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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.

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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 might give you a different advice. Hi, I'm Nick Levinsohn, and I'm Jamie Harmon.

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Boys were both researchers based at the University of Oxford, where we work with the Cochrane Tobacco Addiction Group.

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Welcome to this edition of Let's Talk E-cigarettes. This podcast is a companion to a research project being carried out at the University of Oxford,

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where everyone's research the e-cigarettes literature to find new studies.

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We then use these studies to update our Cochrane systematic review of e-cigarettes for smoking cessation.

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This is called a Living Systematic Review. In each episode of this podcast,

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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.

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So first off, our guide you through what we found in our June 20, 21 searches.

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In a nutshell, we found three references. One was a dissertation which is linked to saying 2016, a study already included in the review.

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The second is a potentially new study identified via Clinical Trials Registry.

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But we are awaiting further detail to confirm whether it is eligible or not.

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And finally, we found a new protocol called Effects of providing tailored information about e-cigarettes in a Web based

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smoking cessation intervention by ELING and colleagues and published in JMI our research protocols.

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This randomised controlled trial will look at the effect of providing information about

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using e-cigarettes for smoking cessation rather than providing the e-cigarettes themselves.

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And so will be an interesting addition to our review when completed. So in addition to what we found in our searches,

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we're also excited to receive an early view of a new paper this month and to speak to

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Professor Thomas Brandon from the University of South Florida about his new study,

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Hot Off the Press in The Lancet Public Health. Interestingly, like the protocol Nicola just spoke about,

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the study didn't test the effects of providing any cigarette, which most of the studies in our review set out to do.

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But instead, in this study, what they did was they investigated the effects of providing tailored advice to duel

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users on how to use their e-cigarettes to quit smoking conventional cigarettes.

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It's a large randomised controlled trial,

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and we'd been aware that results from the study were forthcoming because we'd actually seen a conference abstract earlier this year,

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which we'd spoken about briefly on this podcast.

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So we were delighted when Professor Brendan shared impressed copy of the full article with us a few weeks ago.

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Now that it's just published on the 24th of June,

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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.

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So to start off, can you tell me a little bit about yourself and what got you into doing research on e-cigarettes?

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Sure. And thank you for inviting me, Jamie. This is very exciting.

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I'm a clinical psychologist at the University of South Florida and actually Moffitt Cancer Centre in Tampa, Florida.

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I conduct research on smoking and smoking cessation,

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have been doing so since entering graduate school at the University of Wisconsin back in nineteen eighty two.

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Working with Dr. Ken Baker at the time, you know, I saw my first cigarette, I think,

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in a mall kiosk more than a decade ago, and it was kind of curious about it.

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And like a lot of tobacco researchers, I was pretty sceptical at first,

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given the previous false promises of safe tobacco products such as filters and ultra light cigarettes.

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It just didn't pan out. But then I saw some friends and colleagues actually quit smoking with them.

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And these were the early devices, a signal light devices that delivered very little nicotine.

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And yet they seem to be able to switch.

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And, you know, with millions of smokers eventually using these devices, I just felt research was really needed on that.

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So we started doing some more descriptive research,

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just surveying each cigarette users and getting their opinions and serving their expectancy's or their beliefs about e-cigarettes versus combustible

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cigarettes versus a pharmacotherapy is like nicotine replacement therapies and seeing what they viewed as advantages and disadvantages of it.

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And that's kind of what got us started. It was this great. And and we were super excited to see your new study.

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I'd been aware it was going on. So it's very exciting to see it get to this point.

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But before we go into talking about that study in particular,

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I just wondered because it's specifically around targeting dual users of e-cigarettes and combustible tobacco cigarettes.

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And I think doofuses, our group that we hear a lot about and increasingly a little bit more research is getting done into them.

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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

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there's anything kind of special about this group that we should be aware of?

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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.

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So that suggests that this is largely a group that's already trying to quit smoking.

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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.

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Some are, you know, mostly smoking and vaping a little bit.

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Some are mostly vaping, but still smoking a little bit and everything in between. But through their dual use,

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they seem to be maintaining both their nicotine dependence as well as their exposure to toxicants from the combustible cigarettes.

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So given their quitting motivation, this seemed like a population that could benefit from a fairly minimal intervention,

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you know, self-help type intervention like we do.

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That included some advice on how best to use our e-cigarettes in order to, you know, completely quit smoking.

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Great. So that, I think, leads us nicely into your study in particular.

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So can you tell us a little bit about the methods used and what you set out to do?

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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.

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We wanted to learn about what worked for them and what didn't, because, remember,

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this started about eight years ago and it was very little research on smoking

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cessation of vaping or dual use or anything related to vaping at that time.

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So we gathered information by listening to actual vapours in our laboratory,

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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.

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We call it the extended self-help, which is a distinction between normal self-help,

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where you just give somebody a pamphlet, you know, one time, and that tends not to work too well.

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So we we updated our booklets for this population. We call them if you vape, you know, a guy that quitting smoking for vapours.

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And this series of booklets and pamphlets gets mailed to participants every month for 18 months.

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Once we had the intervention, we recruited nearly twenty nine hundred dual users to a study to follow them for two years.

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And notably, these weren't people who were necessarily trying to quit smoking or seeking help.

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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.

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But once they contacted us, we said, you know, it's possible we may also send you some intervention material to help you quit

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smoking and then we randomised them into three arms in the clinical trial.

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So one arm received no intervention. So they were just a surveillance arm control, just as we recruited them for.

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And then another arm received our new if you VAP intervention, then a third arm received our.

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Previous self-help, which was also 18 months, similar kind of intervention, but not tailored at all toward vapours.

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So just a regular smoking cessation intervention.

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So those were the two, you know, control condition to totally control surveillance only and a regular smoking cessation self-help.

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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.

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Fantastic. Can can I just ask in terms of that, if you vape booklet and the feedback that you got from your focus groups,

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what do you have any examples of the kind of thing that went in that that was different from your traditional self-help manual?

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Yeah, so I mean, you know, we had all the regular smoking cessation material in there.

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We didn't take any of that out, but we added new sections that were specific to vapours.

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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.

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So one example might be and since then, other research has found the same thing.

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One of the pieces of advice was of people who were successful was that they initially, when they were starting to switch,

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took up tobacco flavoured e-cigarettes because that ease the transition from their combustible

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cigarettes to their e-cigarettes because of a similar flavour or menthol if there were menthol smokers.

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And then over time, they switched to a non tobacco flavour like a fruit flavour or dessert flavour, for example.

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And they did that in order to kind of burn the bridge behind them,

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to make it less easy to switch right back to smoking, to distinguish it from smoking.

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And one of the things we learnt that they didn't like to call them even e-cigarettes,

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because that kind of implied it was still smoke and they preferred to call them, you know, vapes and call themselves vapours.

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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.

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And this was one of the early qualitative studies off the very first, but fairly early on.

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And since then, other research has found very similar advice from vapours.

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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.

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That's awesome. Yeah. So we we really had like three sources of the content for our book.

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This one was just a regular smoking cessation material that had been empirically supported,

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and that's based on the cognitive behavioural model and relapse prevention model. Obscure science term definition,

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a cognitive behavioural model aims to help people identify and change automatic

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thought patterns that influence behaviours such as smoking and emotions,

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a relapse prevention model teaches people to identify high risk situations that may lead

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them to return to smoking and provides them with strategies to cope with those situations.

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The second was the information we got from the vapours themselves.

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I just describe and a third source was what we know about nicotine replacement therapies

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because we conceptualise this as perhaps a much more effective nicotine replacement therapy,

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potentially because of its similarities with the act of smoking, you know, sensory motor similarities, obscure science term definition.

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In this context, sensory motor similarities refers to the fact that e-cigarettes mimic some of the sights,

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tastes and smells of smoking, as well as providing the familiar hand to mouth action of smoking.

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So we know that, for example, that one of the problems with nicotine replacement therapy is people often don't use enough of it.

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So, you know, we encourage people to, you know, vape whenever they had cravings or smoke.

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And, you know, emphasise that point is just one example of a translation between NRT and vaping.

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Fantastic. And were there any challenges in getting the study up and running?

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So getting funding and recruiting tour or did it all go fairly smoothly?

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I know there's always some challenges.

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Yeah, I think the main challenge is associated with the divisive, you know, polarised opinions about vaping that are out there.

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I related to today's politics, but, you know, particularly the United States, where people have taken such extreme positions in many cases.

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So to make it through the various review processes from the original grant application to getting the main results published,

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you know, we really have to walk a fine line.

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You know, at one extreme are the anti tobacco advocates who don't distinguish between combustible and non-combustible nicotine products.

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So they don't like the idea that we're even considering possible public health benefits of vaping like smoking cessation.

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But at the other extreme,

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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,

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they think they're consumer products are our seats don't adequately capture their effectiveness.

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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,

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maybe you want to consider quitting your vaping as well and becoming free of nicotine dependence.

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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.

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Their vaping at any point is a completely benign product.

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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.

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But I don't discount the effect of nicotine dependence and, you know, running smoking groups for 40 years.

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That's one of the main reasons people want to quit to get free from that dependence

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and always having to worry about having their products with them and everything else.

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So we give people the option of anyway. But we do it very gently.

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Yeah, it's it is a particularly challenging area to work with in that regard is that one often finds their pleasing No.

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One if standing somewhere in the middle. Yeah. We get criticised from both directions.

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Exactly. Really interesting. And so moving on.

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What did your study find? What kind of were the main results and was there anything that surprised you that came out of that?

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Yeah, well, one of the things know, kind of separate from our intervention self that we found, it was sort of surprising,

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especially given what we knew at the time we started this study was we had pretty high rates of smoking cessation across all groups.

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So I think even in the the surveillance only group, it didn't get any intervention.

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At two years, 40 percent of them had quit their smoking, you know, combustible cigarette.

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So that's a pretty high rate by itself. And other data has shown similar results.

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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.

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And that doesn't seem to be the case. So that's that's really good news right there.

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We found in terms of the intervention itself, we found that our intervention, if you vape booklets,

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were beneficial over the course of the 18 months that people received the booklets.

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So it added another roughly five to eight percent abstinence overall.

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And then a generic intervention that wasn't geared toward vapour specifically fell in between the two.

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So there was some benefit of any kind of help for smoking cessation, somewhat added benefit if it was geared specifically to vapours.

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But one of the interesting things is that the largest effects of the intervention were amongst the most dependent smokers.

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So the least dependent smokers had pretty high rates of cessation more.

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The parent there were the lower overall taxation rates were, but the bigger effect of the intervention itself, and that kind of makes sense.

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It's like nicotine replacement therapies work best with people who are dependent on cigarettes.

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If you're smoking just for social reasons and they're not physically dependent, you know, nicotine patches are going to make much difference.

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And it's probably the same thing with e-cigarettes and that extra help that we can give them for e-cigarettes.

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So after 18 months, those differences narrowed between arms.

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So that suggests to us that either we just sped up the cessation process or perhaps we

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have to extend it even longer to keep them engaged for 18 months may not be enough.

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And that's one of the nice things about having a low cost intervention like this,

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is that I imagine the prospect of extending isn't quite as challenging as it might be if you are,

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let's say, delivering some sort of resource intensive counselling or something.

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Yes, and we did a cost effectiveness analysis, and it is pretty cost effective compared to most interventions.

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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.

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And that might be even more cost effective if it would be fantastic to see.

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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.

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I noticed that in your study the intervention didn't endorse starting to vape.

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And that, of course, makes sense because you're in users who are already vaping.

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But you also write that it really set out, I think you said not to demonise or immediately discourage ongoing vaping,

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but then later, let's say once someone who quit smoking to recommend stopping vaping,

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I was wondering how you worded that, because it feels such a nuanced and complex area and a place where sometimes I

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think we could do better in the way we work and communicate these messages.

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Yeah.

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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,

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even if they were active vapours and are feeling they were getting some benefits from it in terms of cutting down their smoking.

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They didn't want us to suggest that at all. And some of our other research survey research suggests as well.

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So we decided we're not going to talk about quitting your vaping until near the end of the 18 months.

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I think around a 15 month point or so. We brought up that suggestion.

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And, you know, we do mention that we you know, there are likely some negative health consequences of vaping.

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You know, it's still most likely far less than combustible smoking, but there probably still are some.

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But we are but we mostly emphasise the freedom from dependence aspect of it that I mentioned earlier.

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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.

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So our gentle reminders really didn't have any effect overall.

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But we did find another.

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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.

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People were continuing to vape, were more likely to quit smoking at every follow up point, really.

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And I think that along with the overall cessation effects that we found provides additional

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evidence that's been accumulating on the efficacy of vaping for smoking cessation,

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or at least at the very least for switching.

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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,

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mainly trials where people have been provided e-cigarettes,

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but it's really nice to kind of see them encouraged to use their e-cigarettes to help them quit smoking.

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And following along that note around perhaps ceasing vaping at some point in your discussion,

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you note that interventions that facilitate vaping cessation without risking smoking relapse are needed.

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And and I couldn't agree more.

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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,

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a really risky topic because, of course, we don't think there are harm free, but we think that considerably less harmful than smoking.

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And so there's a real Trade-Off around these messages and how we do this.

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Do you have any sense of what these interventions might look like?

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Do you have kind of any ideas that might be too tough of a question, but I'm curious.

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Yeah, I mean, it remains an open question, but I think timing will prove to be important.

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The longer that vapours are smoke free, the probably the easier it will be for them to quit vaping without returning to smoking.

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And that's the key again. Yeah. And that's sort of consistent with some of our findings as well.

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It might be, especially the case of e-cigarettes differ from combustible cigarettes in as many ways as possible.

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Sort of as we were talking about earlier, was flavouring is a sensorimotor characteristic.

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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.

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You're kind of burning those behavioural conditioning bridges behind.

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Obscure science term definition, behavioural conditioning is where a behaviour such as smoking becomes more

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frequent or predictable in response to a particular environment or stimulus,

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such as the smell of tobacco smoke. Therefore, burning these bridges would mean that people unlearn the association between these triggers and the

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response behaviour as you switch away from all the aspects of that are associated with smoking.

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That was one of the advice, pieces of advice that we got from our focus groups as well as,

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you know, try to not not expand your vaping repertoire beyond what your smoking was.

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And that's one reason that, you know, I've not been in favour of legislation that proposes to completely eliminate flavours.

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So I think the flavours are important for switchers. We probably want to get rid of the flavours that are overly appealing to kids.

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You know that you hear a lot about the dinosaur vomit and things like that.

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But having at least an option of a set of flavours are available for adults that want

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to kind of get away from the tobacco flavour associated with smoking is important.

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Did you just say dinosaur vomit just to check? I think there is some flavours like that.

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They're always brought up as examples. I like to hear the examples of bubble gum and stuff.

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I have never thought about that before and I'm intrigued. I mean, I haven't seen these.

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I see, you know, advocates talk about flavours like, wow, OK, sorry, continue just checking that.

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I heard that. Right. You know, perhaps with unicorn vomit, I can't remember something so magical.

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But it also may make sense to gradually fade off the nicotine content of your e-cigarettes.

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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.

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So that's a possibility. OK, I know that in those conversations about nicotine content,

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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.

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So I'll be curious to hear how things go with that. Yeah, I think that's a difference between a gradual,

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fading approach versus just limiting the nicotine out of cigarettes from the start where

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you're likely to be more likely to have that compensatory vaping to get the higher nicotine.

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Whereas if you're gradually reducing it, you know, you're adjusting slowly to these levels and you're physiologically you're adjusting.

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That's really interesting. So that's it for me about your study specifically.

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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.

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What research do you think should be done next in this area?

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If, you know, you had all the time and money in the world, what kind of study might you hope to see?

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Well, first of all, we just need more clinical trials of e-cigarettes, testing or efficacy for smoking cessation.

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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.

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But there have been many barriers to conducting such studies. And that's actually what I wanted to do initially eight years ago.

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But we could not do those studies in the US and that's got me thinking, okay, what can we do?

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Well, maybe we can work with people who've already started using e-cigarettes since we're not allowed to give them to people.

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But we need to do those studies. They should be naturalistic studies as well, you know,

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a variety of research to test them not only under highly controlled settings, but also a more real world settings.

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We also need to study how best to communicate the relative risk of different nicotine products.

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Most people incorrectly believe that e-cigarettes are as dangerous or more dangerous and smoking,

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even when I speak to scientists, because that's what the press tends to play up.

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And that's really a failure in public health messaging. Yeah, I couldn't agree more.

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And then I think we need implementation studies on how public health and medical

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institutions should integrate e-cigarettes into their policies and procedures.

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You know, depending, of course, on the findings that come from these additional clinical trials either way for giving advice for or against,

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we need to learn how to do it.

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And if e-cigarettes continue to be found to be beneficial for smoking cessation, you know how to communicate that message.

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How do we incorporate that into a treatment plan for individuals that we see?

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Absolutely. Well, that is wonderful. So interesting. And I just want to say thank you so much once again.

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Well, thank you for inviting me today. I really enjoyed it. And look forward to your next Cochrane Review.

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Thank you so. Well, I. Really interesting about that chat with Professor Brandon, Jamie was what he was talking about,

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about potentially trying to reduce cigarette use to help people to come off of e-cigarettes when they've used them to quit smoking.

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And that's particularly interesting to me because a lot of the research that I've

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done in the past has been looking at helping people to reduce their smoking.

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So it will be interesting to potentially think about ways that we can use what we've

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learnt about reducing smoking to maybe help people to reduce their e-cigarettes use.

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But also what he touched upon, which I think is really important, is that we don't want people to feel, you know,

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vilified for using e-cigarettes and that they have to get off them too soon because I found it was really useful.

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What he found about people who continued to vape were more likely to be able to sustain cessation.

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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.

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Exactly. It's just that point, I think, about it being a spectrum of risk.

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And so you want people off a higher risk product,

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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.

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But we don't want to be taking people off of vaping, let's say, and then have them go back to smoking.

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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.

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But it's just, I think, extremely important that it be communicated and the research we conducted in a nuanced way.

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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,

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talking about talking to people about what what they think is the best thing to do.

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I think a really great thing about this study was how they had these focus groups with people who vaped and

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asked them about their experiences and then went on to incorporate that into the design of this study.

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And that's just a brilliant use of what we call patient and public engagement.

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And yeah,

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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,

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not necessarily just with electronic cigarettes. Yeah, absolutely. That was one of the things I really enjoyed hearing about as well.

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And and just generally and I think we've touched on it before,

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one of the reasons why this is such a fascinating field to work in and that a lot of the research and a

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lot of the science is really coming from the people who are using e-cigarettes to help them quit smoking.

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And so so they have a really important role to play and continue to keep playing as this evidence evolves.

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Yep, yeah, I agree. Great, well, unless you have anything else to add, Nicola, I think that's it from us.

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Thank you so much for listening and to Professor Brendan for speaking with us.

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

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These kids may help your community in. But to mention the findings we have can tell us what happened long term, even though.

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Vaping is safer than smoking weed may still cause.

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Thinking of switching to. That's what the.

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Smoking isn't bad.

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Thank you to Jonathan Livingston Banks for running searches to Elsa Butler for producing this podcast and to all of you for tuning in.

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Music is written with Johnny 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.