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If basking young mate down the pub about FAPE in hands, what they probably say, no one agrees.

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If it's safe on 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'd give you a different by. Hi, undeclared Linson, and I'm Jamie Herman Boyce.

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Welcome to February's edition of Let's Talk E-cigarettes.

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For those of you who haven't tuned in before, 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 process is called a living systematic review.

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In each podcast episode, we start by going through the studies we found that month and then go into more detail about one of these.

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

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In a nutshell, so January was obviously a quiet month for the publication of e-cigarettes research.

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We didn't find any studies that we weren't already aware of. However, we did find one paper linked to a study already included in our Cochrane Review.

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And we were provided with new data from one of the studies that we had previously listed as ongoing.

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This study is the massive study led by Dr Actioner Bag from the University of Oxford and looks at

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providing e-cigarettes to people with chronic illness who are not motivated to quit in primary care.

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Next stop, Jamie speaks to Actioner about her study in this month's Deep Dive.

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So I am here with Rotch now, which is brilliant. I'm under my blanket once again, feeling very silly.

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So to start off Bruch now, could you tell us a bit about yourself and what got you into doing research on e-cigarettes?

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So I'm a psychologist by background and currently a university research lecturer in the Primary Care Health Sciences Department at Oxford University.

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And it was my first job about 14 years ago now that led me into research and smoking cessation before e-cigarettes were even on the scene.

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And the project that I worked on was a community outreach intervention that was

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designed to promote the stocks making services to Bangladeshi impact Sony men.

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Given the high prevalence in these populations, and that was my first experience of working on a randomised control trial.

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And from then on, I started developing and working on clinical trials of my own with a keen interest in addictions,

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making sation and behaviour change research.

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But it was back in 2015 when e-cigarettes research was starting to gain traction and there was a lot of interest in them,

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but not many clinical trials that I started to think about what could be done in primary care.

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So fortunately for me, I'm based in the same department as the Cochrane Tobacco Addiction Group,

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and I had the opportunity to work on the first systematic review update on e-cigarettes, which helped me think about my research.

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I think that's rather fortunate for us, too, because you have been a major asset to our systematic review team.

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So you're here to tell us about your new study, which I know the results aren't published yet.

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So it's all preliminary, but we are very excited because we've had this study listed as an ongoing study in our review.

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So can you tell us a little bit about how you set it up, how it was designed and what you what you tried to find out?

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Sure. So this study is called the Mask Trial, which is an acronym for Management of Smoking and Primary Care.

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And it was a randomised controlled trial funded by the National Institute for Health Research, which looked at the feasibility,

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acceptability and effectiveness of doctors and nurses offering brief advice about e-cigarettes

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and any cigarette starter pack to hardcore smokers with smoking related chronic disease.

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And we were interested in seeing if people were willing to try and a grant to reduce their smoking and eventually quits.

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And we recruited 325 people from general practises in the UK and we had practises invite patients to the study and people were told that the study

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involved looking at the practitioner and how they talk to them about their smoking and that they may be offered some form of help and advice.

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So we purposefully recruited smokers who weren't interested in quitting anytime soon so that they could look at whether e-cigarettes could be

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used as a harm reduction approach and before delivering the intervention or jeepneys in this is hard to complete our online training programme,

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which lasted around 45 minutes, and we carried out a lot of user testing before rolling it out.

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And the training covered things like how to deliver advice and motivate patients to take up the offer of any cigarettes.

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And they're encouraged to describe the offer positively.

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Stablish evidence based e-cigarettes emphasise switching from smoking and answer the patient's health concerns about vaping.

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And so participants who are interested in taking part had a baseline visit at the practise to cheque for eligibility.

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And then they were booked in for an annual review appointment with their GP or nurse.

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Now, people with chronic diseases in the UK have a routine appointment with their doctor

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or nurse to review their medications and their condition at least once every year.

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And the topic of smoking is often brought up for those that smoke.

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And it was at this consultation where the practitioner offered stunned care, smoking cessation, advice, support to all participants.

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And standard care does vary across practises, but it typically involves the GP or the nurse asking the patient about their smoking status.

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Advising on the best way to quit and then offering a referral to the local stops, making services or procedure or a prescription for pharmacotherapy.

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The patient was randomised by the GP or nurse only if the patient rejected the offer of standard care.

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And so half of the patients recruited in the trial were allocated to a control group

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who received nothing beyond standard care advice that they had already been given.

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And the other half of patients were given brief advice about e-cigarettes,

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which included an emphasis on the benefits of switching and reducing the amount of cigarettes they smoked,

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together with an offer of a free e-cigarettes starter pack,

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which contained three different liquids to start them off of two different nicotine strengths.

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A patient support booklet that we developed for the study,

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which showed them how to use that e-cigarettes and had a list of vape shops where they could purchase refills and parts and so on.

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So they took away their kit and resources in a nice tote bag, which they received.

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And they had a telephone call from someone who was trained and experienced and vaping within the first week of taking away that e-cigarettes.

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And they were on hand to provide support on any technical aspects of the East,

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e-cigarettes and participants had the opportunity to cool the experience vapour for up to two months afterwards.

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Awesome. So, Rachna, what are the things that really strikes me about your study?

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There's so many unique things about it, but I think you're focussed on what's considered a commonly a really hard to reach group.

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So it's people with smoking related illnesses and it's people who turn down standard care as well.

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So they don't want to go. They don't want to be referred to standard smoking cessation Carol.

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I saw some men on Twitter the other day that was like when we talk about hard to reach groups,

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we're actually talking about easy to ignore groups, which I thought was a really interesting way to put it.

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So if you could just tell me a little bit more why this group.

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Right there must have been easier groups to test your intervention in. Why did you go for this group of people?

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Yeah. I mean, smokers with chronic diseases often continue to smoke despite advice to stop from their doctor.

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And, you know, for example, nearly one in five people with heart disease smoke at the point of when they're told that they have heart disease.

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And then more than half of those continue to smoke for at least a year after, despite being given advice to stop by their practitioner.

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And for people with existing conditions, continuing to smoke worsens their health.

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But we know that stopping smoking can improve it. So there are a really important group for a candidate for stopping smoking.

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But they've often tried and failed to stop through traditional methods.

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And e-cigarettes offer obviously offer an alternative method for that.

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And there's evidence that people have been able to stop smoking unintentionally where they wouldn't have done so.

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I'm from trying any cigarette. So it seemed intuitive to offer this to smokers with chronic diseases.

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Fantastic. And can you tell us a little bit more so I know some of our listeners will be from England

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and know exactly what we mean when we talk about seeing the GP and a primary care setting.

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But for insula international listeners, what does that mean?

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Does everyone see a GP in England? How does primary care work?

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What usually happens around smoking? I know you spoke about this a little bit at the beginning.

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And I suppose also, does anything go on with e-cigarettes and primary care?

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Normally at the moment, as is e-cigarettes, I mean, jeepneys are talking to patients about,

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say, primary care is the first points of care for health care advice or treatment in the UK.

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And it can cover general practises, pharmacies or dental practises.

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And and I mentioned that people with smoking related illness,

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they see their GP or nurse at least once a year for an annual review of their chronic condition.

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And the practises are, in fact,

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encouraged through a pay for performance scheme known as the Quality and Outcomes Framework to provide quality care for people with chronic illnesses.

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And so cheapies are incentivised for recording key indicators,

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including the proportion of people that they advise and refer to the stocks making services.

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So an annual review consultation.

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There's a prompt on the GP computer screen to talk about smoking in terms of whether jeepneys in England suggest people try e-cigarettes.

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They're currently unable to prescribe e-cigarettes as there is no medically licenced e-cigarettes currently available in the UK.

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But many UK health authorities, including Public Health England and the Royal College of General Practitioners,

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they've all said the GP should offer advice to smokers about e-cigarettes as a means for stopping smoking.

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But we found from our qualitative work and the work of others that many are

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confused about what information to provide and that they want more training.

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But that completely makes sense.

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So I suppose the moment we've all been waiting for and obviously with all the caveats around the fact this hasn't been peer reviewed yet,

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for the most part. So these are preliminary findings. But can you tell us what you found?

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And I suppose what you think the most interesting or most surprising things are about the findings from your study?

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We were able to follow up 96 percent of participants at two months and 90 percent of participants eight months.

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That's amazing. First of all, that is not what you usually see in smoking cessation research.

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So well done. It was a surprise to us. One of our objectives was to look at smokers uptake in use of e-cigarettes.

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And we found that 90 percent of people accepted the offer of an exit ramp from their GP or mass, with only 16 people rejecting the offer.

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And we found that 68 son was still using that cigarette daily or at least weekly at.

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Two months and also two months,

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we found that those who were offered an a cigarette in the intervention group were three times more likely

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to reduce their smoking by at least half the amount that they smoked compared with a control group.

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So this was around 20 percent in the intervention grade compared to six percent in the control.

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There was no difference between groups and smoking reduction at eight months with

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five percent versus two percent in the intervention group compared to the control,

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only few participants stopped smoking at two months.

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With more people achieving abstinence in the intervention group with two verses, one son in the control.

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But the numbers were too small for overall for any difference between groups.

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And this was similar.

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At eight months, with four percent stopping smoking in the intervention and two percent in the control in terms of acceptability.

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Eighty nine percent of people in the intervention group found the advice given by their GP or nurse appropriate, and 85 percent found it helpful.

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And so we found overall that a practitioner led brief intervention was both feasible and acceptable to deliver in primary care,

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and uptake of the offer of any cigarette was high amongst smokers who were initially unwilling to try.

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Other cessation treatments. And I think that's the most surprising results.

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That 90 percent of people who had initially refused standard smoking cessation support

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were willing to try an alternative approach and take up the offer of any cigarette.

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I think this demonstrates that people need choices and that they are open to trying new approaches when it is offered to them.

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Amazing. I mean, that is so interesting to hear about.

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And I think really, I don't know reflects how important it is to be able to offer these things.

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And I know that that in other countries there are so many different regulations that might mean

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physicians are not talking to their patients about other ways to potentially transition off of smoking.

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And I think, you know, we know that most people who successfully quit have had to try lots of different methods before getting there.

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Some people do quit the first time they try. But that is the minority.

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And I just I really hope I suppose as a field, both in research and practise, we keep exploring ways,

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ways to reach out to people who have, you know, who aren't keen to engage in in traditional treatments.

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Probably a lot of the time because they haven't worked for them previously.

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So I think that gives us a lot of, I suppose, food for thought about next steps and what what kind of.

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If it was up to you, what research would you like to be seeing done fall this study and what do you think the best next steps would be?

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So we found that Apsley rates of abstinence were low.

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And so a larger trial is needed to determine whether this approach can, in fact, lead to more people quitting in the long term.

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Our qualitative research that we conducted alongside the trial was particularly

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interesting where we interviewed practitioners and patients from the trial.

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And although the training for practitioners covered concepts like harm reduction,

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many of the tepees and nurses struggled to engage with harm reduction and were more

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comfortable and familiar with recommending e-cigarettes as a short term step to quitting.

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Doctors tend to rely on this concept of do no harm when it comes to treating

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patients and say harm reduction is something that's that jars with this idea.

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And so I think there's definitely opportunities there for further training of practitioners,

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both and in terms of harm reduction and in terms of e-cigarettes, because we found that even with evidence, training, awareness of, you know,

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official sanctions from public health bodies to advise patients on using e-cigarettes offerings,

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making that many were still reluctant to recommend e-cigarettes and most maintains, like previously held views about ethics in safety.

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It's really interesting.

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I think that thing with low absolute numbers is so then we see across loads of smoking cessation research where we know that we would be dubious.

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I probably wouldn't trust the data if I was looking at a smoking cessation study and the majority of people quit smoking.

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I think how are they measuring smoking cessation here? And I think the thing I always try and think about when we convey those results,

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that absolutely more research is needed to see if the difference between groups was present or not.

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But even if you're doubling quit rates from, let's say, two to four percent, if that's a real doubling,

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if you had one hundred people and two to further people quit because they were given me cigarette,

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you might be saving one life through that, which is is incredibly important.

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We think about her harmful smoking is and how meaningful it is to quit.

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So that is excellent. I really love your qualitative work on this, too.

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And so I'm looking forward to not only seeing the quantitative numbers published, but also looking more into the qualitative work.

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One final question for you. Is that another thing that I think is kind of unique about your study?

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Was this almost I don't know what you'd call it. I'm going to call it a buddy system, but you might disagree.

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Having people on hand who'd used e-cigarettes before to support people who are trying to use them.

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And I wondered if you, I suppose, had any feedback about that,

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either from the participant who was had that support or the people who were getting involved as buddies and how that worked.

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Yet we know that people appreciate is having that initial telephone call from someone who who was experiencing these cigarette use.

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And, you know, often it was the case that, you know,

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some of these patients had never tried in a cigarette before and even though we provided a a beginners start.

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It's patients who tend to be older, who have never used a cigarette, were were less familiar and sort of the technical aspects of of cigarette use.

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And so they they found that having having this kind of this experienced vapour.

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Who who called them up and could offer that advice was was really important.

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And some of them in the interviews had actually said that, you know,

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they would appreciate kind of group support while they're using e-cigarettes in terms of the patients getting in contact with the experienced vapour.

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After the initial call, we didn't find that many people took up that opportunity.

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And and again, I think some of the patients sent that if they had that that face to face support, it might have been different and they might.

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That's so interesting. Yeah. Yeah. And telephonist makes sense.

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Well, thank you so much. Such an interesting study. Great to hear about it.

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Yeah. And as you work with me, I am sure I will have more chats with you about this study in the future, which I look forward to.

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Thanks much. It was really great to hear from Russia.

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And it was a very interesting slant to look at people who weren't interested in quitting at the start of the study.

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The fact that despite that 90 percent of people accepted these cigarettes is pretty eye opening.

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Another of the things that stood out for me is what Russians said about jeepneys.

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Uncertainty about offering e-cigarettes as a treatment and an obvious barrier is the fact that they weren't able to prescribe them.

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Absolutely. And we also know that there are barriers just in terms of how comfortable health care providers are when talking about e-cigarettes,

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let alone recommending them to their patients. So in a survey done by Cancer Research UK, which was published at the end of 2019,

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they found that approximately half of the health care providers surveyed said that if a patient had stopped

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smoking and they'd done that using e-cigarettes and they'd stop smoking for at least three months,

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they'd advise that patient not to use e-cigarettes in the long term. But that kind of makes sense.

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We know that there is lots of uncertainty about long term effects of e-cigarettes,

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but we do have loads of data on nicotine replacement therapy, which is considered both safe and effective.

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However, in the same survey, when asked about nicotine replacement, a similar proportion of health care providers.

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So that's around 50 percent. So they would advise people against using that long term if they'd used it to stop smoking.

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And that actually fits in nicely with a study we recently made aware of in the US.

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The study by Steinberg and colleagues was published last year in the Journal of General Internal Medicine.

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It looked at nicotine risk misperception amongst US physicians, and the majority, approximately 80 percent,

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strongly agreed that nicotine directly contributes to the development of cardiovascular disease, COPD and cancer.

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For the record, this isn't correct. It's tobacco that causes the increased risk of these diseases in people who smoke, not nicotine.

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So we still have worked to be done. And the good news is we intend to keep at it.

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So please subscribe to this podcast on iTunes or Spotify and join us next month for the next instalment of Let's Talk E-cigarettes.

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So that's it from us this month. Thank you so much for listening. And a massive thanks to ratchet up for this interview.

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Smidgens B C, this may help you.

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Yeah. But some mention the findings we have can tell us what whatever happened long term,

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even though we know vape in is safer than smoking, we may still find.

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Thank you to Jonathan Livingston Banks for running searches to Elsa Butler for producing this podcast.

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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.