If asking your mate down the pub about vaping is what they probably say, no one agrees with safer or not, so you might as well smoke anyway.
Now, what Jemmy needs is a Cochrane review. All the facts have been checked at least twice.
They find there's a lot that the experts agree on.
I might give you a different advice. Hi, I'm Nick Levinsohn, and I'm Jamie Harmon.
Boys were both researchers based at the University of Oxford, where we work with the Cochrane Tobacco Addiction Group.
Welcome to this edition of Let's Talk E-cigarettes. This podcast is a companion to a research project being carried out at the University of Oxford,
where everyone's research the e-cigarettes literature to find new studies.
We then use these studies to update our Cochrane systematic review of e-cigarettes for smoking cessation.
This is called a Living Systematic Review. In each episode of this podcast,
we start by going through the studies we found that month and then go into more detail about a particular study or topic related to e-cigarettes.
So first off, our guide you through what we found in our June 20, 21 searches.
In a nutshell, we found three references. One was a dissertation which is linked to saying 2016, a study already included in the review.
The second is a potentially new study identified via Clinical Trials Registry.
But we are awaiting further detail to confirm whether it is eligible or not.
And finally, we found a new protocol called Effects of providing tailored information about e-cigarettes in a Web based
smoking cessation intervention by ELING and colleagues and published in JMI our research protocols.
This randomised controlled trial will look at the effect of providing information about
using e-cigarettes for smoking cessation rather than providing the e-cigarettes themselves.
And so will be an interesting addition to our review when completed. So in addition to what we found in our searches,
we're also excited to receive an early view of a new paper this month and to speak to
Professor Thomas Brandon from the University of South Florida about his new study,
Hot Off the Press in The Lancet Public Health. Interestingly, like the protocol Nicola just spoke about,
the study didn't test the effects of providing any cigarette, which most of the studies in our review set out to do.
But instead, in this study, what they did was they investigated the effects of providing tailored advice to duel
users on how to use their e-cigarettes to quit smoking conventional cigarettes.
It's a large randomised controlled trial,
and we'd been aware that results from the study were forthcoming because we'd actually seen a conference abstract earlier this year,
which we'd spoken about briefly on this podcast.
So we were delighted when Professor Brendan shared impressed copy of the full article with us a few weeks ago.
Now that it's just published on the 24th of June,
we can talk about it on the podcast and are so grateful to Professor Brendan for finding the time to talk to us in this month's deep dive.
So to start off, can you tell me a little bit about yourself and what got you into doing research on e-cigarettes?
Sure. And thank you for inviting me, Jamie. This is very exciting.
I'm a clinical psychologist at the University of South Florida and actually Moffitt Cancer Centre in Tampa, Florida.
I conduct research on smoking and smoking cessation,
have been doing so since entering graduate school at the University of Wisconsin back in nineteen eighty two.
Working with Dr. Ken Baker at the time, you know, I saw my first cigarette, I think,
in a mall kiosk more than a decade ago, and it was kind of curious about it.
And like a lot of tobacco researchers, I was pretty sceptical at first,
given the previous false promises of safe tobacco products such as filters and ultra light cigarettes.
It just didn't pan out. But then I saw some friends and colleagues actually quit smoking with them.
And these were the early devices, a signal light devices that delivered very little nicotine.
And yet they seem to be able to switch.
And, you know, with millions of smokers eventually using these devices, I just felt research was really needed on that.
So we started doing some more descriptive research,
just surveying each cigarette users and getting their opinions and serving their expectancy's or their beliefs about e-cigarettes versus combustible
cigarettes versus a pharmacotherapy is like nicotine replacement therapies and seeing what they viewed as advantages and disadvantages of it.
And that's kind of what got us started. It was this great. And and we were super excited to see your new study.
I'd been aware it was going on. So it's very exciting to see it get to this point.
But before we go into talking about that study in particular,
I just wondered because it's specifically around targeting dual users of e-cigarettes and combustible tobacco cigarettes.
And I think doofuses, our group that we hear a lot about and increasingly a little bit more research is getting done into them.
But I just want to read before we get into the specifics of your study, can you tell us a bit about why you chose to do a study into users and if
there's anything kind of special about this group that we should be aware of?
Yes. Well, you know, about 70 percent of vapours say they started vaping in order to quit smoking or to seriously cut down on smoking.
So that suggests that this is largely a group that's already trying to quit smoking.
It's really motivated to quit smoking. Despite this, many of them seem to get stuck at dual use, using both products to different degrees.
Some are, you know, mostly smoking and vaping a little bit.
Some are mostly vaping, but still smoking a little bit and everything in between. But through their dual use,
they seem to be maintaining both their nicotine dependence as well as their exposure to toxicants from the combustible cigarettes.
So given their quitting motivation, this seemed like a population that could benefit from a fairly minimal intervention,
you know, self-help type intervention like we do.
That included some advice on how best to use our e-cigarettes in order to, you know, completely quit smoking.
Great. So that, I think, leads us nicely into your study in particular.
So can you tell us a little bit about the methods used and what you set out to do?
Sure. Well, first, we conducted focus groups with dual users, those who had been able to quit smoking completely switch over and those who hadn't.
We wanted to learn about what worked for them and what didn't, because, remember,
this started about eight years ago and it was very little research on smoking
cessation of vaping or dual use or anything related to vaping at that time.
So we gathered information by listening to actual vapours in our laboratory,
and then we incorporated this information into our self-help intervention, which is a series of booklets we sent people over a course of 18 months.
We call it the extended self-help, which is a distinction between normal self-help,
where you just give somebody a pamphlet, you know, one time, and that tends not to work too well.
So we we updated our booklets for this population. We call them if you vape, you know, a guy that quitting smoking for vapours.
And this series of booklets and pamphlets gets mailed to participants every month for 18 months.
Once we had the intervention, we recruited nearly twenty nine hundred dual users to a study to follow them for two years.
And notably, these weren't people who were necessarily trying to quit smoking or seeking help.
We just recruited a saying. We're doing a study to follow dual users and see how they progressed over time and that's how we recruited them.
But once they contacted us, we said, you know, it's possible we may also send you some intervention material to help you quit
smoking and then we randomised them into three arms in the clinical trial.
So one arm received no intervention. So they were just a surveillance arm control, just as we recruited them for.
And then another arm received our new if you VAP intervention, then a third arm received our.
Previous self-help, which was also 18 months, similar kind of intervention, but not tailored at all toward vapours.
So just a regular smoking cessation intervention.
So those were the two, you know, control condition to totally control surveillance only and a regular smoking cessation self-help.
And then we just, you know, assessed them for there's both are smoking or vaping for every three months for the next two years.
Fantastic. Can can I just ask in terms of that, if you vape booklet and the feedback that you got from your focus groups,
what do you have any examples of the kind of thing that went in that that was different from your traditional self-help manual?
Yeah, so I mean, you know, we had all the regular smoking cessation material in there.
We didn't take any of that out, but we added new sections that were specific to vapours.
And then the examples we use, the sort of testimonials that were part of our booklets and pamphlets were all based on the stories that papers told us.
So one example might be and since then, other research has found the same thing.
One of the pieces of advice was of people who were successful was that they initially, when they were starting to switch,
took up tobacco flavoured e-cigarettes because that ease the transition from their combustible
cigarettes to their e-cigarettes because of a similar flavour or menthol if there were menthol smokers.
And then over time, they switched to a non tobacco flavour like a fruit flavour or dessert flavour, for example.
And they did that in order to kind of burn the bridge behind them,
to make it less easy to switch right back to smoking, to distinguish it from smoking.
And one of the things we learnt that they didn't like to call them even e-cigarettes,
because that kind of implied it was still smoke and they preferred to call them, you know, vapes and call themselves vapours.
That's just one of several examples. They also gave advice about how to ease off the nicotine content and actually a lot of interesting things.
And this was one of the early qualitative studies off the very first, but fairly early on.
And since then, other research has found very similar advice from vapours.
It's so interesting. And I just really like that model of kind of getting that feedback from the community and putting that into the booklets.
That's awesome. Yeah. So we we really had like three sources of the content for our book.
This one was just a regular smoking cessation material that had been empirically supported,
and that's based on the cognitive behavioural model and relapse prevention model. Obscure science term definition,
a cognitive behavioural model aims to help people identify and change automatic
thought patterns that influence behaviours such as smoking and emotions,
a relapse prevention model teaches people to identify high risk situations that may lead
them to return to smoking and provides them with strategies to cope with those situations.
The second was the information we got from the vapours themselves.
I just describe and a third source was what we know about nicotine replacement therapies
because we conceptualise this as perhaps a much more effective nicotine replacement therapy,
potentially because of its similarities with the act of smoking, you know, sensory motor similarities, obscure science term definition.
In this context, sensory motor similarities refers to the fact that e-cigarettes mimic some of the sights,
tastes and smells of smoking, as well as providing the familiar hand to mouth action of smoking.
So we know that, for example, that one of the problems with nicotine replacement therapy is people often don't use enough of it.
So, you know, we encourage people to, you know, vape whenever they had cravings or smoke.
And, you know, emphasise that point is just one example of a translation between NRT and vaping.
Fantastic. And were there any challenges in getting the study up and running?
So getting funding and recruiting tour or did it all go fairly smoothly?
I know there's always some challenges.
Yeah, I think the main challenge is associated with the divisive, you know, polarised opinions about vaping that are out there.
I related to today's politics, but, you know, particularly the United States, where people have taken such extreme positions in many cases.
So to make it through the various review processes from the original grant application to getting the main results published,
you know, we really have to walk a fine line.
You know, at one extreme are the anti tobacco advocates who don't distinguish between combustible and non-combustible nicotine products.
So they don't like the idea that we're even considering possible public health benefits of vaping like smoking cessation.
But at the other extreme,
or the pro vaping advocates who don't even believe that e-cigarettes should be treated as therapies that are tested by randomised controlled trials,
they think they're consumer products are our seats don't adequately capture their effectiveness.
And, you know, we actually suggested at the very end of our intervention, we say, you know, if you've been able to quit smoking,
maybe you want to consider quitting your vaping as well and becoming free of nicotine dependence.
And we do this very gently. But I've got blowback from the pro vaping extremists that, you know, we shouldn't even be encouraging people to quit.
Their vaping at any point is a completely benign product.
And it's just fine if they vape. And it's certainly a lot safer in smoking as far as we know at this point.
But I don't discount the effect of nicotine dependence and, you know, running smoking groups for 40 years.
That's one of the main reasons people want to quit to get free from that dependence
and always having to worry about having their products with them and everything else.
So we give people the option of anyway. But we do it very gently.
Yeah, it's it is a particularly challenging area to work with in that regard is that one often finds their pleasing No.
One if standing somewhere in the middle. Yeah. We get criticised from both directions.
Exactly. Really interesting. And so moving on.
What did your study find? What kind of were the main results and was there anything that surprised you that came out of that?
Yeah, well, one of the things know, kind of separate from our intervention self that we found, it was sort of surprising,
especially given what we knew at the time we started this study was we had pretty high rates of smoking cessation across all groups.
So I think even in the the surveillance only group, it didn't get any intervention.
At two years, 40 percent of them had quit their smoking, you know, combustible cigarette.
So that's a pretty high rate by itself. And other data has shown similar results.
Again, at the time you started this study, the fear was that the users would be smoking and would be stuck in dual use forever.
And that doesn't seem to be the case. So that's that's really good news right there.
We found in terms of the intervention itself, we found that our intervention, if you vape booklets,
were beneficial over the course of the 18 months that people received the booklets.
So it added another roughly five to eight percent abstinence overall.
And then a generic intervention that wasn't geared toward vapour specifically fell in between the two.
So there was some benefit of any kind of help for smoking cessation, somewhat added benefit if it was geared specifically to vapours.
But one of the interesting things is that the largest effects of the intervention were amongst the most dependent smokers.
So the least dependent smokers had pretty high rates of cessation more.
The parent there were the lower overall taxation rates were, but the bigger effect of the intervention itself, and that kind of makes sense.
It's like nicotine replacement therapies work best with people who are dependent on cigarettes.
If you're smoking just for social reasons and they're not physically dependent, you know, nicotine patches are going to make much difference.
And it's probably the same thing with e-cigarettes and that extra help that we can give them for e-cigarettes.
So after 18 months, those differences narrowed between arms.
So that suggests to us that either we just sped up the cessation process or perhaps we
have to extend it even longer to keep them engaged for 18 months may not be enough.
And that's one of the nice things about having a low cost intervention like this,
is that I imagine the prospect of extending isn't quite as challenging as it might be if you are,
let's say, delivering some sort of resource intensive counselling or something.
Yes, and we did a cost effectiveness analysis, and it is pretty cost effective compared to most interventions.
I mean, it's just about selling the booklets. We'd like to do a like a mobile health version of this, as well as in our or upcoming plans.
And that might be even more cost effective if it would be fantastic to see.
So kind of going back to that point we were talking about earlier in terms of treading the fine line, I suppose, when it comes to vaping.
I noticed that in your study the intervention didn't endorse starting to vape.
And that, of course, makes sense because you're in users who are already vaping.
But you also write that it really set out, I think you said not to demonise or immediately discourage ongoing vaping,
but then later, let's say once someone who quit smoking to recommend stopping vaping,
I was wondering how you worded that, because it feels such a nuanced and complex area and a place where sometimes I
think we could do better in the way we work and communicate these messages.
Yeah.
So one of the lessons we learnt from those early focus groups is the vapours were very sensitive to any suggestion they should give up their vaping,
even if they were active vapours and are feeling they were getting some benefits from it in terms of cutting down their smoking.
They didn't want us to suggest that at all. And some of our other research survey research suggests as well.
So we decided we're not going to talk about quitting your vaping until near the end of the 18 months.
I think around a 15 month point or so. We brought up that suggestion.
And, you know, we do mention that we you know, there are likely some negative health consequences of vaping.
You know, it's still most likely far less than combustible smoking, but there probably still are some.
But we are but we mostly emphasise the freedom from dependence aspect of it that I mentioned earlier.
And that's kind of how we introduced that. Now, interestingly, we didn't find any significant differences across arms in terms of vaping reduction.
So our gentle reminders really didn't have any effect overall.
But we did find another.
Studies have found this, too, that the more people vaped or let me put it this way, people who are vaped were more likely to have quit smoking.
People were continuing to vape, were more likely to quit smoking at every follow up point, really.
And I think that along with the overall cessation effects that we found provides additional
evidence that's been accumulating on the efficacy of vaping for smoking cessation,
or at least at the very least for switching.
Yeah, and I think this study is such a nice piece of the puzzle, as it were, when it comes to our Cochrane Review, where all we have so far,
mainly trials where people have been provided e-cigarettes,
but it's really nice to kind of see them encouraged to use their e-cigarettes to help them quit smoking.
And following along that note around perhaps ceasing vaping at some point in your discussion,
you note that interventions that facilitate vaping cessation without risking smoking relapse are needed.
And and I couldn't agree more.
So I think that is probably another area of research that we're going to hopefully start seeing more of, because I think it is just, again,
a really risky topic because, of course, we don't think there are harm free, but we think that considerably less harmful than smoking.
And so there's a real Trade-Off around these messages and how we do this.
Do you have any sense of what these interventions might look like?
Do you have kind of any ideas that might be too tough of a question, but I'm curious.
Yeah, I mean, it remains an open question, but I think timing will prove to be important.
The longer that vapours are smoke free, the probably the easier it will be for them to quit vaping without returning to smoking.
And that's the key again. Yeah. And that's sort of consistent with some of our findings as well.
It might be, especially the case of e-cigarettes differ from combustible cigarettes in as many ways as possible.
Sort of as we were talking about earlier, was flavouring is a sensorimotor characteristic.
So e-cigarettes that don't look or feel quite as much like combustible cigarettes might be easier to give up without going back to smoking again.
You're kind of burning those behavioural conditioning bridges behind.
Obscure science term definition, behavioural conditioning is where a behaviour such as smoking becomes more
frequent or predictable in response to a particular environment or stimulus,
such as the smell of tobacco smoke. Therefore, burning these bridges would mean that people unlearn the association between these triggers and the
response behaviour as you switch away from all the aspects of that are associated with smoking.
That was one of the advice, pieces of advice that we got from our focus groups as well as,
you know, try to not not expand your vaping repertoire beyond what your smoking was.
And that's one reason that, you know, I've not been in favour of legislation that proposes to completely eliminate flavours.
So I think the flavours are important for switchers. We probably want to get rid of the flavours that are overly appealing to kids.
You know that you hear a lot about the dinosaur vomit and things like that.
But having at least an option of a set of flavours are available for adults that want
to kind of get away from the tobacco flavour associated with smoking is important.
Did you just say dinosaur vomit just to check? I think there is some flavours like that.
They're always brought up as examples. I like to hear the examples of bubble gum and stuff.
I have never thought about that before and I'm intrigued. I mean, I haven't seen these.
I see, you know, advocates talk about flavours like, wow, OK, sorry, continue just checking that.
I heard that. Right. You know, perhaps with unicorn vomit, I can't remember something so magical.
But it also may make sense to gradually fade off the nicotine content of your e-cigarettes.
And I'm actually on the advisory board of a Start-Up that's developing a therapeutic e cigarette that would automatically do that kind of fading.
So that's a possibility. OK, I know that in those conversations about nicotine content,
there is the concern that's expressed that people would then essentially inhale more of the nasties in the process of trying to get more nicotine.
So I'll be curious to hear how things go with that. Yeah, I think that's a difference between a gradual,
fading approach versus just limiting the nicotine out of cigarettes from the start where
you're likely to be more likely to have that compensatory vaping to get the higher nicotine.
Whereas if you're gradually reducing it, you know, you're adjusting slowly to these levels and you're physiologically you're adjusting.
That's really interesting. So that's it for me about your study specifically.
If there's anything you want to add on it, please do. But also always like to hear from people kind of following on the research they've done so far.
What research do you think should be done next in this area?
If, you know, you had all the time and money in the world, what kind of study might you hope to see?
Well, first of all, we just need more clinical trials of e-cigarettes, testing or efficacy for smoking cessation.
It really amazes me that there are so few trials of a product that is used so much and it could have so significant public health impact.
But there have been many barriers to conducting such studies. And that's actually what I wanted to do initially eight years ago.
But we could not do those studies in the US and that's got me thinking, okay, what can we do?
Well, maybe we can work with people who've already started using e-cigarettes since we're not allowed to give them to people.
But we need to do those studies. They should be naturalistic studies as well, you know,
a variety of research to test them not only under highly controlled settings, but also a more real world settings.
We also need to study how best to communicate the relative risk of different nicotine products.
Most people incorrectly believe that e-cigarettes are as dangerous or more dangerous and smoking,
even when I speak to scientists, because that's what the press tends to play up.
And that's really a failure in public health messaging. Yeah, I couldn't agree more.
And then I think we need implementation studies on how public health and medical
institutions should integrate e-cigarettes into their policies and procedures.
You know, depending, of course, on the findings that come from these additional clinical trials either way for giving advice for or against,
we need to learn how to do it.
And if e-cigarettes continue to be found to be beneficial for smoking cessation, you know how to communicate that message.
How do we incorporate that into a treatment plan for individuals that we see?
Absolutely. Well, that is wonderful. So interesting. And I just want to say thank you so much once again.
Well, thank you for inviting me today. I really enjoyed it. And look forward to your next Cochrane Review.
Thank you so. Well, I. Really interesting about that chat with Professor Brandon, Jamie was what he was talking about,
about potentially trying to reduce cigarette use to help people to come off of e-cigarettes when they've used them to quit smoking.
And that's particularly interesting to me because a lot of the research that I've
done in the past has been looking at helping people to reduce their smoking.
So it will be interesting to potentially think about ways that we can use what we've
learnt about reducing smoking to maybe help people to reduce their e-cigarettes use.
But also what he touched upon, which I think is really important, is that we don't want people to feel, you know,
vilified for using e-cigarettes and that they have to get off them too soon because I found it was really useful.
What he found about people who continued to vape were more likely to be able to sustain cessation.
And what we really don't want to be doing is discouraging people from continuing to vape, where that's stopping them from going back to smoking.
Exactly. It's just that point, I think, about it being a spectrum of risk.
And so you want people off a higher risk product,
first and foremost onto a medium risk product and then off of that medium risk product if they can just be off all products generally.
But we don't want to be taking people off of vaping, let's say, and then have them go back to smoking.
And that wouldn't be a success at all. So it's an area that I think we're starting to see more on around vaping cessation.
But it's just, I think, extremely important that it be communicated and the research we conducted in a nuanced way.
And I think it was nice to see that Professor Brennan and colleagues have put a lot of work in this trial around really nailing that messaging,
talking about talking to people about what what they think is the best thing to do.
I think a really great thing about this study was how they had these focus groups with people who vaped and
asked them about their experiences and then went on to incorporate that into the design of this study.
And that's just a brilliant use of what we call patient and public engagement.
And yeah,
I thought that was really impressive and something that would be great if we could use more in research and all kinds of research in the future,
not necessarily just with electronic cigarettes. Yeah, absolutely. That was one of the things I really enjoyed hearing about as well.
And and just generally and I think we've touched on it before,
one of the reasons why this is such a fascinating field to work in and that a lot of the research and a
lot of the science is really coming from the people who are using e-cigarettes to help them quit smoking.
And so so they have a really important role to play and continue to keep playing as this evidence evolves.
Yep, yeah, I agree. Great, well, unless you have anything else to add, Nicola, I think that's it from us.
Thank you so much for listening and to Professor Brendan for speaking with us.
Please subscribe on iTunes or Spotify and stay tuned for our next episode.
These kids may help your community in. But to mention the findings we have can tell us what happened long term, even though.
Vaping is safer than smoking weed may still cause.
Thinking of switching to. That's what the.
Smoking isn't bad.
Thank you to Jonathan Livingston Banks for running searches to Elsa Butler for producing this podcast and to all of you for tuning in.
Music is written with Johnny Berliner and I and performed by Johnny are live in systematic reviews supported by funding from Cancer Research UK.
The Cochrane Tobacco Addiction Group also receives core infrastructure funding from the National Institutes for Health Research.
The views expressed in this podcast are those of Nicola and I and do not represent those of the funders.