If basking young mate down the pub about FAPE in hands, one, they probably say.
No one agrees if it's safer on nuts, so you might as well smoke anyway.
Now, what Jemmy needs is a Cochrane review. All the facts have been checked at least twice.
They find there's a lot that the experts agree on.
I'd give you a different by. Hi, I'm declared insane.
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.
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,
where every month we search the e-cigarettes literature to find new studies.
We then use these studies to update our Cochrane systematic review of e-cigarettes for smoking cessation.
This is called a living systematic review. In each episode of this podcast,
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.
So we'll start by describing what we found on our search on the 1st of March.
In a nutshell, this month we also searched conference abstracts from the annual meeting of the Society for Research on Nicotine and Tobacco.
We found four new studies, five new ongoing studies and five papers linked to studies already include in our review offers.
Two new included. Studies came from that conference.
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it's important to be aware of when we think about conference, some stress that they have limited detail and often from unpublished research.
And so these results could be subject to change.
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.
It's a large, randomised controlled trial of almost 3000 people carried out in users of conventional cigarettes and e-cigarettes.
People were assigned to one of three groups. So the first group received no treatment.
The Sankaran group received generic smoking cessation self-help booklets and the third group were
provided with smoking cessation self-help booklets that were specifically targeted at your users.
Participants were followed up for two years,
and the initial findings reported suggest high abstinence rates in people who received the intervention targeted at jewel users.
Then no treatment with quit rates achieved by those receiving the generic self-help falling somewhere between the two.
The lead author of the second abstract was Caroline Cobb from Virginia Commonwealth University in the US.
Her team report on another randomised controlled trial of 520 people that was also government funded.
Participants were all current smokers who were interested in reducing their smoking but not quitting.
People were randomised to four different study groups,
so they either got an electronic cigarette that contains zero milligrams per millilitre of nicotine liquid,
eight milligrams per millilitre, 36 milligrams per millilitre, or a cigarette shaped plastic tube for six months.
The results in this abstract focus only on predictors of people's withdrawal from the trial,
which isn't something that we're looking at in our review. However, we'll be looking out for results.
Looking at the effect and safety of the different approaches.
The third abstract we found was also from the Society for Research on Nicotine and Tobacco Conference,
and it was led by Christopher Russell at the Centre for Substance Abuse Research in Glasgow, Scotland.
It was a randomised controlled trial of over 400 adults who smoked,
and they were randomised to nicotine replacement therapy or two apart a cigarette product for three months.
Within the people randomised to the party's cigarette product,
they were split into those with pod devices containing either nicotine, salt, illiquid pods or freebase nicotine iPods.
They reported twenty one point three percent of people had quit in the nicotine replacement therapy group at six months,
compared to thirty point three percent in the nicotine salt pod group and twenty four point three percent in the Freebase Nicotine Pod Group.
The abstract indicates that funding came from the cigarette industry. The fourth is also a conference abstract,
but this one was published back in 2015 and we found it because we are screening
a new systematic review to see if it included studies that we've missed.
It was led by Joel Isaan Hoffer at the Baylor College of Medicine in Texas, and it was a really small study.
It also looked at nicotine replacement therapy versus e-cigarettes.
And here it was provided for three weeks to veterans who met the criteria for tobacco use disorder.
They measured a range of short term outcomes. And the one of interest for our review is carbon monoxide.
They reported that carbon monoxide was significantly reduced from baseline in both groups, but they don't give comparisons between groups.
And these are preliminary findings. So very limited details were available and this was funded by the Veterans Affairs Medical Centre.
This month, Jamie spoke to Professor Caitlin Notley from the University of East Anglia,
who is a co-author of the Cochrane Electronic Cigarettes Living Review that has lots of other research in this area.
Cochrane Review focuses on quantitative data,
which means it looks at numbers such as how many people quit smoking or how many of experienced adverse effects.
However, in e-cigarettes research, qualitative research methods also have a really important role to play.
Obscure science term definition.
By quantitative methods, we mean the types of methods that are often used to answer questions about experience, meaning and perspective.
So an example of this might be interviews with people who have switched from smoking to vaping.
Caitlin is experienced in carry out this type of research and she talked to Jamie about it in this month's deep dive.
Really excited to have Caitlin here to talk to us about her research.
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?
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.
So I I guess I have a strong grounding in the principles of harm reduction.
I worked as a post doc on a study looking at supervised consumption for opiate maintenance therapy, actually leading the process evaluation study.
Alongside that trial, obscure science term definition.
The Centre for Disease Control defines a process evaluation as a way of determining whether programme activities have been implemented as intended.
So that means looking at, if any, sort of activity.
For example, a health care intervention has been delivered to the right people at the right time in the right way.
So really interested in the views and experiences of people who were supervised,
consuming their opiate maintenance therapy very much from their perspective that using a substitute medication
to reduce the harm from illicit heroin was the way that treatment services were going at the time.
And then following a period of maternity leave,
I was lucky enough to secure a postdoctoral fellowship funded by the Society for the Study of Addiction,
focussed on the topic of smoking relapse prevention.
So at the time at the UEA, we had an HCA funded trial looking at the effectiveness of a relapse prevention intervention.
And I again led a process evaluation study alongside.
This is the first part of my fellowship programme of work. And then I undertook a qualitative, systematic review and some qualitative work,
really trying to understand the phenomenon of smoking relapse for pregnant women who'd quit smoking during pregnancy.
And what we found was it was incredibly common for pregnant women to find it quite easy to quit smoking.
But actually, the rates of relapse immediately after pregnancy were incredibly high.
Around about 75 percent of women who quit smoking in pregnancy would eventually relapse in the 12 months following pregnancy.
So the programme of work was really trying to understand what was going on there.
And during that time, e-cigarettes just kind of came to the fore.
They really took off as a consumer phenomenon. It seemed that people were just deciding to use e-cigarettes.
And as a research community, we really didn't know much about them. And coming from this background in substance misuse,
I immediately saw there's huge potential for e-cigarettes to be a harm reduction tool to help people stop smoking.
And then linking in with the the idea of relapse prevention,
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.
Quit from smoking in the long term is an attractive substitution, if you like, for tobacco.
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.
And I'm starting to think about it coming into play on smoking.
So you clearly have a really impressive track record and tobacco addiction and
cigarette research and those two particular areas which you've now touched upon.
I'd like to delve into a bit more today, if we can.
The first of those is, is your interest in relapse prevention, and the second is your interest in some more vulnerable populations.
So to start with, can you tell us a bit more about relapse prevention?
So what does that mean in the context of smoking? Says part of my post-doctoral fellowship.
I explored the reasons for relapsing to smoking amongst pregnant and postpartum women and being a social scientist.
I was really interested in that kind of whole range of reasons that women might relapse back to smoking really,
as well as the sort of physical addiction to nicotine through smoking,
that it was clear that as a strong psychological dependence to smoking a very strong social element.
Of course, most women learnt to smoke as part of a kind of social exchange and being part of a group of smokers,
incredibly important to many people, very strong cultural links.
So for people born in a. Culture where it's the norm to continue to smoke,
it's incredibly difficult to move away from and particular interest of mine is the idea of social identity.
So for women who quit smoking during pregnancy, often the tobacco smoking has been a core part of their identity as a young woman.
And for many women,
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.
Obviously, many young women sort of struggled to become a mum and to kind of take on that new identity as a mother.
And for some, going back to smoking was kind of something for themselves, if you like.
So they're really important kind of social,
psychological dimensions that seem to be really important in terms of relapses are a complex psychosocial phenomenon.
But really, interestingly,
at the time before e-cigarettes and smoking cessation treatment seemed to me to focus just on one aspect of tobacco addiction.
So nicotine replacement therapy, for example, focussed on their physical dependence to nicotine,
but didn't really help people with their social and psychological aspects of the addiction.
And behavioural support was really helpful for many people trying to quit smoking,
but focus particularly on the psychological aspects of tobacco addiction without really addressing the kind of social and cultural aspects.
So no treatment for helping people quit smoking seemed to attend to all the dimensions
of tobacco addiction that really made it such a difficult addiction to overcome.
And, of course, relapse is incredibly common.
So the average smoker we knew tended to try to quit smoking around seven times before they actually succeeded.
Clearly, there's a lot going on in relapse and a lot of kind of a multi-dimensional need for support.
And so I guess seeing relapses are kind of relapsing.
Remitting condition that needed ongoing support was the kind of angle that I started to come from when exploring the phenomenon.
Particularly for women, as I said, kind of relapsing back to smoking seemed to be about regaining a sense of
themselves that perhaps they had lost during pregnancy when they'd quit smoking.
So when e-cigarettes came along, it seemed that they were an exciting kind of alternative,
a way that people might kind of deal with all the aspects of tobacco addiction that previous treatments hadn't been out to address.
So, of course, e-cigarettes mostly contain nicotine to deal with any physical addiction,
but also it seemed that they had a psychological element to it.
You know, people could use them in a habitual way, just as they previously perhaps might have used to tobacco,
and they could substitute the hand to mouth action of smoking that perhaps they'd become very dependent on.
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.
E-cigarettes seemed to perhaps offer an alternative identity that people could switch to.
So, you know, becoming a vapour instead of seeing themselves as a smoker.
And also something really important, I think that's often missed in the medical literature when we're talking about treatments for smoking cessation,
is that people seem to really enjoy using e-cigarettes. There was a pleasurable aspect to them in their own right.
So for the first time, perhaps there was a treatment available for smoking cessation that people might actually not find difficult or painful.
They might actually enjoy vaping in its own right. And this really led me to think that, you know,
something that's pleasurable but also helps people overcome their tobacco addiction could mean that they could be supported to actually
stay quit from smoking in the long term because the pleasurable alternative might be something that they want to carry on using.
Thank you for talking to a relapse prevention. And I think that point you made about e-cigarettes being a relatively exciting
development in the field because of their pretty unique ability to touch on behavioural,
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.
But what I also wanted to touch on is that I know that in 2019 you were involved in a systematic review
looking at the use of e-cigarettes for smoking cessation or reduction in vulnerable populations.
So I was hoping you might be able to tarsal a little bit more about that review
and what you found and and also how how do we define vulnerable populations?
Why are we interested in these specific groups?
In what way do we think maybe interventions will be different in those groups than they might be another populations?
So, yeah, in the review, your you mentioned was led by a friend and colleague of mine, Dr Sara Gentry,
who published in Nicotine in Tobacco Research asking whether e-cigarettes might be
an effective aid for smoking cessation or reduction amongst vulnerable populations.
So first off, defining vulnerability. Obviously, it's incredibly complex to define what we mean by a vulnerable group.
And we have to be really careful not to stigmatise groups that might already already be very marginalised.
So for this review in particular, we focussed on green groups experiencing multiple disadvantage and health inequity.
So groups such as those who might be misusing other substances,
those with serious mental illness groups experiencing homelessness or involved with the clinic,
the criminal justice system, and all of these groups were particularly vulnerable to smoking related harm.
So amongst all of those groups, prevalence of smoking remains over 70 percent of those populations incredibly high,
obviously, compared to that major smoking now in the general population, which is currently just less than 15 percent.
So we were really, really interested in focussing on these groups because despite the challenges in their lives,
we know that smoking tobacco, that's most likely to cause these groups severe disease and ultimately premature death.
So the findings of that review. Well, it was a mixed methods review because the literature in the field is extremely varied.
There were there was a lack of files looking specifically at vulnerable populations.
So we didn't have studies that we were able to combine in our meta analysis like we might do with the Cochrane Review.
We included nine studies in total. Five from the US, none actually undertaken in the UK.
Five of the studies were quantitative studies. As I said, no trials.
And for qualitative studies. So a primary outcome was focussed on smoking cessation.
The way in which smoking cessation was measured in these studies really varied.
Often not biochemically validated, and the outcome was collected anywhere between four weeks and 18 months.
Follow up so you can see very for rate and the cessation outcome then varied
between nought percent and fourteen point three percent for these populations.
Severely importantly, across the studies, we didn't find any adverse events, particularly being reported,
which is obviously an exciting finding when you look at a cessation intervention and the qualitative studies,
a qualitative findings, I guess, were really what was very interesting with this review.
We were interested in what the barriers and facilitators to switching to e-cigarettes or other cessation methods might be for these populations.
And we found some very specific barriers.
And facilitators say, for example, being able to access supplies for these populations could be very difficult.
Affordability of products was something that was a big barrier to use.
But we did find some facilitators, for example, acceptance of our harm reduction approach.
So seemed to be an increased acceptance of switching to reduced harm product and also seeing
vaping e-cigarettes as a more socially acceptable than perhaps other groups might have seen them.
And then really interestingly, across the studies as a whole, we did find us statistically significant level of smoking reduction.
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.
And quite positively, we saw that as perhaps being on a pathway towards eventual cessation.
But obviously, due to the low quality of included studies, we were unable to really assess the effectiveness of e-cigarettes for vulnerable groups.
Although evidence from one moderate quality study did show that e-cigarettes might be at least as effective as nicotine replacement studies.
And as I said, the thematic synthesis, the qualitative synthesis that we undertook showed that e-cigarettes really did have a
potential to attend to the whole range of aspects of smoking addiction for vulnerable groups.
So they might be a pleasurable alternative to tobacco smoking. They might promote social connectedness that might be important for these groups.
But really importantly, we found that vulnerable populations particularly were in need of additional support to access these alternatives to smoking,
to help them to become more more affordable and to support them to maintain ongoing use.
So that's something I think we find across e-cigarettes.
Research, particularly in the qualitative literature, is that people need support not just to switch in the short term,
but to troubleshoot problems that they might have along the way,
say that they are able to maintain that switch and not relapse back to tobacco making grey.
And I think, you know, that reviews conducted back in 2019 and it's been interesting,
encouraging it since we've started doing the living review process.
But now that we're doing our monthly searches, we're finding a lot more studies targeted to these more vulnerable populations.
And I think that's a pretty good encouraging because often traditionally in research,
those are actually the groups who who don't get looked at and don't get involved in studies.
And certainly in the case of smoking, as we know from those statistics, which are actually quite shocking,
those disparities in years, these are the groups where we're actually we should be doing most of our research, probably.
So finally, just touched on on what you were talking about a little bit last.
So why we do our Cockram of year? Most of the work I do tends to focus on quantitative outcomes.
So the numbers side of things. But clearly there's a lot that we can also learn from qualitative research in this field.
And I was wondering if you could. Tell us a little bit about what we've learnt, I suppose,
from qualitative research about e-cigarettes that we'd really be missing if we're only
looking at the quantitative data and how we might be able to better take both into account,
I suppose, when thinking about policies and treatments moving forward. Yeah, I think so.
I think that's a really important question.
I mean, starting out as a primarily qualitative research show, I could never have imagined actually becoming involved in a Cochrane review.
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.
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.
So when we were asking questions about how people might use in e-cigarettes,
why they might ease any cigarette or in what ways we might support sustained switching,
we need experiential data gathered through interviews, observations, focus groups and preferably longitudinally,
say, following people over time, obviously for effectiveness questions which are incredibly important.
We need to quantify the outcomes to look at adverse events.
We need cohort studies, measuring events and exposures.
How many trials, of course, to test one treatment against another or against a controlled group.
So it's really,
really important to triangulate the different types of evidence in order that we can converge on a consensus view to influence policy in practise.
I mean, it's really interesting to think about how much mixed methods evidence is enough.
I think certainly in the UK with the Public Health England report and through the work that the Cochrane Group is doing,
we're now in a position perhaps to say we have enough evidence that e-cigarettes can
be considered a useful cessation and possibly a useful relapse prevention tool.
But obviously, internationally, there still different viewpoints on that.
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?
I think one of the interesting things, I suppose in all areas to some extent, but particularly in e-cigarettes,
I think one of the things that can be very, very powerful are actually just stories.
Right. Particularly when you're when you're sitting around a policymaking table or are thinking about clinical decisions.
Those stories, as they might relate to young people and cigarette use can be really striking.
It can be really emotive and give us an insight that we might not have from the data.
And similarly, I think those stories about people using e-cigarettes for smoking cessation can also be really informative.
But we don't we don't hear about them as much. So. I think that's one thing that I.
I like seeing from the qualitative data sometimes, too, is just the voices of people who have tried using e-cigarettes to quit smoking.
And the challenges that they've faced along the way, which can help us design better interventions and better policy.
We hope so. Last question for you is just following on from the research we've discussed today.
What research do you think could be done next if someone gave you tons of money as Caitlin designed any study you want?
What would you like to do? Well, that's a big question.
I mean, although smoking prevalence at a population level, you know, it has decreased year on year.
And as I said, in the U.K., we're around about 15 percent now.
The population can continue to smoke. Prevalence does remain much, much higher in some populations.
And I think that's really clearly where we need to focus our intervention efforts now.
So we need to assess the effectiveness of interventions targeted at those vulnerable groups who are the most
likely to experience multiple health inequalities and be the groups that are likely to be continuing to smoke.
So I guess my my top three would be to develop and test interventions with those vulnerable populations,
particularly with those experiencing homelessness or substance misuse, those not motivated to quit smoking.
And, of course, pregnant women who are extremely vulnerable, both in terms of their own health,
but also the health of their developing child and the children in the family.
Secondly, to develop and test relapse prevention interventions. Obviously, this is, you know, my programme of work.
But really importantly, I think we have ignored relapse over the years in tobacco control research.
We've focussed a lot of effort on helping people to quit smoking.
We've got great support for smoking cessation in terms of pharmacological and behavioural support.
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.
And I really think that's where we need to target interventions next and develop guidance
for health professionals around what they can best be doing to support relapse prevention.
And then finally, I think we need implementation research.
So we do have good evidence now on the effectiveness of e-cigarettes for smoking cessation.
But what we need to do is ensure that e-cigarettes as an effective intervention can be used within routine care.
So we need to educate our health care professionals. We need to educate the public about the reduced risk of using an e-cigarettes.
There's still huge public misperception about harms of nicotine that needs addressing.
And really importantly, I think we need to focus efforts on working with assets that already exist within communities,
say, particularly thinking about vulnerable populations, working with support groups,
perhaps with vape shops that are available on the High Street,
really using those resources that people tap into in their everyday lives and reach out to those
groups who aren't accessing support for smoking cessation via kind of their medical means,
perhaps. Great. Well, thank you so much.
Yeah.
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.
Which, of course, are also really important.
That was a really great interview, Jamie, and something I found particularly interesting, having a background in psychology myself.
Is that idea of smoking perhaps being part of somebody's social identity?
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.
And that also kind of leads nicely onto the idea of these different dimensions of tobacco addiction.
So there's different elements such as that biological addiction to nicotine.
But obviously there's also important factors involved in in the psychological aspects.
So people's relationship with other people who who smoke perhaps or worries even about the
health of people around them when they're smoking or play into people's smoking behaviour.
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.
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.
Or in a successful tool to help people quit smoking?
We really just looking at the numbers, doesn't tell the whole picture.
And that's why it's so important to hear about people's experiences through research like that.
Caitlin does. And kind of time that into a review. That's one of the reasons why in our review we have some studies.
Obviously, most of them look at e-cigarettes with nicotine,
but some of them actually look at e-cigarettes without nicotine as an intervention in and of themselves,
because though they're not addressing that pharmacological aspect of addiction, they are there to help address those behavioural,
social and psychological cues that so many people struggle with when they're trying to quit smoking.
So that's it from us this month. Please subscribe on iTunes or Spotify. And stay tuned for our next episode.
But some mention the findings we have can tell us what happened, Loung.
It's safer than smoking. We may still buying cars. Thank you to Jonathan Livingston.
Thanks for running searches to Elsa Butler for producing this podcast. And to all of you for tuning in.
Music is written with Johnny Berliner and I and performed by Johnny are live in systematic reviews supported by funding from Cancer Research UK.
The Cochrane Tobacco Addiction Group also receives core infrastructure funding from the National Institutes for Health Research.
The views expressed in this podcast are those of Nicola and I and do not represent those of the funders.