019 and it's been interesting,

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encouraging it since we've started doing the living review process.

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But now that we're doing our monthly searches, we're finding a lot more studies targeted to these more vulnerable populations.

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And I think that's a pretty good encouraging because often traditionally in research,

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those are actually the groups who who don't get looked at and don't get involved in studies.

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And certainly in the case of smoking, as we know from those statistics, which are actually quite shocking,

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those disparities in years, these are the groups where we're actually we should be doing most of our research, probably.

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So finally, just touched on on what you were talking about a little bit last.

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So why we do our Cockram of year? Most of the work I do tends to focus on quantitative outcomes.

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So the numbers side of things. But clearly there's a lot that we can also learn from qualitative research in this field.

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And I was wondering if you could. Tell us a little bit about what we've learnt, I suppose,

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from qualitative research about e-cigarettes that we'd really be missing if we're only

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looking at the quantitative data and how we might be able to better take both into account,

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I suppose, when thinking about policies and treatments moving forward. Yeah, I think so.

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I think that's a really important question.

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I mean, starting out as a primarily qualitative research show, I could never have imagined actually becoming involved in a Cochrane review.

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But I suppose as my career has progressed, I've started to feel really strongly that we need different methods to answer different research questions.

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And it's really important that we include the whole range of methods in order to answer the whole range of questions that need answering.

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So when we were asking questions about how people might use in e-cigarettes,

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why they might ease any cigarette or in what ways we might support sustained switching,

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we need experiential data gathered through interviews, observations, focus groups and preferably longitudinally,

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say, following people over time, obviously for effectiveness questions which are incredibly important.

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We need to quantify the outcomes to look at adverse events.

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We need cohort studies, measuring events and exposures.

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How many trials, of course, to test one treatment against another or against a controlled group.

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So it's really,

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really important to triangulate the different types of evidence in order that we can converge on a consensus view to influence policy in practise.

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I mean, it's really interesting to think about how much mixed methods evidence is enough.

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I think certainly in the UK with the Public Health England report and through the work that the Cochrane Group is doing,

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we're now in a position perhaps to say we have enough evidence that e-cigarettes can

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be considered a useful cessation and possibly a useful relapse prevention tool.

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But obviously, internationally, there still different viewpoints on that.

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So it's interesting to think about, you know, at what point might there be enough evidence to to really convince people of the need for policy change?

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I think one of the interesting things, I suppose in all areas to some extent, but particularly in e-cigarettes,

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I think one of the things that can be very, very powerful are actually just stories.

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Right. Particularly when you're when you're sitting around a policymaking table or are thinking about clinical decisions.

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Those stories, as they might relate to young people and cigarette use can be really striking.

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It can be really emotive and give us an insight that we might not have from the data.

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And similarly, I think those stories about people using e-cigarettes for smoking cessation can also be really informative.

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But we don't we don't hear about them as much. So. I think that's one thing that I.

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I like seeing from the qualitative data sometimes, too, is just the voices of people who have tried using e-cigarettes to quit smoking.

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And the challenges that they've faced along the way, which can help us design better interventions and better policy.

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We hope so. Last question for you is just following on from the research we've discussed today.

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What research do you think could be done next if someone gave you tons of money as Caitlin designed any study you want?

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What would you like to do? Well, that's a big question.

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I mean, although smoking prevalence at a population level, you know, it has decreased year on year.

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And as I said, in the U.K., we're around about 15 percent now.

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The population can continue to smoke. Prevalence does remain much, much higher in some populations.

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And I think that's really clearly where we need to focus our intervention efforts now.

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So we need to assess the effectiveness of interventions targeted at those vulnerable groups who are the most

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likely to experience multiple health inequalities and be the groups that are likely to be continuing to smoke.

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So I guess my my top three would be to develop and test interventions with those vulnerable populations,

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particularly with those experiencing homelessness or substance misuse, those not motivated to quit smoking.

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And, of course, pregnant women who are extremely vulnerable, both in terms of their own health,

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but also the health of their developing child and the children in the family.

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Secondly, to develop and test relapse prevention interventions. Obviously, this is, you know, my programme of work.

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But really importantly, I think we have ignored relapse over the years in tobacco control research.

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We've focussed a lot of effort on helping people to quit smoking.

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We've got great support for smoking cessation in terms of pharmacological and behavioural support.

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And of course, e-cigarettes, if people choose to switch to e-cigarettes, but we put much less effort into helping people stay quit in the long term.

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And I really think that's where we need to target interventions next and develop guidance

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for health professionals around what they can best be doing to support relapse prevention.

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And then finally, I think we need implementation research.

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So we do have good evidence now on the effectiveness of e-cigarettes for smoking cessation.

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But what we need to do is ensure that e-cigarettes as an effective intervention can be used within routine care.

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So we need to educate our health care professionals. We need to educate the public about the reduced risk of using an e-cigarettes.

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There's still huge public misperception about harms of nicotine that needs addressing.

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And really importantly, I think we need to focus efforts on working with assets that already exist within communities,

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say, particularly thinking about vulnerable populations, working with support groups,

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perhaps with vape shops that are available on the High Street,

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really using those resources that people tap into in their everyday lives and reach out to those

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groups who aren't accessing support for smoking cessation via kind of their medical means,

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perhaps. Great. Well, thank you so much.

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Yeah.

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This is all brand super interesting and kind of nice change from talking about the various randomised controlled trials that we tend to focus on.

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Which, of course, are also really important.

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That was a really great interview, Jamie, and something I found particularly interesting, having a background in psychology myself.

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Is that idea of smoking perhaps being part of somebody's social identity?

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And how do you know if you give up smoking, you might need to make that switch to knew the way that you feel about yourself.

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And that also kind of leads nicely onto the idea of these different dimensions of tobacco addiction.

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So there's different elements such as that biological addiction to nicotine.

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But obviously there's also important factors involved in in the psychological aspects.

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So people's relationship with other people who who smoke perhaps or worries even about the

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health of people around them when they're smoking or play into people's smoking behaviour.

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Absolutely. And I think that was that was one of the reasons we are keen to have Caitlin on so massive, thanks to Caitlin for coming on.

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And it's one of those things when we think about all the different aspects of smoking and all the different elements that we'd hope.

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Or in a successful tool to help people quit smoking?

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We really just looking at the numbers, doesn't tell the whole picture.

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And that's why it's so important to hear about people's experiences through research like that.

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Caitlin does. And kind of time that into a review. That's one of the reasons why in our review we have some studies.

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Obviously, most of them look at e-cigarettes with nicotine,

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but some of them actually look at e-cigarettes without nicotine as an intervention in and of themselves,

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because though they're not addressing that pharmacological aspect of addiction, they are there to help address those behavioural,

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social and psychological cues that so many people struggle with when they're trying to quit smoking.

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So that's it from us this month. Please subscribe on iTunes or Spotify. And stay tuned for our next episode.

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But some mention the findings we have can tell us what happened, Loung.

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It's safer than smoking. We may still buying cars. Thank you to Jonathan Livingston.

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Thanks for running searches to Elsa Butler for producing this podcast. And to all of you for tuning in.

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Music is written with Johnny Berliner and I and performed by Johnny are live in systematic reviews supported by funding from Cancer Research UK.

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The Cochrane Tobacco Addiction Group also receives core infrastructure funding from the National Institutes for Health Research.

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The views expressed in this podcast are those of Nicola and I and do not represent those of the funders.