1 00:00:06,250 --> 00:00:14,500 If basking young lady down the pub about FAPE in hands, what they probably say, no one agrees. 2 00:00:14,500 --> 00:00:19,690 If it's safe on not so, you might as well smoke anyway. 3 00:00:19,690 --> 00:00:26,390 Now, what Jemmy needs is a Cochrane review. All the facts have been checked at least twice. 4 00:00:26,390 --> 00:00:30,040 They find there's a lot that the experts agree on. 5 00:00:30,040 --> 00:00:38,170 I'd give you a. Hi, I'm Nicola Linson. 6 00:00:38,170 --> 00:00:45,280 And I'm Jamie Harmon Boyce. We're both researchers based at the University of Oxford, where we work with the Cochrane Tobacco Addiction Group. 7 00:00:45,280 --> 00:00:53,140 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, 8 00:00:53,140 --> 00:00:57,730 where every month we search the e-cigarettes literature to find new studies. 9 00:00:57,730 --> 00:01:03,730 We then use these studies to update our Cochrane systematic review of e-cigarettes for smoking cessation. 10 00:01:03,730 --> 00:01:08,230 This is called a living systematic review. In each episode of this podcast, 11 00:01:08,230 --> 00:01:17,190 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. 12 00:01:17,190 --> 00:01:24,690 So for our in a nutshell, this month, we ran our searches on the 1st of April. 13 00:01:24,690 --> 00:01:32,100 And we found one paper that was linked to a study already in the review and two new ongoing studies. 14 00:01:32,100 --> 00:01:38,130 However, we didn't find any completely new and completed studies this month at all. 15 00:01:38,130 --> 00:01:45,660 Excitingly, though, this month we publish an update to our review of e-cigarettes for smoking cessation. 16 00:01:45,660 --> 00:01:51,720 And that's what we're going to talk to you about in more detail and also answer some listener questions in our next section. 17 00:01:51,720 --> 00:02:05,010 This month, deep dive. So out at the end of April is an updated version of our Cochrane Review of electronic cigarettes for smoking cessation. 18 00:02:05,010 --> 00:02:11,130 This update includes six new included studies added since our October 2020 version. 19 00:02:11,130 --> 00:02:16,800 And if you've been listening to our podcasts since December, you will have heard about each of these studies and a little bit of detail. 20 00:02:16,800 --> 00:02:26,490 So I'd encourage you to listen to previous episodes if you want to know more about them in terms of how these studies affected our overall review. 21 00:02:26,490 --> 00:02:30,390 There aren't any really major changes when it comes to cessation. 22 00:02:30,390 --> 00:02:36,600 We didn't find evidence that changes our current moderate certainty and our conclusions that nicotine containing e-cigarettes 23 00:02:36,600 --> 00:02:44,190 help more people quit at six months or longer than e-cigarettes without nicotine or than nicotine replacement therapy. 24 00:02:44,190 --> 00:02:50,280 And similarly, didn't find any evidence that changed our conclusions of uncertain evidence 25 00:02:50,280 --> 00:02:54,480 around nicotine containing e-cigarettes compared to no intervention whatsoever. 26 00:02:54,480 --> 00:02:59,910 But a reminder to people that that isn't necessarily reflecting the fact that 27 00:02:59,910 --> 00:03:03,840 we don't think nicotine e-cigarettes would be beneficial in that context, 28 00:03:03,840 --> 00:03:08,550 because we know that nicotine e-cigarettes, compared to nicotine replacement therapy, nicotine e-cigarettes appear to work better. 29 00:03:08,550 --> 00:03:15,540 Same when we compare them to non nicotine cigarette. It's just that the quality of the evidence we have comparing nicotine e-cigarettes to no 30 00:03:15,540 --> 00:03:18,990 intervention whatsoever or by the very nature of the way those studies are designed, 31 00:03:18,990 --> 00:03:23,300 considered a little less certain. According to Cochrane's standards. 32 00:03:23,300 --> 00:03:29,660 Really excitingly, I think the two things, at least that that I'm most excited about with this new update are, 33 00:03:29,660 --> 00:03:37,160 first of all, that finally we have our first randomised controlled trial of a pod, a cigarette device included. 34 00:03:37,160 --> 00:03:38,990 And for people who want to hear more about that study, 35 00:03:38,990 --> 00:03:45,920 that is the study by Professor Kim Pulvers and colleagues which we covered in January's deep dive. 36 00:03:45,920 --> 00:03:52,340 I've been working on this review since 2014, and pretty soon into it, we started calling for studies of pod devices. 37 00:03:52,340 --> 00:03:58,070 So it was great to finally see one and be able to include it in our review. Also, previously, 38 00:03:58,070 --> 00:04:03,080 all of our findings related to adverse effects and serious adverse effects were considered 39 00:04:03,080 --> 00:04:07,880 low to very low certainty simply because we just didn't have very much evidence on them. 40 00:04:07,880 --> 00:04:11,210 In this version, that's broadly the same, except for with one exception. 41 00:04:11,210 --> 00:04:17,210 So in our group of studies, which compare nicotine e-cigarettes to non nicotine e-cigarettes, 42 00:04:17,210 --> 00:04:21,290 we used to have low certainty, evidence that there didn't seem to be any difference in adverse effects. 43 00:04:21,290 --> 00:04:27,080 And now we've had more evidence added in this update and essentially upgraded the certainty and that evidence. 44 00:04:27,080 --> 00:04:34,790 So we now have moderate certainty, evidence of no difference in the number of people experiencing adverse effects in 45 00:04:34,790 --> 00:04:39,980 those using nicotine e-cigarettes compared to those using non nicotine e-cigarettes. 46 00:04:39,980 --> 00:04:42,860 So it really encourage you all to take a look at the review, 47 00:04:42,860 --> 00:04:48,620 will have some updated briefing documents available to look at as well around our new findings. 48 00:04:48,620 --> 00:04:55,730 And it's just really nice to be able to do this now as a living systematic review and mean that we can incorporate these studies as they come out. 49 00:04:55,730 --> 00:05:03,410 But with that being said, I think we'll turn it over to you essentially and look at some of the questions you've submitted to us over this past month. 50 00:05:03,410 --> 00:05:07,700 On Twitter, we asked for people to send in questions because we knew the new version of the 51 00:05:07,700 --> 00:05:11,390 review was coming out and we were really impressed by all of the thoughtful, 52 00:05:11,390 --> 00:05:15,890 helpful questions that came in. So Niccola is going to be summarising those. 53 00:05:15,890 --> 00:05:19,580 I'm going to be doing my best to answer them somewhat succinctly. 54 00:05:19,580 --> 00:05:26,510 And Nicola will also be chipping in to comment on what I've said and if there's anything I've forgotten or even possibly gotten wrong. 55 00:05:26,510 --> 00:05:34,610 Thanks, Jamie. So it's a bit of a change of scene for Jamie. Usually the interviewer, she has become the interviewee. 56 00:05:34,610 --> 00:05:44,360 So firstly, we have a number of questions or topics for discussion that came in about the real world relevance of our review. 57 00:05:44,360 --> 00:05:54,090 So firstly, somebody asked if we could have bit of a discussion of the limitations of all cities, obscure science term definition. 58 00:05:54,090 --> 00:06:01,370 Our S.T. is shorthand for randomised controlled trial. Nice defines this as a study in which a number of similar people are randomly assigned 59 00:06:01,370 --> 00:06:06,020 to two or more groups to test a specific drug treatment or other intervention. 60 00:06:06,020 --> 00:06:09,500 One group, the experimental group, has the intervention and tested the other. 61 00:06:09,500 --> 00:06:16,160 The comparison or control group as an alternative intervention, a dummy intervention, placebo or no intervention at all. 62 00:06:16,160 --> 00:06:21,800 The groups are followed up to see how effective the experimental intervention was. Outcomes are measured at specific times. 63 00:06:21,800 --> 00:06:28,460 And any difference in response between the groups is assessed statistically. This method is also used to reduce bias. 64 00:06:28,460 --> 00:06:35,570 Somebody asked if we could have a bit of a discussion of the limitations of all sweetie's in assessing diffusion of innovation. 65 00:06:35,570 --> 00:06:42,920 Uptake is driven by product appeal and consumer choice or preferences and factors like price branding, 66 00:06:42,920 --> 00:06:47,000 the wider environment, including positive and negative communications. 67 00:06:47,000 --> 00:06:52,400 And they also mention accidental. So that that's a great question. 68 00:06:52,400 --> 00:06:58,610 And there's a lot to unpack there. And I think it's certainly something we should all be considering. 69 00:06:58,610 --> 00:07:03,980 You know, when we think about randomised controlled trials, for many reasons, 70 00:07:03,980 --> 00:07:08,480 they're considered kind of the best way to test whether or not a treatment works. 71 00:07:08,480 --> 00:07:11,900 But, of course, there are lots of limitations around that as well, 72 00:07:11,900 --> 00:07:16,280 especially when we're evaluating something like e-cigarettes, which has so many behavioural, 73 00:07:16,280 --> 00:07:25,220 cultural, societal, psychological drivers involved, which are adding so much added complexity as to how an intervention might work. 74 00:07:25,220 --> 00:07:32,940 So I think it's really tricky. And basically what I'd say is that, of course, we can't just rely on evidence from randomised controlled trials. 75 00:07:32,940 --> 00:07:36,640 And I think that's the case for e-cigarettes, but it's also the case for, 76 00:07:36,640 --> 00:07:40,550 you know, any public health interventions certainly that you might think about. 77 00:07:40,550 --> 00:07:46,670 And what we view our job as an Cochrane is following is Cocklin Standards and doing these rigorous reviews 78 00:07:46,670 --> 00:07:52,220 of the evidence which look at interventions delivered in the way they're delivered and trials essentially. 79 00:07:52,220 --> 00:07:55,790 And those trials are sometimes more or less representative of real life. 80 00:07:55,790 --> 00:08:00,200 But what we'd hope is being done in the policymaking context is that indeed, 81 00:08:00,200 --> 00:08:04,750 from conversations with policymakers, I think a lot of the time is is a triangulation of data. 82 00:08:04,750 --> 00:08:07,250 So they're looking at data from our Cochrane Review of e-cigarettes, 83 00:08:07,250 --> 00:08:12,470 but also what we would hope they were doing was looking at population data on smoking. 84 00:08:12,470 --> 00:08:14,840 Update on smoking cessation, 85 00:08:14,840 --> 00:08:23,030 on how this might vary across groups in the community to really think about the impacts of interventions both in these tightly controlled setting. 86 00:08:23,030 --> 00:08:28,520 And in what people might refer to as the real world and tying into that that 87 00:08:28,520 --> 00:08:31,790 last point from that question on accidental quitter's is a really good point. 88 00:08:31,790 --> 00:08:38,060 I think what that refers to is this phenomenon that we know about anecdotally. 89 00:08:38,060 --> 00:08:39,920 I don't think it's been studied all that much, though. 90 00:08:39,920 --> 00:08:46,250 Hopefully more is going on in this area about people who smoke, who don't have any intentions to quit smoking. 91 00:08:46,250 --> 00:08:50,900 They start using e-cigarettes and all of a sudden they find themselves not smoking anymore. 92 00:08:50,900 --> 00:08:58,360 And essentially and that way they quit. They've quit smoking. But by accident, they didn't set out on any intervention designed to achieve that. 93 00:08:58,360 --> 00:09:04,340 And and that's the kind of information that's really difficult to capture in a randomised controlled trial. 94 00:09:04,340 --> 00:09:11,060 We do have studies that are designed specifically. They say they're only recruiting people who smoke, who don't want to quit smoking. 95 00:09:11,060 --> 00:09:16,220 But even then, clearly, the e-cigarettes are being provided in a context that's been supportive of 96 00:09:16,220 --> 00:09:20,540 cutting down how much people smoke and ultimately quitting smoking altogether. 97 00:09:20,540 --> 00:09:25,400 And so, again, that's just a really good point out why randomised controlled trials, though, are really important. 98 00:09:25,400 --> 00:09:32,120 Piece of the picture are not the entire picture. And of course, when decisions are being made by policymakers, by people who smoke, 99 00:09:32,120 --> 00:09:39,230 by health care providers, we would hope that that a broad array of evidence is taken into account. 100 00:09:39,230 --> 00:09:41,690 Thanks, Jamie. These are some really good points. 101 00:09:41,690 --> 00:09:49,100 And I think it also relates to another point somebody made when they were talking about why the relative risk perception 102 00:09:49,100 --> 00:09:55,430 of combustible cigarettes and electronic cigarettes aren't usually taken into account when measuring efficacy. 103 00:09:55,430 --> 00:09:58,220 So I think he's kind of already covered that next question. 104 00:09:58,220 --> 00:10:04,640 So I'll move on to another question we have, which again, is is related to that real world relevance, 105 00:10:04,640 --> 00:10:09,200 but specifically mentions two of these studies that we've got included in the review. 106 00:10:09,200 --> 00:10:16,190 So this person says hi. Some clinical studies, for example, Higher Kartal proposed various vape products, 107 00:10:16,190 --> 00:10:23,240 as in what people would get in real life, while others imposed unique products, taste or nicotine levels. 108 00:10:23,240 --> 00:10:34,640 For example, this study by Eisenberg. Could you think a little bit about the realism of study results on the important property of FAPE adjustability? 109 00:10:34,640 --> 00:10:38,540 I think that's another excellent question. 110 00:10:38,540 --> 00:10:45,650 And my personal feeling on this, I suppose, is that actually you probably need studies of both types because they serve different purposes. 111 00:10:45,650 --> 00:10:51,380 And I think there's a spectrum of how representative studies are of real life context, 112 00:10:51,380 --> 00:10:56,180 but also real have context must may vary depending on country and the situation someone's in. 113 00:10:56,180 --> 00:11:06,620 So I think these studies like like Kayak's, which look at proposing various different products and people can choose what suits them best. 114 00:11:06,620 --> 00:11:11,000 I think there's there's a real argument for that being what is currently most representative of real life. 115 00:11:11,000 --> 00:11:17,240 Right. Where you could you could walk into a vape shop and and pick what you wanted to best, suit your needs and tastes. 116 00:11:17,240 --> 00:11:22,250 But also, if we think about how e-cigarettes could be used and, for example, 117 00:11:22,250 --> 00:11:29,600 the possibility of them being prescribed to help smokers quit than actually in that case, 118 00:11:29,600 --> 00:11:34,340 probably there's gonna be a lot more limited choice within the space of what can be prescribed, 119 00:11:34,340 --> 00:11:40,340 because we know getting anything licenced for prescription is a challenge in and goes through a lot of different steps. 120 00:11:40,340 --> 00:11:47,090 And so in that case, maybe having these studies which test a specific product are also really quite useful and informative. 121 00:11:47,090 --> 00:11:54,050 So I'm not necessarily sure that one is better than the other, but I think we definitely need both. 122 00:11:54,050 --> 00:12:00,200 You know, if we just had all of these studies testing only one type of a cigarette with only one strength or only one taste, 123 00:12:00,200 --> 00:12:06,980 that wouldn't serve us particularly well. But similarly, of all the studies we had just said, users could pick whichever one they wanted. 124 00:12:06,980 --> 00:12:12,920 It might make it more difficult for us to even be able to say, OK, this type of device looks more effective than this type of device. 125 00:12:12,920 --> 00:12:17,690 So I think having both is really useful and it's a good thing that we have both in the review. 126 00:12:17,690 --> 00:12:21,050 All right. Thank you, Jamie. So kind of moving on slightly now. 127 00:12:21,050 --> 00:12:28,610 Some more questions that we got, talking more about the methods of the review that we've used in coming up with our evidence. 128 00:12:28,610 --> 00:12:32,870 So we have a question that relates to risk of bias. 129 00:12:32,870 --> 00:12:34,790 And somebody has mentioned that, unfortunately, 130 00:12:34,790 --> 00:12:42,530 some professionals use the call for more studies with low risk of bias as a means of discrediting the evidence base to date. 131 00:12:42,530 --> 00:12:47,150 Yeah, that's another important point. Cochrane Reviews are considered. 132 00:12:47,150 --> 00:12:56,300 Goldfeder We follow a very kind of such transparent and rigorous set of guidelines for assessing risk of bias within studies. 133 00:12:56,300 --> 00:13:01,100 And that means that we tend to be very critical. You know, part of part of systematic reviews is critical appraisal. 134 00:13:01,100 --> 00:13:07,130 Say, okay, where where could this study go wrong? Is there any reason why we might not trust these results? 135 00:13:07,130 --> 00:13:11,360 And one of the challenges in our review of e-cigarettes for smoking cessation, 136 00:13:11,360 --> 00:13:16,040 and it's simply just a methodologically, is that we include different study types. 137 00:13:16,040 --> 00:13:22,320 So when you compare an uncontrolled study to a randomised controlled trial, that uncontrolled study is always going to show up. 138 00:13:22,320 --> 00:13:26,370 As being higher risk of bias, and that means that because in our review, 139 00:13:26,370 --> 00:13:30,600 where we do include uncontrolled size, we have quite a few which are showing up as high risk of bias. 140 00:13:30,600 --> 00:13:34,410 And we do make calls for more studies are at low risk of bias. 141 00:13:34,410 --> 00:13:43,080 I think the important point to make is that the studies that contribute to our main analysis, we do consider for the most part to be low risk of bias. 142 00:13:43,080 --> 00:13:48,450 And we also test whether our results are sensitive to the inclusion of studies at high risk. 143 00:13:48,450 --> 00:13:53,430 So that means if we have four studies looking at something and one of them is high risk of bias, 144 00:13:53,430 --> 00:13:58,860 we'll take that study out and see what only the studies that we judged to be kind of the lowest risk of bias, 145 00:13:58,860 --> 00:14:02,730 the highest trustworthiness, what they say. 146 00:14:02,730 --> 00:14:07,740 So actually, even though we have a case where we have a lot of studies with high risk of bias, 147 00:14:07,740 --> 00:14:11,040 I'd say still the major threat to certainty in our review and the reason why 148 00:14:11,040 --> 00:14:14,610 we can't say things with more certainty is just a lack of studies overall, 149 00:14:14,610 --> 00:14:21,870 not a lack of low risk of bias studies. So when we call for more studies, we want them to look into more things. 150 00:14:21,870 --> 00:14:28,350 We want them to look into different sorts of devices. And of course, we also want them to be conducted to minimise any potential risk of bias. 151 00:14:28,350 --> 00:14:33,140 But that shouldn't necessarily be taken as discrediting the evidence base. 152 00:14:33,140 --> 00:14:40,490 There's some really good points that. Amy, thank you. So another point someone's raised, which I think is a really important point. 153 00:14:40,490 --> 00:14:48,150 To be able to talk around is someone said that they'd like us to please in our review sake as unsustainable, sustained cessation. 154 00:14:48,150 --> 00:14:51,870 So they define that as more than one year. 155 00:14:51,870 --> 00:14:55,860 Could you give us a little bit of background on on the cessation at home? 156 00:14:55,860 --> 00:15:01,250 Cessation basically means the number of people who's quit smoking and how we assess that in our 157 00:15:01,250 --> 00:15:09,330 review and how that's relevant to people either quitting in the long term or in the short term. 158 00:15:09,330 --> 00:15:19,020 Yeah, absolutely. So we only look at cessation or quitting smoking at six months or longer and we use the longest follow up time point. 159 00:15:19,020 --> 00:15:24,810 So if a study reported at six months, one year, two years, for example, we'd use that two year time point. 160 00:15:24,810 --> 00:15:35,700 And the reason why we look at six months or longer is because we know in the shorter term those quitting rates can be really variable. 161 00:15:35,700 --> 00:15:39,540 But we do have some evidence that over the longer, longer term, you know, 162 00:15:39,540 --> 00:15:47,250 if you look at six months versus one year versus two years, typically a few people will have relapse to smoking. 163 00:15:47,250 --> 00:15:52,200 But the outcome that we look at in our reviews isn't the absolute number of people who quit. 164 00:15:52,200 --> 00:15:56,730 It's the difference that in e-cigarettes makes to that number. So it's the relative difference. 165 00:15:56,730 --> 00:16:04,050 So basically comparing people using an e-cigarettes to people not using any cigarette or using any cigarette without nicotine. 166 00:16:04,050 --> 00:16:08,820 And what other studies have shown is that this comparison is pretty stable. 167 00:16:08,820 --> 00:16:16,320 So over the course of six months, one year, two years, the difference between groups will remain broadly similar. 168 00:16:16,320 --> 00:16:20,370 But this is something once we have more studies, we can investigate in more detail as well. 169 00:16:20,370 --> 00:16:28,800 And apologies if you can hear some thrashing about. My dog has just come in from a walk and is wagging his tail vigorously. 170 00:16:28,800 --> 00:16:34,890 Great. Great for the dog and great. See. 171 00:16:34,890 --> 00:16:41,460 So then somebody else has kind of got a question, I suppose relates to that risk of bias. 172 00:16:41,460 --> 00:16:53,280 Question from earlier asking us how Tresh studies on vaping are detected and how we might assess wrong or not conclusive methodologies. 173 00:16:53,280 --> 00:16:56,910 Yeah, that's a great question. So I think, you know, in our review specifically, 174 00:16:56,910 --> 00:17:03,150 we use that risk of bias still that I talked about to critically assess each of the studies against a number of domains. 175 00:17:03,150 --> 00:17:08,250 But, of course, already within our review. And as I kind of mentioned earlier, in the context of real world, 176 00:17:08,250 --> 00:17:14,970 we are restricting to only a certain type of studies or types of studies within this space. 177 00:17:14,970 --> 00:17:19,050 So there are a lot of studies outside of that space which may well, 178 00:17:19,050 --> 00:17:24,290 some of them might be conducted beautifully and really trustworthy and others might not be. 179 00:17:24,290 --> 00:17:28,600 And what I suppose this question isn't isn't just related to vaping. 180 00:17:28,600 --> 00:17:31,410 This is about science generally is unfortunately, 181 00:17:31,410 --> 00:17:38,730 we know that despite all of the cheques and balances that have been tried to be put in place around peer review registry and protocols in advance, 182 00:17:38,730 --> 00:17:39,690 et cetera, 183 00:17:39,690 --> 00:17:48,750 we still get a case where a lot of studies come through which might not necessarily be using the best methodologies to answer the questions at hand. 184 00:17:48,750 --> 00:17:56,730 And all we can do, I suppose, as readers, as people who consume evidence in that way, is look at it and really think critically about it. 185 00:17:56,730 --> 00:18:02,010 Do I trust these outcomes? What could be going wrong here? What are the interests of the people writing this? 186 00:18:02,010 --> 00:18:09,450 Do they have any financial reason to hope that they find something so really challenging? 187 00:18:09,450 --> 00:18:13,740 And one of things we hope we're doing with this podcast is talking a little bit more about e-cigarettes, 188 00:18:13,740 --> 00:18:19,410 evidence generally and where some of the weaknesses might be and where some of the stronger points might be. 189 00:18:19,410 --> 00:18:26,260 But it's it's a continual learning process. For everyone, including us as researchers and and even as scientists, 190 00:18:26,260 --> 00:18:32,380 we can go in with the best intentions and still find that what we've done might be subject to some sort of bias. 191 00:18:32,380 --> 00:18:39,250 And we have to be aware of that. And so whenever we write, we always include a section in our discussion on limitations and places where people should 192 00:18:39,250 --> 00:18:45,740 be aware that it might not necessarily represent a conclusive answer to the question at hand. 193 00:18:45,740 --> 00:18:47,200 Right. Thanks, Jamie. 194 00:18:47,200 --> 00:18:58,060 So on next set of questions, relate to some topic areas that are kind of around the periphery of wall our review looks at at the moment. 195 00:18:58,060 --> 00:19:01,920 And the first one of these is thinking about flavours. 196 00:19:01,920 --> 00:19:09,580 So different is cigarette vapour flavours. So this person says flavour bans are being taken up by a number of governments throughout the world. 197 00:19:09,580 --> 00:19:16,990 How about a review of the roles at non tobacco flavours, play in product acceptability and successful quit rates? 198 00:19:16,990 --> 00:19:25,960 Such a good question. And in an ideal world, within our review, we'd have sections of studies comparing different flavours directly. 199 00:19:25,960 --> 00:19:30,040 We don't have those studies yet. We hope they'll come out in due course. 200 00:19:30,040 --> 00:19:35,680 And probably if we were to do a review now that was looking at the role of flavours, 201 00:19:35,680 --> 00:19:41,590 we'd have to look at a much wider range of study type study lengths and outcomes 202 00:19:41,590 --> 00:19:46,420 in order to find enough literature to make it worthwhile to do a review. But it is something that we're keeping an eye on. 203 00:19:46,420 --> 00:19:50,950 And we're really hoping that as new studies come out and as maybe we become more 204 00:19:50,950 --> 00:19:54,700 confident in the role of nicotine containing e-cigarettes for smoking cessation, 205 00:19:54,700 --> 00:19:58,750 we can look at some more questions about optimising their use and flavour, 206 00:19:58,750 --> 00:20:02,680 being, of course, one of those as might be device type of nicotine strength and also the other 207 00:20:02,680 --> 00:20:06,810 support provided to someone when they're trying to stop smoking with a cigarette. 208 00:20:06,810 --> 00:20:09,770 Great. Thank you, Jamie. It's a really interesting topic. 209 00:20:09,770 --> 00:20:16,980 And as Jamie says, it's not something that we would exclude from our review, in fact, to these type of studies would definitely be included. 210 00:20:16,980 --> 00:20:23,740 Say, for example, if if there was a study looking at tobacco flavour e-cigarettes, this is a fruit flavour, 211 00:20:23,740 --> 00:20:28,640 a cigarette, that would be something that we could include in our review and potentially draw conclusions on. 212 00:20:28,640 --> 00:20:37,120 But it's just that these studies don't exist yet. They also meet all of their eligibility criteria and therefore we don't have them in the review. 213 00:20:37,120 --> 00:20:46,420 So the next question on a kind of slightly different topic is, well, somebody said to us, let's talk about Second-Hand Vapour. 214 00:20:46,420 --> 00:20:50,350 So obviously, that's something that's not in the review as it stands. 215 00:20:50,350 --> 00:20:56,230 Can you cheque around that a little bit, Jamie? Oh, yes. I would love to talk about Second-Hand Vapour. 216 00:20:56,230 --> 00:21:00,160 And in fact, listening to that question and thinking about it now, 217 00:21:00,160 --> 00:21:04,600 it's making me think I wonder if that would be a good topic for a podcast at some point, 218 00:21:04,600 --> 00:21:08,980 if we could find some most of expertise in the area and get them on and talk to them about it, 219 00:21:08,980 --> 00:21:19,120 because they're probably there are people who study this more than I do. I think second home vapour is incredibly important to understand more about. 220 00:21:19,120 --> 00:21:24,130 And we're getting there, you know, there there are more and more studies, more and more reports talking about this. 221 00:21:24,130 --> 00:21:28,780 And I think what we have so far broadly suggests that the harms from Second-Hand Vapour 222 00:21:28,780 --> 00:21:35,260 are considerably less than any harms from Second-Hand combustible tobacco smoke. 223 00:21:35,260 --> 00:21:40,540 But I think this is just such a critical area to focus on because we know that so much of the success 224 00:21:40,540 --> 00:21:46,120 of some of the tobacco control movement in the past has been around this issue of Second-Hand, 225 00:21:46,120 --> 00:21:52,930 combustible tobacco smoke and its impact on young people. And, you know, I completely support that. 226 00:21:52,930 --> 00:21:58,660 And I think somehow we've stopped talking about it in terms of vaping it. 227 00:21:58,660 --> 00:22:05,860 It almost seems like it's not as much of a question. And of course, we need to know if Second-Hand Vapour has harms to bystanders. 228 00:22:05,860 --> 00:22:13,180 But we also need to know in people who switch from smoking to vaping what the impacts are on the people around them. 229 00:22:13,180 --> 00:22:18,370 So what are the impacts on the kids at home whose parents have switched from smoking to vaping? 230 00:22:18,370 --> 00:22:21,880 Is it having a comparable impact on on that child's asthma control? 231 00:22:21,880 --> 00:22:25,810 What's happening in terms of things like Rath's of Sudden Infant Death Syndrome, 232 00:22:25,810 --> 00:22:29,650 which we know is is increased from Second-Hand, combustible tobacco smoke. 233 00:22:29,650 --> 00:22:31,600 So I think there's a whole field of research here, 234 00:22:31,600 --> 00:22:40,510 which is so conceptually important and practically important to the people who smoke, to the people around them, to policymakers. 235 00:22:40,510 --> 00:22:46,930 So I hope that we can see more on this. And and in fact, maybe if we can find someone who's willing to talk to us about it, 236 00:22:46,930 --> 00:22:50,800 possibly do a podcast episode focussed on those kids, I personally would love to know more. 237 00:22:50,800 --> 00:22:54,850 I just know from reading around the topic as opposed to directly doing any research on it. 238 00:22:54,850 --> 00:22:55,480 Thanks, Jamie. 239 00:22:55,480 --> 00:23:04,270 And I agree there's definitely some things coming up there that have been really good to have an expert on to talk to us about in the podcasts. 240 00:23:04,270 --> 00:23:09,910 So the next one also is something that I do know a great deal about. 241 00:23:09,910 --> 00:23:15,390 We'll see. We'll see what Jamie knows. And I'm also hoping that I'm gonna be able to pronounce this. 242 00:23:15,390 --> 00:23:21,830 So apologies in advance. I haven't pronounced it correctly, but the next topic someone's asked is just. 243 00:23:21,830 --> 00:23:30,200 Maybe having a chat around is the elimination of opening glycol and glycerine from the body and using e-cigarettes. 244 00:23:30,200 --> 00:23:38,480 So that specific question around the elimination of problem glycol glycerine from the body isn't something that we look at in our review. 245 00:23:38,480 --> 00:23:43,170 But again, is really interesting and I know is something that is being investigated. 246 00:23:43,170 --> 00:23:45,590 And so it could be that at some point, again, in this podcast, 247 00:23:45,590 --> 00:23:51,720 we we bring on an expert who's looking at these more lab based studies to look into this and a bit more detail. 248 00:23:51,720 --> 00:23:59,510 Great. And and so finally, in these kind of related topic areas, somebody has asked us a bit about young vaping across the world. 249 00:23:59,510 --> 00:24:03,910 And obviously, again, that's not something that we're covering in this particular review. 250 00:24:03,910 --> 00:24:08,510 But I know you probably have some thoughts on that. Yeah, well, the main thought, 251 00:24:08,510 --> 00:24:13,760 I have a life that I'm delighted to say that we have now received funding from Cancer 252 00:24:13,760 --> 00:24:21,080 Research UK to start up a new Cochrane Review looking at the impact of e-cigarettes, 253 00:24:21,080 --> 00:24:27,350 availability and use on young people, particularly on young people's smoking behaviour. 254 00:24:27,350 --> 00:24:33,470 So it's something where we know there's there's a lot of conflicting statements out there from guideline developers, 255 00:24:33,470 --> 00:24:41,120 from scientists about the role that vaping plays in young people and particularly in terms of cigarette initiation. 256 00:24:41,120 --> 00:24:45,560 And so that's something that that in the next couple of years we'll be paying a lot of attention to. 257 00:24:45,560 --> 00:24:51,310 And I'm sure we'll be talking about a bit more on this podcast as we get more into it as time goes on. 258 00:24:51,310 --> 00:25:00,380 All right. Said that on next. Lot of questions all relating really to our systematic living, systematic review process. 259 00:25:00,380 --> 00:25:08,180 Should I say so? Somebody is asked is what is the cycle for regular future reviews? 260 00:25:08,180 --> 00:25:15,710 Yes. So basically within the Libyan systematic review process, what we do is we search for new evidence every month, 261 00:25:15,710 --> 00:25:23,150 but we only update the review when we find sufficient information from the searches that we think the update would be meaningful. 262 00:25:23,150 --> 00:25:28,820 And so this time around, we incorporated evidence from searching over a number of months. 263 00:25:28,820 --> 00:25:33,920 And basically what triggered us to update is that we had evidence that strengthened the fact, 264 00:25:33,920 --> 00:25:41,630 the certainty of our conclusion of no difference between nicotine and non nicotine e-cigarettes and the number of people experiencing adverse events. 265 00:25:41,630 --> 00:25:48,650 And also, we had our first study of pot devices. So we felt like it was really important for people looking at the review to know that new evidence. 266 00:25:48,650 --> 00:25:54,860 And so we can't say exactly when the next review will come because it will depend on what studies we find. 267 00:25:54,860 --> 00:26:00,100 But we certainly have already found some new studies from last month that we will incorporate in a future version. 268 00:26:00,100 --> 00:26:05,920 So I would anticipate, but wouldn't promise that we'll have another one out probably towards the end of this year. 269 00:26:05,920 --> 00:26:06,530 Right. 270 00:26:06,530 --> 00:26:15,500 And it's really exciting that to see these reviews coming out quicker so that we can inform you all of this new evidence as it becomes available. 271 00:26:15,500 --> 00:26:21,410 Exactly. So that same person is also asked, can the impact of this view be broadened? 272 00:26:21,410 --> 00:26:24,110 Given the data doesn't lend broadly? 273 00:26:24,110 --> 00:26:30,770 And so they're saying, you know, it might not be included in all kind of international's smoking cessation guidance? 274 00:26:30,770 --> 00:26:34,820 Yeah. That's a really good question. Actually, I have the list of questions in front of me. 275 00:26:34,820 --> 00:26:36,830 TUDA touches on a few others. 276 00:26:36,830 --> 00:26:45,500 So one question about Cochrane, Taiwan translating the systematic review and another comment on the new German cessation guideline, 277 00:26:45,500 --> 00:26:49,280 which doesn't mention the October review. So these are all about impact. 278 00:26:49,280 --> 00:26:51,890 And I think one of the things we're trying to do with this podcast, 279 00:26:51,890 --> 00:26:56,030 but also in a lot of other activities around ours, are just disseminate our findings. 280 00:26:56,030 --> 00:26:59,900 You know, our job in Cochrane is not to tell anyone what to do. 281 00:26:59,900 --> 00:27:04,020 It's not to make recommendations. It's just to say this is what the evidence shows. 282 00:27:04,020 --> 00:27:08,450 And an area like e-cigarettes where the evidence is evolving so rapidly, 283 00:27:08,450 --> 00:27:11,840 it's really important that people do have the most UP-TO-DATE evidence to hand. 284 00:27:11,840 --> 00:27:17,570 And so we'd proactively work with guideline developers, with clinicians, and, of course, 285 00:27:17,570 --> 00:27:25,040 are trying to access and talk to people who smoke as well about the evidence we have on e-cigarettes. 286 00:27:25,040 --> 00:27:33,440 One of the issues which I am kind of completely, I suppose, understanding of when it comes to guideline development and sorry, that's my doorbell. 287 00:27:33,440 --> 00:27:38,600 So we're going to have a momentary pause one second. So sorry about that. 288 00:27:38,600 --> 00:27:42,530 That was the doorbell, the joys of working from home. We've had the dog. You've had the doorbell. 289 00:27:42,530 --> 00:27:44,870 The dog was also very excited about the doorbell. 290 00:27:44,870 --> 00:27:49,100 But what I was in the midst of saying was that one of the things I'm most sympathetic to with guideline 291 00:27:49,100 --> 00:27:53,660 developers is that they often follow a process that began in that similar to ours in Cochrane, 292 00:27:53,660 --> 00:28:01,250 where we search for new evidence. But then the time between searching for that new evidence and the guideline coming out can be quite long. 293 00:28:01,250 --> 00:28:07,000 So it's quite possible that, for example, in the German guidelines, which have been referred to at the time, they search for new evidence. 294 00:28:07,000 --> 00:28:12,830 October 2020, Cochrane Review wasn't out there yet and that that's a problem for our views. 295 00:28:12,830 --> 00:28:16,610 That's why we've moved to a live in systematic review for our Cochrane Review of e-cigarettes. 296 00:28:16,610 --> 00:28:20,720 And actually some guideline developers are now looking at living guidelines for certain topics. 297 00:28:20,720 --> 00:28:24,140 I think probably the. Covered pandemic has made this more relevant than ever. 298 00:28:24,140 --> 00:28:32,090 So, yeah, just to say we are trying to stay on top of this and trying to update our reviews and make clear that that updated information is available. 299 00:28:32,090 --> 00:28:36,320 But there may be valid reasons why it's not being used as quickly as we'd hope it might be. 300 00:28:36,320 --> 00:28:39,920 And we do do our best to engage with guideline developers. 301 00:28:39,920 --> 00:28:43,250 We do try to be proactive in that where we can be. 302 00:28:43,250 --> 00:28:51,620 Obviously, it's hard for us to keep on top of things internationally, and it's always useful for us if guideline developers reach out to us. 303 00:28:51,620 --> 00:28:54,260 We don't always know what's going on everywhere. 304 00:28:54,260 --> 00:29:01,430 And in fact, Jamie has spoken to a number of different policy makers and even governments about all our review. 305 00:29:01,430 --> 00:29:07,080 So be reassured that it is getting out there. But it is hard to cover all of those bases. 306 00:29:07,080 --> 00:29:16,010 Isn't it, Jamie? Yeah, absolutely. And I suppose it's worth mentioning that Cochran do also make a lot of effort to translate, 307 00:29:16,010 --> 00:29:25,910 ah, plain language summaries into lots of different languages. So say the question about translating into Mandarin, for example. 308 00:29:25,910 --> 00:29:32,600 I'm not a hundred percent sure if the plain language summary for our 2020 review has been translated into Mandarin as yet. 309 00:29:32,600 --> 00:29:37,070 But definitely there are a lot of translation efforts going on and a lot of plain 310 00:29:37,070 --> 00:29:41,840 language summaries of all group are translated into a lot of different languages. 311 00:29:41,840 --> 00:29:46,360 So it's, again, something that Cockram tried really hard on. 312 00:29:46,360 --> 00:29:50,200 So our final question. In fact, our final question in this section. 313 00:29:50,200 --> 00:29:56,690 But our final question overall basically asks you to speak to Jamie. 314 00:29:56,690 --> 00:30:04,700 The fact that Cochrane's rigorous evidence reviews are the global gold standard for all fields of public health except tobacco control. 315 00:30:04,700 --> 00:30:10,460 I suppose it's important to say that that's an opinion and would be interesting to to hear what you think about that, Jamie. 316 00:30:10,460 --> 00:30:19,700 They all say say perhaps this say something about where tobacco control is today and evidence that doesn't fit dogma is simply rejected out of hand. 317 00:30:19,700 --> 00:30:26,210 I, I would love to have kind of a long conversation about that, I suppose. 318 00:30:26,210 --> 00:30:29,210 I think there's a lot of context that comes into this statement. 319 00:30:29,210 --> 00:30:35,810 You know, personally, I think a lot of tobacco control has looked at Cochrane's evidence reviews. 320 00:30:35,810 --> 00:30:40,340 We know that they're used extensively in national and international guidelines. 321 00:30:40,340 --> 00:30:44,930 And this includes lots of guidelines on different tobacco control interventions, 322 00:30:44,930 --> 00:30:48,290 including, you know, the Cochrane Review of Nicotine Replacement Therapy, for example, 323 00:30:48,290 --> 00:30:52,700 was was cited as one of the central documents behind the World Health Organisation's 324 00:30:52,700 --> 00:30:56,930 decision to list nicotine replacement therapy as a globally essential medicine. 325 00:30:56,930 --> 00:31:00,290 So I think we do have a role on tobacco control and and we are listened to. 326 00:31:00,290 --> 00:31:04,040 But I think where this question comes from is in within the context of e-cigarettes. 327 00:31:04,040 --> 00:31:10,700 And there I think there is a huge amount of variation country by country at the moment around e-cigarettes, 328 00:31:10,700 --> 00:31:17,740 legislation, conversations, policies, and I suppose. 329 00:31:17,740 --> 00:31:21,610 What we need to think about, not just in tobacco control, 330 00:31:21,610 --> 00:31:27,250 but across all of science is being open to evidence and being open to the fact that evidence might change. 331 00:31:27,250 --> 00:31:38,350 Methods might change. Situations might change. And I think we need nuance when we are looking at evidence and also considering societal contexts. 332 00:31:38,350 --> 00:31:45,340 And if the evidence doesn't fit our context. That doesn't necessarily mean the context is wrong or the evidence is wrong. 333 00:31:45,340 --> 00:31:49,960 But it does mean there's a disconnect that needs actual thought. We need to be transparent about it. 334 00:31:49,960 --> 00:31:57,670 We need to be clear on why we think the evidence might not suit our needs as opposed to simply not addressing that evidence. 335 00:31:57,670 --> 00:32:04,510 And when we set out to do our Cochrane reviews, we really genuinely try to be agnostic about every hour of every intervention we're looking at. 336 00:32:04,510 --> 00:32:11,350 So when I set out to do our e-cigarettes review, if this evidence had found that e-cigarettes didn't work at all, 337 00:32:11,350 --> 00:32:14,590 didn't help anyone, quit smoking, I would have been very confident in saying that. 338 00:32:14,590 --> 00:32:22,900 Just as I'm very confident say now that we do have evidence, growing update on update about a promising roll of e-cigarettes for smoking cessation. 339 00:32:22,900 --> 00:32:27,700 So I think for us in Cochrane, it's really easy for us to stick with the evidence for those making policies. 340 00:32:27,700 --> 00:32:30,190 They're considering so many different elements. 341 00:32:30,190 --> 00:32:38,020 And I suppose all we can ask is that the evidence is fairly considered, transparently considered and openly discussed. 342 00:32:38,020 --> 00:32:42,340 Thanks, Jamie. And I think it's important to remember and also gives me the opportunity to give 343 00:32:42,340 --> 00:32:46,840 a shameless plug that this electronic cigarettes review isn't the only review. 344 00:32:46,840 --> 00:32:49,960 There are groups that Cochran's Bacco addiction group put out. 345 00:32:49,960 --> 00:33:00,250 We have a range of reviews looking at different treatments for tobacco addiction, ways of preventing tobacco addiction and on various of topics. 346 00:33:00,250 --> 00:33:07,750 So, you know, our evidence gets out there on a wide range of topics within tobacco control. 347 00:33:07,750 --> 00:33:13,210 And if you're interested in that wider area, then please cheque out all the reviews as well. 348 00:33:13,210 --> 00:33:22,660 So that's it from us this month. Thanks so much for listening. Do cheque out our new review, which is out at the end of April. 349 00:33:22,660 --> 00:33:28,000 Thanks again. Please subscribe on iTunes or Spotify and stay tuned for our next episode. 350 00:33:28,000 --> 00:33:39,710 This is me. Yeah. But some mention the findings we have can tell us what happened, Lungu. 351 00:33:39,710 --> 00:33:47,770 Even though we know Maybin is safer than smoking weed, still buying cars. 352 00:33:47,770 --> 00:34:06,380 Switching to. Thank you to Jonathan Livingston Banks for running searches to Elsa Butler for producing this podcast. 353 00:34:06,380 --> 00:34:08,210 And to all of you for tuning in. 354 00:34:08,210 --> 00:34:16,280 Music is written with Johnny Berliner and I and performed by Johnny are live in systematic reviews supported by funding from Cancer Research UK. 355 00:34:16,280 --> 00:34:22,100 The Cochrane Tobacco Addiction Group also receives core infrastructure funding from the National Institutes for Health Research. 356 00:34:22,100 --> 00:34:27,005 The views expressed in this podcast are those of Nicola and I and do not represent those of the funders.