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If asking your mate down the pub about Theepan is what they probably say, no one agrees if it's safe or not, 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 give you a different advice. Hi, I'm Nicole Allinson.

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And I'm Jamie Harmon. 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 research 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 we start by going through the studies.

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We have found that one and then go into more detail about a particular study or topic related to e-cigarettes.

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This month we carried out our searches on the first of July 2021 and we identified two papers that are

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linked to studies already included in the review and two new included studies that Nicola will now cover.

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In a nutshell, the first new study is reported in a paper by Catherine Kimber and colleagues at South Bank University in the UK.

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It's a randomised study with two weeks follow up comparing psychologic and tank models of e-cigarettes with different nicotine concentrations.

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And the outcomes of interest for our review were change in carbon monoxide levels and adverse effects.

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The authors found that carbon monoxide decreased in all groups, but for both carbon monoxide and adverse events,

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there were no statistically significant between group differences.

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A second news study was by Katmai Smith and colleagues at Queen Mary, University of London,

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also in the U.K. It was a randomised controlled trial comparing e-cigarettes with nicotine

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replacement as a harm reduction intervention in people who smoked and found quitting difficult.

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You'll hear more about this study and its results in this month's deep dive.

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This month, Dr. Mark Smith and I couldn't find a time that suited us both, so I sat through some questions and she kindly recorded her answers.

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First, I asked her to tell us a bit about herself and how she got into E cigarette research.

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Hello, my name is Dr. Katmai Smith and I'm a senior research fellow at Queen Mary University of London.

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I've worked for the Health and Lifestyle Research Unit for the past 17 years.

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And when I first began, we were doing a lot of research studies into Varenicline, which was a new medication being used to treat smokers at the time.

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I was also involved in clinical work treating patients at the local hospital trust,

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supporting pregnant smokers, as well as the general public accessing our community.

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Stop smoking service. Our clinic is the ideal setup for a researcher as having the experience of engaging with smokers and seeing the things we do in

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research in real life really gives a good perspective on what the reality will work and what will help engage participants.

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Over the last 10 years. Our focus has turned to e-cigarettes.

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We noticed in clinic more and more smokers were telling us they were using them to help them to stop

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smoking and often went off the medication and not helped previously and finding really useful.

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Since then, we've done several studies, including the first randomised controlled trial,

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which is published in 2019 in the New England Journal of Medicine,

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which was to compare e-cigarettes versus nicotine replacement therapy study found that one year follow the quit rates with

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doubled in the participants assigned to e-cigarettes and showed the clinical relevance e-cigarettes have as a stop smoking aid.

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Next, I ask you to tell us a bit about why they chose to use the group they did.

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People who had tried to stop smoking before and hadn't been able to do so using kind of traditional quitting AIDS.

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Currently, there is a gap in stocks making service policy and how best to help smokers

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who have failed in previous quit attempts using conventional cessation aids.

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From what we know, almost 80 percent of smokers who access treatment will still be smoking one year later.

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This is not for want of trying a desire to stop smoking.

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And at the time of applying for this grant, there was very little research being done with e-cigarettes in a treatment context.

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But there were strong reason to believe e-cigarettes may have potential to help highly

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dependent smokers who had failed to with conventional cessation aids in the past.

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So I think what Katie touches on there is really important. We know that there are lots of things that can boost people's chances of quitting,

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like nicotine replacement therapy, varenicline and all sorts of behavioural support.

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But we also know they don't work for everyone. And that's why when e-cigarettes first came to the market,

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there was some enthusiasm that this might be an opportunity for a new treatment option for people to help them quit,

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particularly if they tried to quit previously and been unsuccessful.

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So I then went on and asked Katie about how she ran this new study.

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We recruited a hundred and thirty five participants in total and they recruited from my clinic

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as we were able to target those who had not been successful with those in previous attempts.

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And we also use social media to advertise the city participants were included, if they were over 18 years of age,

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had a history of unsuccessful quitting with a stop smoking medication,

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and had no preference to use or not to use either nicotine replacement therapy or any cigarette.

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We excluded participants who were pregnant or currently using any cigarette or stop smoking medications.

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Interested participants were invited to a baseline visit where eligibility was confirmed by our research team and informed consent was collected.

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Participants were then randomised to either to receive an e-cigarettes or nicotine replacement therapy and instructed on how to obtain their products.

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So for the Naziism at the baseline visit,

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participants selected an innovative products or product combination from all available nicotine replacement therapies such as nicotine patch,

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chewing gum, nasal spray, mouth spray. And they were provided as per our standard practise on a letter of recommendation which allows

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them to go to the local pharmacy to get a two week supply of the medication of choice.

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Participants paid a prescription charge of eight 60 unless they were exempt and letters of

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recommendation were provided for up to eight weeks as per standard practise at the time.

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Participants either picked up from the clinic their letter of recommendation,

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or they were posted to the participants directly and participants were free to switch to a different NRT product if required in the cigarette arm.

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At the baseline visit, participants were shown three different refillable Essig products.

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They were indicating to see the smoke and the tech mini with variable voltage and explain the principles of their use by the research team.

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They were instructed to obtain one of these if they liked them or could choose another product of their choice,

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together with initial samples of liquid with a strengthened flavour of their choice,

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either via a voucher for up to 40 pounds,

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a local vape shop that had agreed to provide the service or via the suppliers and claim a refund against their receipt of up to 40 pounds.

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Participants then paid for further supplies themselves or e-cigarettes, liquid and any parts were paid for by the participant.

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They were then encouraged to try liquids of different strength and flavours if their initial purchase did not meet their needs.

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Those wishing to stop smoking altogether were asked to set a target quit date around the time of the second visit to the clinic.

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Typically a week later, participants were then asked to bring their products along to the second visit to confirm that they

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obtained the products to try the product in front of the research team and to rate their experience.

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They were then asked to start using the products.

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Only after this visit, participants received brief instructions on product use and were advised to use their products,

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which is possible instead of smoking. Those opting for smoking cessation also received the standard advice on coping with urges to smoke.

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Participants also signed a commitment form.

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This was to say that they would only use their allocated product for the first four weeks and after that they were free to do as they pleased.

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Participants receive phone calls one and four weeks later to monitor product use and smoking status and to provide brief support.

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And this this was provided by our experienced smoking advisors as part of our research team.

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At four weeks and six months, participants who reported stopping smoking or reducing cigarette consumption by at least

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50 percent compared to baseline were invited to provide a carbon monoxide reading.

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Participants receive Tempa for their time and travel at both of these extra visits.

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And now for the exciting. But I then asked Katie what they found.

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Our study found that validated smoking reduction, which included also people who completely stopped smoking,

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was achieved by twenty six point five percent in their cigarette arm and six percent in their nicotine replacement therapy.

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Obscure science term definition. In the context of smoking cessation studies,

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we use validation to check the when people say they have reduced their smoking or have quit, that this is truly the case.

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This is because people may not want to tell the researcher that they have returned to smoking.

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We do that by taking a biological measure of the waste products of smoking.

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In this case, the researchers measured carbon monoxide in participants, exhaled breath to see if this had reduced it.

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Follow up in comparison to the amount exhaled at the start of the study when they were smoking as normal.

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Our study was powered on seeing a reduction in smoking is the main finding.

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However, even with a hundred and thirty five participants we were able to see sustained,

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validated absence raises six months, which were nineteen point one percent versus three percent.

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And this was in a population you could reduce rather than quit if they preferred, although not unexpected.

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As we know, e-cigarettes have potential to work this way. It's a surprise that rates between the two hours were so significant.

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I think it really does go to show that giving a smoker the right tools has a

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significant impact on the success of quit attempts and from the results of this study,

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even without standard intensive support. Well, those quit rates are Eye-Opening.

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Although the study was originally designed to look at how many people reduce smoking,

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it's impressive that such a clear difference in quitting emerged.

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As I see it, I think one of the strengths of this study is the fact that they allowed people to either attempt to reduce or quit,

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which probably reflects the mixture of approaches people take when they use e-cigarettes without support.

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I think that's a great point, because one of the interesting things about the study,

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and I actually did ask Katie to talk a bit more about why they decided to look at reduction in the first place as discussed,

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our focus was on how we bridge the gap for smokers and able to quit with the current best treatments and.

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Whether they could benefit from approaches that often offer a means to reduce the harm from smoking without ceasing nicotine use,

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that idea is not new. And nicotine replacement therapy has been licenced for a cut down to quit approached for over 10 years.

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And several studies have reported that such issues can facilitate a significant reduction in smoke intake,

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as well as quitting smoking altogether at a later date. The approach, however, can be costly, as medication may be used for a longer.

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The quit rate it generates are often low and usually are only achieved with regular and intensive behavioural support and monitoring,

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which is why this approach is seldom used in practise harm reduction approach.

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For many years.

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The only next step, and we know when using any cigarette that this is a 95 percent reduction in harmful toxins compared with continue spiking.

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So it's very likely that there will be a health benefit.

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But looking into this is very complex and you have to control the smoke has increased risks of many diseases due to that previous smoking.

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And many of the things that are smoking may have developed, may not emerge until later in life, sometimes when they've even stopped smoking.

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So if we were to look at health benefits in a group of smokers,

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it's important we compare like for like ice smokers with or without e-cigarettes and have a similar smoking period before quitting.

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We're currently doing some long term research into this topic now, and it's really a really important area that needs further research to help

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fully understand the role of e-cigarettes and cessation and harm reduction.

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While I find that fascinating and can't wait to see that research. So next, I ask Katie just to talk a bit more about her experiences,

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the support that people might need to quit if they're quitting with e-cigarettes compared to if they're quitting nicotine replacement therapy,

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because this is something they discussed briefly in their paper.

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Our experience in clinic is that for NRT, participants need clear guidance and support on how to use their products,

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but also to understand other aspects of use, such as taste, talking about side effects and strategies for how and when to use the product.

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E-cigarettes seem to deliver quickly what a smoker desires, both in terms of nicotine and sensorimotor aspects of smoking.

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The VAP, the hit, the flavour,

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all of these things kind of combined and seem to work a lot better with e-cigarettes compared with nicotine replacement in practise.

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And so this seems to mean participants can pick it up and go with it quite easily, changing products,

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using different e-cigarettes, using different eclectically liquids, and they use them when needed without giving them up.

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They don't just suddenly stop and and pause. They they look and search and kind of actively keep using the products.

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This is not usually the case.

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They're not if they don't like it quite often, they will stop it and then it will wait to seek advice before starting something else.

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And possibly that is also down to the fact that NRT is not as easy and it can be very expensive to purchase over the counter.

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And so there's other factors that play a part with NRT.

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But for those reasons, we wanted to explore more the role of this minimal support and goal when using e-cigarettes,

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which is what the study was set up to do. So finally, I asked Katie what research she thinks should be done next.

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We already mentioned the importance of harm reduction and its impact on smokers, which I think is the priority area for many in in our field.

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The other focus to our research now is looking into e-cigarettes with and without support.

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We know, although there are fantastic services in the UK to support smokers, however,

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we know that only a small percentage of smokers actually access them when they want to quit.

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Understanding the role of support with e-cigarettes is imperative to supporting Future Critter's.

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It may be the case of simply handing someone in e-cigarettes started back in hospital may be enough to stop attempts or like NRT,

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we may need to factor in intensive supports, help smokers quit. We wait and see what future research shows.

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Is really interesting to hear about another great study from the group Queen Mary comparing e-cigarettes to NRT.

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This is a key comparison for us as an art to the current standard treatment for smoking cessation that is routinely provided.

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It's most interesting for us to be able to see how e-cigarettes compare to this,

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and this study will have more participants to that analysis in our review, which is great.

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Yeah, I always get very excited when we have another study that we can add to one of our main analyses.

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So we're looking forward to doing that in a subsequent update.

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And with that, that's it for us this month.

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We're taking a break next month because our kids are off school and we're going to spend some time off work, but we will be back in September.

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Thanks so much for listening and massive thanks once again to Dr Meyer Smith for taking the time to share her thoughts on her study.

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Please subscribe on iTunes or Spotify and stay tuned for our next episode.

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This may help your community in.

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To mention the Fineman's we have can tell us what happened long time.

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Even the. Vaping is safer than smoking weed may still cause for concern.

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I'm thinking of switching to Ben, doing this for.

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Thank you to Jonathan Livingston Banks 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 Berlinale 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.