WEBVTT 1 00:00:04.500 --> 00:00:17.219 Rachel Rosen: Welcome to the tobacco online policy seminar tops and thanks for joining us today. I am Dr. Rachel Rosen, a postdoctoral research fellow at Massachusetts General Hospital and Harvard Medical School. 2 00:00:17.650 --> 00:00:34.040 Rachel Rosen: Pops is organized by Mike Pesco at University of Missouri, Steve Shang at the Ohio State University, Michael Darden at John Hopkins University, Jamie Hartman Boyce, at University of Massachusetts, Amherst and Justin White, at Boston University. 3 00:00:34.620 --> 00:00:39.160 Rachel Rosen: The Seminar will be 1 h with questions from the Moderator and discussant. 4 00:00:39.260 --> 00:00:53.530 Rachel Rosen: The audience may pose questions and comments in the Q. And a panel, and the moderator will draw from these questions and comments in conversation with the presenter. Please review the guidelines on tobaccopolicy.org for acceptable questions. 5 00:00:53.620 --> 00:00:57.839 Rachel Rosen: Please keep the questions professional and related to the research being discussed. 6 00:00:58.370 --> 00:01:04.819 Rachel Rosen: Questions that meet the seminar series. Guidelines will be shared with the presenter afterwards, even if they are not read aloud. 7 00:01:04.980 --> 00:01:07.400 Rachel Rosen: Your questions are very much appreciated. 8 00:01:08.130 --> 00:01:17.350 Rachel Rosen: This presentation is being video recorded and will be made available along with presentation slides on the tops website, tobaccopolicy.org. 9 00:01:17.360 --> 00:01:25.190 Rachel Rosen: I will turn the presentation over to today's moderator, Jamie Hartman Boyce from the University of Massachusetts, Amherst, to introduce our speaker. 10 00:01:25.810 --> 00:01:42.019 Jamie Hartmann-Boyce: Thanks so much, Rachel. Today we begin our winter 2025. Season with a grand Rounds. Presentation by Benjamin Toll, entitled E-cigarettes in the Us. Use by physicians prevalence, intentions to quit, and findings from several trials investigating methods for quitting. 11 00:01:42.710 --> 00:02:00.090 Jamie Hartmann-Boyce: based out of the Medical University of South Carolina. Dr. Benjamin Toll is a licensed clinical psychologist, a professor of Public Health Sciences and Psychiatry, Vice Chair of Research for the Department of Public Health Sciences, Co-director of the lung cancer screening program and director of the Health Tobacco Treatment program. 12 00:02:00.450 --> 00:02:07.580 Jamie Hartmann-Boyce: Dr. Toll has received grants from the Us. National Institutes of Health, including multiple r. 0. 1 grants from the National Cancer Institute. 13 00:02:07.590 --> 00:02:21.179 Jamie Hartmann-Boyce: and is an author of over 150 peer reviewed publications relating to nicotine and tobacco research, including several large clinical trials, investigating smoking, cessation, and several pilot clinical trials, testing treatments for e-cigarette use. 14 00:02:21.460 --> 00:02:32.929 Jamie Hartmann-Boyce: He has also published multiple clinical practice guidelines and official policy statements for major medical associations, and is the current president of the Society for Research on Nicotine and Tobacco. 15 00:02:33.120 --> 00:02:36.489 Jamie Hartmann-Boyce: Dr. Toll. Thank you for presenting for us today. 16 00:02:39.210 --> 00:02:43.710 Benjamin Toll: Alright. Thank you very much, Jamie. That was a lovely introduction. 17 00:02:44.580 --> 00:02:48.370 Benjamin Toll: We did not plan to both wear green, but we are both wearing green. 18 00:02:48.520 --> 00:02:52.180 Benjamin Toll: which is really great. I'm gonna share my screen now. 19 00:02:53.560 --> 00:02:56.019 Benjamin Toll: So here. 20 00:02:56.910 --> 00:02:58.320 Benjamin Toll: here we go. 21 00:02:58.340 --> 00:03:03.769 Benjamin Toll: And then I'm gonna start to go to presentation mode and ken 22 00:03:04.100 --> 00:03:06.346 Benjamin Toll: Serena or 23 00:03:07.860 --> 00:03:13.470 Benjamin Toll: Jamie, just let me know that you can see it, that it's sharing in in presentation mode. 24 00:03:13.470 --> 00:03:14.830 Jamie Hartmann-Boyce: It's looking good. 25 00:03:14.830 --> 00:03:19.099 Benjamin Toll: Okay. Great alright, thanks, Jamie. So 26 00:03:20.079 --> 00:03:27.269 Benjamin Toll: I am. Gonna I appreciate Jamie and Mike and the board for having me come talk 27 00:03:27.340 --> 00:03:36.850 Benjamin Toll: today. We're gonna talk about a variety of subjects concerning e-cigarettes and tobacco 28 00:03:37.620 --> 00:04:03.499 Benjamin Toll: conflicts of interest in the past 10 years. So I have testified since 2015 on behalf of plaintiffs who have filed litigation against the industry. That's mostly, but not exclusively. Philip Morris Reynolds and jewel labs. I worked as a paid consultant on a single advisory board about e-cigarettes for Pfizer 29 00:04:03.540 --> 00:04:12.268 Benjamin Toll: quite some time ago. So 2018 is when I I did that 30 00:04:13.020 --> 00:04:21.999 Benjamin Toll: and we, of course, know that their drug that they represented when Loe approximately 2019 or 2020 31 00:04:23.077 --> 00:04:47.779 Benjamin Toll: so I just want to give you my professional perspective. Just so that you understand the lens that I view our work through. So I direct the operations for a tobacco treatment service that touches approximately 10,000 tobacco users per year. It's a large health 32 00:04:47.930 --> 00:05:05.176 Benjamin Toll: system, 11 hospitals and many, many outpatient clinics. Usually we provide medications for tobacco treatment. That's mostly patches, gum and lozenges. 33 00:05:06.730 --> 00:05:21.049 Benjamin Toll: in the hospital. Those are what's more, prevalent, and most of our physicians, especially hospitalists, don't feel comfortable prescribing a medication that needs follow up 34 00:05:21.565 --> 00:05:23.699 Benjamin Toll: although we we, of course, are 35 00:05:23.880 --> 00:05:26.040 Benjamin Toll: trying to change that somewhat. 36 00:05:26.946 --> 00:05:28.519 Benjamin Toll: About half 37 00:05:29.240 --> 00:05:36.179 Benjamin Toll: or more than half of these medically compromised patients have died or will die 38 00:05:36.330 --> 00:05:38.500 Benjamin Toll: from use of tobacco. 39 00:05:38.590 --> 00:05:39.760 Benjamin Toll: So 40 00:05:39.820 --> 00:05:48.040 Benjamin Toll: it really hurts my heart when I open up our medical record. And there's a big black box that comes up in my medical record. 41 00:05:48.300 --> 00:05:53.400 Benjamin Toll: which is epic. There's a big black box that comes up and says, this patient is 42 00:05:54.190 --> 00:06:03.120 Benjamin Toll: deceased, and that's very upsetting for for me it. It hurts every time frankly, and so I 43 00:06:03.280 --> 00:06:07.390 Benjamin Toll: and the fierce a fierce advocate for patience. 44 00:06:07.420 --> 00:06:17.419 Benjamin Toll: and all of these patients that use tobacco and have a myriad of psychiatric and of medical problems. They need our help 45 00:06:18.420 --> 00:06:37.260 Benjamin Toll: for the quitting process and for their other health issues. Frankly. So, if they quit smoking. If they quit vaping in general, especially for smoking. In general, it will improve almost all of their other health issues. 46 00:06:37.280 --> 00:06:39.490 Benjamin Toll: I'm also a passionate 47 00:06:39.980 --> 00:06:56.799 Benjamin Toll: a passion advocate for trainees and for colleagues. I feel that trainees are our future, and so we must fight for them, because in 20 years I'll be gone, and hopefully they'll be here and they'll be fighting that good fight. 48 00:06:56.990 --> 00:06:58.070 Benjamin Toll: So 49 00:06:59.742 --> 00:07:06.490 Benjamin Toll: I am funded by the Musc Hollings cancer Center. That's the Grant number there. 50 00:07:06.560 --> 00:07:14.770 Benjamin Toll: Some of these are of the of the pilots that I'm gonna mention are are funded by Startup funds 51 00:07:14.910 --> 00:07:33.899 Benjamin Toll: from the cancer center. I've had multiple grants, as Jamie mentioned. That's all public on this website, as Jamie mentioned, I am the president of Sr. And T. But the content of this presentation is not the official views 52 00:07:34.090 --> 00:07:36.270 Benjamin Toll: of SR. And T. So 53 00:07:36.870 --> 00:07:41.539 Benjamin Toll: this is kind of a broad framework of what we're gonna talk through today. 54 00:07:42.060 --> 00:07:57.259 Benjamin Toll: We're going to go through considerations for providers concerning e-cigarettes. We'll talk about the importance, the very, very vast importance of 18 to 24 year olds. 55 00:07:58.420 --> 00:08:00.510 Benjamin Toll: any cigarette prevalence. 56 00:08:00.560 --> 00:08:09.249 Benjamin Toll: We're gonna talk about. The the very clear data that show that most E cigarette users 57 00:08:09.590 --> 00:08:12.010 Benjamin Toll: have plans to quit. 58 00:08:12.160 --> 00:08:15.269 Benjamin Toll: And those data of are from Path 59 00:08:16.288 --> 00:08:22.389 Benjamin Toll: we're gonna go through pilot study of Nrt, that's Patch plus lozenge 60 00:08:22.660 --> 00:08:25.050 Benjamin Toll: or quitting vaping. 61 00:08:25.080 --> 00:08:33.080 Benjamin Toll: And then the last trial that will run through is a review of of the drug, formally called 62 00:08:33.110 --> 00:08:39.750 Benjamin Toll: Chantix, is now generic. Well, I'm sorry it was Chantics or chanpix 63 00:08:40.200 --> 00:08:45.780 Benjamin Toll: in the rest of the world. Now, generic versus 64 00:08:45.880 --> 00:08:48.909 Benjamin Toll: placebo for wedding vaping. 65 00:08:49.370 --> 00:08:55.610 Benjamin Toll: So if I have seen any further, it's only because I'm standing on the shoulders of giants. 66 00:08:55.640 --> 00:09:00.259 Benjamin Toll: Of course, Isaac Newton said that, and he was talking about 67 00:09:00.400 --> 00:09:07.560 Benjamin Toll: all of the scientists before him, like Galileo and Magellan, who had 68 00:09:07.720 --> 00:09:14.990 Benjamin Toll: whose work he had built upon. And so these are my mentors and sponsors. 69 00:09:15.690 --> 00:09:19.299 Benjamin Toll: and I think you guys can see my 70 00:09:19.540 --> 00:09:38.749 Benjamin Toll: my pointer right? So I'm just gonna point. So this is Mark Sabel. He's a psychologist that's now retired. But that's who I trained with for graduate school mark is probably best known for creation of a timeline. Follow back, or Tl, Fb. 71 00:09:39.580 --> 00:09:41.030 Benjamin Toll: And funnily 72 00:09:41.590 --> 00:10:08.169 Benjamin Toll: I said, I mentioned in in Jamie's podcast. Called let's Talk, E. Cigarettes, which is fantastic by the way, and and available on spotify and apple, and all of the streaming platforms certainly go listen to it. It's a great podcast but they have this cute part where there, if you say something like timeline. Follow back. There's a dog that barks, it goes. 73 00:10:08.220 --> 00:10:18.052 Benjamin Toll: and and they say obscure scientific reference, and then they say what it is. So apparently Mark's timeline is an obscure scientific reference. 74 00:10:18.480 --> 00:10:43.319 Benjamin Toll: but it is the way that most of us measure smoking and drinking behaviors, and Mark in graduate school really taught me how to write a good paper, and taught me how to be a rigorous scientist. Next is Stephanie from Yale, who was one of my 2 postdoc mentors, and Stephanie really is an incredibly rigorous scientist, and she 75 00:10:43.320 --> 00:10:47.219 Benjamin Toll: taught me she's currently the co-pi of the Lt. Course. 76 00:10:47.290 --> 00:11:16.630 Benjamin Toll: She taught me how to just write a really good grant, and how to be a very thoughtful scientist. And and and by the way, we're we're still in in touch. I still see her. I just talked to Mark a few weeks ago he just turned 80, and he is now retired. And then there's Peter Salovey, who was one of my postdoc mentors, and he introduced me and and helped me 77 00:11:16.630 --> 00:11:20.607 Benjamin Toll: to become a game frame 78 00:11:22.620 --> 00:11:27.719 Benjamin Toll: investigator. So a framing of framing messages. 79 00:11:27.780 --> 00:11:44.460 Benjamin Toll: type of a scientist where I looked rigorously at game frame universal messages. And Peter. When I met Peter in 2,002. He was the chair of the Department of Psychology. 80 00:11:44.460 --> 00:12:10.679 Benjamin Toll: And I was so excited I was like, Wow, I'm being trained by the chair of psychology. And then he just rose through the ranks at Yale, through a few deanships, and then Provost, and then he was President for many years, and he just stepped down last year. He's still faculty at at Yale, and Peter really taught me how to delegate. So 81 00:12:10.730 --> 00:12:24.589 Benjamin Toll: Peter surrounds himself with a huge group of very smart people, and he taught me how to just delegate things in a a way that allows you to get 82 00:12:24.790 --> 00:12:26.540 Benjamin Toll: a lot done frankly. 83 00:12:27.030 --> 00:12:28.870 Benjamin Toll: Next is Roy Herbst. 84 00:12:28.900 --> 00:12:35.789 Benjamin Toll: who is a very long time sponsor and a professor at Yale. Roy 85 00:12:36.460 --> 00:12:41.439 Benjamin Toll: brought me into the world of cancer. And he brought me to the big. 86 00:12:41.670 --> 00:12:48.749 Benjamin Toll: the big conferences, and he introduced me to the Ceos and got me to publish in very large cancer 87 00:12:48.820 --> 00:12:51.820 Benjamin Toll: journals, and he helped me to go to 88 00:12:52.100 --> 00:13:04.909 Benjamin Toll: Congressional briefings. He's just a really lovely guy that cares very much about cancer and science and and he's been a great sponsor and a great friend. 89 00:13:05.410 --> 00:13:07.000 Benjamin Toll: And of course we 90 00:13:07.190 --> 00:13:09.169 Benjamin Toll: of course, we all know Dr. 91 00:13:09.280 --> 00:13:11.639 Benjamin Toll: Comments who I met Mike 92 00:13:14.530 --> 00:13:17.150 Benjamin Toll: It was the early 2,000 s. 93 00:13:17.380 --> 00:13:24.320 Benjamin Toll: Back when there were T-charps, and that stands for transdisciplinary tobacco. Use Research 94 00:13:24.770 --> 00:13:41.341 Benjamin Toll: Center, and I was at a teacher conference. And you know Mike and I were in line for lunch, and Mike said it. It'd be great for you to test your framing through my quit line. And I said, Really, that sounds great. And then 95 00:13:41.750 --> 00:14:10.020 Benjamin Toll: From there, from there Mike helped me get my very 1st R. 21, and since then I've worked with Mike on on numerous studies, and it's been a great relationship, and Mike is a very careful scientist that is incredibly loyal, and a force in this field, and we all appreciate his passion very much. So from here. I am now going to talk about 96 00:14:10.590 --> 00:14:18.540 Benjamin Toll: teams and my teams. So so this quote, my teammates have my back and I have theirs. 97 00:14:18.550 --> 00:14:20.280 Benjamin Toll: This is from 98 00:14:21.040 --> 00:14:27.610 Benjamin Toll: 2 time. Mvp. Lamar Jackson, who is the quarterback of 99 00:14:27.780 --> 00:14:36.220 Benjamin Toll: the Ravens where I'm from, so I'm from Baltimore, and I'll talk about that a bit during this talk. But in Baltimore we talk about the flock 100 00:14:36.380 --> 00:14:42.840 Benjamin Toll: and having a team that matters, a team that you care about. And so this is my flock. So 101 00:14:42.900 --> 00:14:48.380 Benjamin Toll: we have a large team in musc of great scientists 102 00:14:48.530 --> 00:15:03.550 Benjamin Toll: and great administrators that just do wonderful things. So that's my team. And I care very much about this team, and it's a team that we are excited to work with 103 00:15:03.610 --> 00:15:05.670 Benjamin Toll: on a daily basis. 104 00:15:05.910 --> 00:15:06.950 Benjamin Toll: So 105 00:15:07.410 --> 00:15:10.700 Benjamin Toll: one of the team members is Dr. Tracy Smith. 106 00:15:10.960 --> 00:15:35.810 Benjamin Toll: who worked with me and and Dr. King on a letter that came out in Nature medicine. And so that's Dr. Brian King, who we all know, and who is the director of the center for tobacco products at the FDA, and a lovely guy and a great scientist. And we approached Dr. King. 107 00:15:35.810 --> 00:15:44.886 Benjamin Toll: So Tracy and I approached. Dr. King said, this is a picture of Brian and I from the Scotland Conference, 108 00:15:45.390 --> 00:15:55.629 Benjamin Toll: we approach Brian at the Texas Conference. So before Scotland was San Antonio, Texas, and we approached him and said 109 00:15:56.000 --> 00:15:59.369 Benjamin Toll: I had just met with a a physician 110 00:15:59.590 --> 00:16:08.910 Benjamin Toll: from a very good school that I'm not gonna mention the name. But he said to me. 111 00:16:09.320 --> 00:16:12.539 Benjamin Toll: and yeah, this was an oncologist 112 00:16:13.820 --> 00:16:17.790 Benjamin Toll: I meet with loads of oncologists, and he said. 113 00:16:18.370 --> 00:16:21.240 Benjamin Toll: vapes. Those are worse than smoking 114 00:16:21.450 --> 00:16:28.290 Benjamin Toll: right. I didn't put my head in my hands at that time, but I did say to Brian. 115 00:16:28.340 --> 00:16:39.280 Benjamin Toll: You know I am very opposed to youth vaping. But I do think that our physicians need to to know that in general 116 00:16:39.680 --> 00:16:44.390 Benjamin Toll: e-cigarettes have less risk than combusted cigarettes. 117 00:16:44.420 --> 00:16:56.050 Benjamin Toll: and that was what started a conversation and led to this important letter. And I'm just gonna share our conclusions. If I can get this thing to move forward. 118 00:16:57.225 --> 00:16:58.220 Benjamin Toll: So 119 00:16:59.210 --> 00:17:13.150 Benjamin Toll: 1st line is that clinicians should provide counseling and an approved medication for treatment. There's no question. So for a cigarette smoker 120 00:17:13.220 --> 00:17:15.539 Benjamin Toll: that comes to your clinic 121 00:17:16.000 --> 00:17:18.889 Benjamin Toll: start with Meds and with counseling 122 00:17:19.020 --> 00:17:21.440 Benjamin Toll: for adults that continue to smoke. 123 00:17:21.700 --> 00:17:31.439 Benjamin Toll: Our doctors and providers may consider talking about the relative risks of products and educate 124 00:17:31.450 --> 00:17:41.740 Benjamin Toll: patients, that exclusive use of any cigarette, instead of cigarettes, would cut down on exposure to known toxicants and carcinogens. 125 00:17:41.840 --> 00:17:45.919 Benjamin Toll: and they need to reinforce that the importance 126 00:17:46.070 --> 00:17:55.349 Benjamin Toll: of complete transitioning away from combusted products to get the full full benefits to their health. 127 00:17:55.770 --> 00:17:59.120 Benjamin Toll: If patients do choose to use any 128 00:17:59.170 --> 00:18:10.560 Benjamin Toll: cigarette for complete transitioning, providers should make patients aware of the 23 products that have been authorized by the FDA. We just hosted Brian here 129 00:18:10.770 --> 00:18:16.339 Benjamin Toll: at for for one of our named lectures. It was the Rosenblatt lecture that's hosted by Mike. 130 00:18:17.605 --> 00:18:18.530 Benjamin Toll: And 131 00:18:18.970 --> 00:18:22.859 Benjamin Toll: Brian said at that time, and I agree 132 00:18:23.140 --> 00:18:40.310 Benjamin Toll: you should be talking about the products that have gone through the very rigorous review by the FDA, and been shown scientifically to have fewer toxicants and fewer carcinogens. So it's important that. And I know that this is a polarizing issue. 133 00:18:40.320 --> 00:18:46.259 Benjamin Toll: But I do agree with Dr. King that that's what we should do. And the 134 00:18:46.360 --> 00:18:48.640 Benjamin Toll: other thing that we say 135 00:18:48.750 --> 00:18:50.449 Benjamin Toll: in the article 136 00:18:50.580 --> 00:18:52.420 Benjamin Toll: that I didn't have room in this 137 00:18:52.550 --> 00:18:54.450 Benjamin Toll: presentation to 138 00:18:54.500 --> 00:19:00.150 Benjamin Toll: to to type out. But we'll say verbally, is that we're very opposed 139 00:19:00.340 --> 00:19:03.679 Benjamin Toll: to youth. Use one and 2. 140 00:19:04.830 --> 00:19:13.790 Benjamin Toll: Our doctors may talk about the idea of complete transitioning away from combusted products, but 141 00:19:14.330 --> 00:19:17.430 Benjamin Toll: the end goal should be 142 00:19:17.590 --> 00:19:18.800 Benjamin Toll: quitting 143 00:19:19.280 --> 00:19:26.070 Benjamin Toll: the vape too, so they can vape for a specified time period. But our end goal 144 00:19:26.310 --> 00:19:29.980 Benjamin Toll: should be to transition then off 145 00:19:30.290 --> 00:19:33.452 Benjamin Toll: of that vape. So I'm gonna 146 00:19:34.330 --> 00:19:37.763 Benjamin Toll: transition now to talking about 147 00:19:39.050 --> 00:19:41.029 Benjamin Toll: my views on e-cigarettes. 148 00:19:41.320 --> 00:19:42.570 Benjamin Toll: So 149 00:19:43.110 --> 00:19:44.150 Benjamin Toll: I 150 00:19:44.380 --> 00:19:47.469 Benjamin Toll: I grew up in Baltimore, and my dad was poor. 151 00:19:47.660 --> 00:19:49.779 Benjamin Toll: and we had mice. This is a mouse. 152 00:19:50.339 --> 00:20:02.089 Benjamin Toll: And mice mice are vermin comes from the Latin word vermis, which means worm. So that's the little worm like larvae, and and the insects that infest food. 153 00:20:02.150 --> 00:20:09.839 Benjamin Toll: So mice, poop, and pee all over your residence. It's quite gross. They spread illness, they spread death. 154 00:20:09.990 --> 00:20:16.159 Benjamin Toll: they they eat your food. So if your cereal is not in plastic, if it's in. 155 00:20:16.580 --> 00:20:23.370 Benjamin Toll: If it's in a carb or box they'll chew right through, and they'll get to your cereal. They they hurt your sleep 156 00:20:23.480 --> 00:20:26.830 Benjamin Toll: so they scurry through your walls. They scratch. 157 00:20:27.290 --> 00:20:32.350 Benjamin Toll: They're really like they're really a bad, bad thing to have 158 00:20:32.460 --> 00:20:37.279 Benjamin Toll: inside your residence for me. That's a combusted cigarette. 159 00:20:38.330 --> 00:20:44.370 Benjamin Toll: This is a cat. In fact, this is my cat. Her name is Roxanne or Roxy. 160 00:20:44.530 --> 00:20:47.410 Benjamin Toll: So yeah, as you can see. 161 00:20:47.760 --> 00:20:55.250 Benjamin Toll: she's much more attractive than mice, so cats in general are much more attractive than mice. 162 00:20:55.700 --> 00:20:56.650 Benjamin Toll: but 163 00:20:57.590 --> 00:21:03.850 Benjamin Toll: they do poop and pee. It's in a litter box, so it's more contained, but it is still a burden. 164 00:21:03.890 --> 00:21:06.100 Benjamin Toll: They cause bad allergies 165 00:21:06.400 --> 00:21:07.690 Benjamin Toll: to humans. 166 00:21:07.830 --> 00:21:11.080 Benjamin Toll: They scratch up and destroy your furniture. 167 00:21:11.110 --> 00:21:13.560 Benjamin Toll: they bite and scratch you. 168 00:21:13.590 --> 00:21:23.500 Benjamin Toll: A cat bite is, in fact, quite dangerous. So if you have a true full cat bite. It can lead to sepsis. It can cause very serious 169 00:21:23.710 --> 00:21:25.469 Benjamin Toll: problems for me. 170 00:21:25.830 --> 00:21:27.539 Benjamin Toll: That's an e-cigarette. 171 00:21:27.570 --> 00:21:29.740 Benjamin Toll: So, to be clear. 172 00:21:29.840 --> 00:21:31.829 Benjamin Toll: we have mice who are 173 00:21:32.350 --> 00:21:40.250 Benjamin Toll: really really bad. That's gonna bust a cigarette, and then a much more appealing and attractive animal. 174 00:21:40.740 --> 00:21:45.740 Benjamin Toll: But that still has several issues and several 175 00:21:45.810 --> 00:21:51.240 Benjamin Toll: problems and still has some risk and problems that come with it. 176 00:21:51.930 --> 00:21:52.960 Benjamin Toll: So 177 00:21:53.470 --> 00:21:59.467 Benjamin Toll: now I'm gonna try to speed up. Because I see it's 12. It's 1223. So 178 00:22:00.790 --> 00:22:30.269 Benjamin Toll: I want to transition to talking about the importance of young adults. So the industry has always cared about young adults. So Philip Morris called these yams and yas, and they studied them, and they noted in their previously secret documents that they foreshadow the future performance of brands. So these are from the San Francisco library. The only segment that would not fill out the surveys are yams 179 00:22:31.660 --> 00:22:44.549 Benjamin Toll: And share was declining among yafs, and followed by softening among 25 to 34 yafs were of particular importance, because they 180 00:22:45.470 --> 00:22:49.760 Benjamin Toll: because they represent and they foreshadow the brand's long term 181 00:22:49.770 --> 00:22:53.489 Benjamin Toll: performance. When you turn 18, 182 00:22:53.700 --> 00:23:13.149 Benjamin Toll: you are generally graduating high school, possibly going to college. You're on your own, you have your own, your your own money, and that's when a time of great transition and a time where, if you can establish brand loyalty, it stays with you. 183 00:23:13.820 --> 00:23:14.780 Benjamin Toll: So 184 00:23:15.060 --> 00:23:32.780 Benjamin Toll: this is Brandon Sanford and Naomi Brownstein. So Brandon is at the time that he did. This study was one of my postdoc fellows. He is now an assistant professor of family medicine at Musc, and that's Naomi Brownstein, who is an associate 185 00:23:32.940 --> 00:23:46.540 Benjamin Toll: professor of biostats here in the Department of Public Health Sciences. So this is using waves, one through 6 of the FDA's path study. And that's a nationally representative 186 00:23:46.770 --> 00:24:01.259 Benjamin Toll: study, of course, of it varies, but approximately 45,000 people that that represent our our country. These are the definitions for established smoking and established vaping. 187 00:24:02.640 --> 00:24:09.020 Benjamin Toll: So here's what Brandon found. So these dark bars are established 188 00:24:09.080 --> 00:24:15.060 Benjamin Toll: smoking, and the years here. So this starts in 2013, and it goes up through 2021. 189 00:24:15.090 --> 00:24:22.640 Benjamin Toll: So the the the darker brown bars are smoking, and it's unequivocally going down. 190 00:24:23.320 --> 00:24:30.900 Benjamin Toll: and these lighter bars are vaping, and the white bars are the never smokers that vape. 191 00:24:31.060 --> 00:24:49.340 Benjamin Toll: So if you look at these bars, they are unequivocally going up. At the time we published this wave 6 was restricted use. We obtained it, and we were floored. That there are now, as of 3 years ago. 192 00:24:49.490 --> 00:24:54.169 Benjamin Toll: there are now more, never smoking vapors than established 193 00:24:54.710 --> 00:25:13.289 Benjamin Toll: smokers, and that brings us to the great Wayne Gretzky that said ice skate to where the Puck is going to be, not to where it's been. So the Puck has been here. It has been in smoking, but it's going to be in vaping, so we need as a field 194 00:25:13.690 --> 00:25:20.219 Benjamin Toll: to shift a large number of our resources towards treatment of vaping. 195 00:25:20.640 --> 00:25:23.320 Benjamin Toll: Why, why should we do that? Well. 196 00:25:23.350 --> 00:25:27.942 Benjamin Toll: this brings me to Dr. Palmer, who was one of my 197 00:25:28.880 --> 00:25:37.160 Benjamin Toll: my pre, Doc and Postdoc, fellows that is now an instructor, and soon to be assistant professor at 198 00:25:37.340 --> 00:25:46.229 Benjamin Toll: Musc. She did 2 great studies of pathway 4 and 5, in which she found that 199 00:25:46.270 --> 00:25:54.999 Benjamin Toll: approximately 3 fifths in wave, 4 plan to quit, and a smaller number had tried to to quit 200 00:25:55.060 --> 00:25:59.980 Benjamin Toll: and in Wave 5. It was 2 thirds plus that planned to quit 201 00:26:01.117 --> 00:26:10.660 Benjamin Toll: and almost 20% that it tried to quit. And I believe I'm supposed to stop here and pause to see if there's questions. 202 00:26:11.500 --> 00:26:16.479 Jamie Hartmann-Boyce: Thanks, so much, Ben, and thanks also to the call out to our podcast which I appreciate. 203 00:26:16.807 --> 00:26:28.889 Jamie Hartmann-Boyce: So our discussant today is Dr. Joanna Strucht, an assistant professor from Massachusetts General Hospital, and Harvard Medical School. I'm going to 1st open up to Joanna for any comments or questions she might have at this point. 204 00:26:30.010 --> 00:26:48.259 Joanna Streck: I will save my questions for the end. But just to comment. I loved your nod to patient care, mentoring your own mentors, your mentees and kind of the cycle of mentorship. Yeah, and I've enjoyed the talk so far, and I have some questions for the end. But I don't want to interrupt your flow. Now. 205 00:26:48.260 --> 00:27:02.250 Benjamin Toll: Okay, great. So I'm going to keep going. Then. Thank you. Dr. Streck and Dr. Bryce. I'm going to move forward to a study that was conducted by Dr. Palmer. 206 00:27:03.311 --> 00:27:09.349 Benjamin Toll: And I believe that you have access to the 6 papers I'm talking through 207 00:27:09.380 --> 00:27:10.485 Benjamin Toll: today. 208 00:27:12.530 --> 00:27:25.890 Benjamin Toll: Amanda looked at. This was a mix of both mono vapors and dual users. We all know, of course, the dual use means use of both cigarettes and e-cigarettes. 209 00:27:26.270 --> 00:27:44.689 Benjamin Toll: In this study. She randomized 30 participants in a 2 to one fashion. To treatment versus control treatment was approximately one month of the 21 milligram patch and the 4 milligram lozenge. The control was a referral to the South Carolina swit 210 00:27:44.830 --> 00:27:55.810 Benjamin Toll: to the South Carolina. Quit line and you you can see right here that the 2 to one, you know, gave us about 18 that got treatment and 12 that got 211 00:27:55.820 --> 00:27:57.190 Benjamin Toll: control. 212 00:27:59.260 --> 00:28:00.460 Benjamin Toll: So 213 00:28:00.690 --> 00:28:02.639 Benjamin Toll: what she found was 214 00:28:02.680 --> 00:28:06.970 Benjamin Toll: 40% of the people in the treatment group 215 00:28:07.070 --> 00:28:09.660 Benjamin Toll: that got patch plus lozenge 216 00:28:10.230 --> 00:28:11.710 Benjamin Toll: quit e cigarettes. 217 00:28:12.550 --> 00:28:16.320 Benjamin Toll: Unfortunately, no one in the control group quit. 218 00:28:17.630 --> 00:28:28.319 Benjamin Toll: and then the dual. And then it gets really interesting for the dual users, so notably none of the dual users quit smoking a quarter 219 00:28:28.650 --> 00:28:30.139 Benjamin Toll: quit vaping. 220 00:28:30.440 --> 00:28:32.749 Benjamin Toll: but continued to smoke. 221 00:28:33.060 --> 00:28:39.910 Benjamin Toll: So that's the wrong way on the the continuum of of risk. 222 00:28:39.990 --> 00:28:41.160 Benjamin Toll: We want 223 00:28:41.290 --> 00:28:47.509 Benjamin Toll: folks ideally to quit both, but if they're gonna quit one that they quit smoking and they keep vaping. 224 00:28:48.001 --> 00:28:51.970 Benjamin Toll: So Dr. Palmer is now. So I I think. 225 00:28:52.240 --> 00:28:58.920 Benjamin Toll: and we agree that it may be that dual users need higher doses of nicotine. 226 00:28:59.010 --> 00:29:03.649 Benjamin Toll: So Dr. Palmer was funded thankfully by the Acs 227 00:29:03.740 --> 00:29:15.740 Benjamin Toll: to do. Again, a small pilot of 45 subjects, in which it's varying doses of Nrt. But higher doses for dual users and 228 00:29:16.310 --> 00:29:19.090 Benjamin Toll: her last. Her last follow up 229 00:29:19.100 --> 00:29:31.479 Benjamin Toll: is going to be in about a week, so we are very excited to see those data and stay tuned, as we hope to publish those data in the near future. So stay tuned for that. 230 00:29:32.070 --> 00:29:36.120 Benjamin Toll: And then the last trial I'm gonna talk through 231 00:29:36.270 --> 00:29:39.750 Benjamin Toll: today is with my colleague and good friend Lisa. 232 00:29:40.360 --> 00:30:01.629 Benjamin Toll: who is at Yale, and was just a few years behind me, starting at Yale. I'm not going to say what years? Because it was a long time ago. But we have been close colleagues and friends for about 15 years. And this is a group of people at Yale and 233 00:30:01.700 --> 00:30:04.124 Benjamin Toll: at Musc who have 234 00:30:04.860 --> 00:30:12.500 Benjamin Toll: who have worked on this study. And Lisa presented these data in Scotland. 235 00:30:12.530 --> 00:30:25.630 Benjamin Toll: So this was a 2 month study that was across 2 sites. So we got 20 people down here in Charleston, and Lisa's group got 20 at Yale. 236 00:30:26.073 --> 00:30:43.430 Benjamin Toll: We. We then randomized them to drug or placebo that went for so the Med use went from week 0 up through week 8, and then we followed them for 4 more weeks for a 1 month. Follow up 237 00:30:43.890 --> 00:31:03.049 Benjamin Toll: is the primary care model. So this was a self directed booklet a 5 to 10 min phone call, but we tried for 5. I did. I did a handful of these calls like just to make sure that the operations were going well in this pilot. 238 00:31:03.494 --> 00:31:14.599 Benjamin Toll: And the the outcomes were point prevalence at 7 for the past 7 days right here at week 8, and right here at week 12. 239 00:31:15.360 --> 00:31:18.750 Benjamin Toll: So here's what the group looks like. 240 00:31:18.860 --> 00:31:22.630 Benjamin Toll: So the split on gender was good. 241 00:31:23.182 --> 00:31:25.659 Benjamin Toll: It was a mostly white group. 242 00:31:27.480 --> 00:31:30.529 Benjamin Toll: The the history of smoking was about half 243 00:31:31.622 --> 00:31:34.270 Benjamin Toll: most people vape daily. 244 00:31:35.142 --> 00:31:43.167 Benjamin Toll: and through through the day. So they were continuously vaping. It's a very modern group. So they kept vaping 245 00:31:44.100 --> 00:31:46.600 Benjamin Toll: they had vaped for about 5 years. 246 00:31:47.061 --> 00:31:52.799 Benjamin Toll: This Ec dependence is the promise measure, and these are very high numbers. 247 00:31:54.610 --> 00:31:59.139 Benjamin Toll: so that you know this is a dependent group. 248 00:31:59.680 --> 00:32:05.920 Benjamin Toll: And they're mostly using dispose and carts. So they're they. They are using 249 00:32:06.520 --> 00:32:08.929 Benjamin Toll: almost exclusively 250 00:32:09.842 --> 00:32:21.479 Benjamin Toll: those devices. And they're almost exclusively salt based. And it's a mixed psychiatric group. So many psych problems 251 00:32:22.110 --> 00:32:23.759 Benjamin Toll: as we see 252 00:32:24.070 --> 00:32:25.799 Benjamin Toll: in most samples 253 00:32:25.850 --> 00:32:29.890 Benjamin Toll: of of tobacco users in modern times. 254 00:32:30.270 --> 00:32:31.190 Benjamin Toll: So 255 00:32:33.630 --> 00:32:36.109 Benjamin Toll: here's what we did. We randomized 40 256 00:32:36.200 --> 00:32:42.439 Benjamin Toll: people to drug or placebo. One participant had a dose 257 00:32:42.660 --> 00:32:49.019 Benjamin Toll: reduction. I called her several times and consulted with Dr. Gray, who's our 258 00:32:49.120 --> 00:32:50.960 Benjamin Toll: our psychiatrist 259 00:32:51.520 --> 00:32:55.039 Benjamin Toll: on the Musc side, and talked. 260 00:32:55.200 --> 00:33:14.869 Benjamin Toll: you know, with her about she had high nausea and so we talked about cutting back her dose 9 other participants had aes that were the common kind of usual suspects for this asset. So that's nausea, insomnia. 261 00:33:14.940 --> 00:33:16.639 Benjamin Toll: and vivid dreams. 262 00:33:18.010 --> 00:33:21.750 Benjamin Toll: Here's the the findings for this 263 00:33:22.020 --> 00:33:46.509 Benjamin Toll: preliminary study. So a nice treatment difference between treatment and placebo at the end of treatment that that degrades slightly, but is still is still very much there at the one month. Follow up. What's interesting is that participants that had a smoking history, regardless of group. 264 00:33:46.510 --> 00:34:04.479 Benjamin Toll: had a much higher chance of quitting. So that's an interesting finding. And that was a significant finding. Now let's talk about smoking, obviously one fear of treating vaping, especially if you have a smoking history is that you're going to go back to smoking? 265 00:34:04.898 --> 00:34:18.300 Benjamin Toll: And we thankfully did not find that to be true in the drug group. So we had 2 participants for whom that occurred and for the participant that took the drug asset. 266 00:34:18.790 --> 00:34:23.959 Benjamin Toll: They quit both products and for the patient that didn't have 267 00:34:23.969 --> 00:34:29.089 Benjamin Toll: drug she or or he stopped smoking 268 00:34:30.530 --> 00:34:33.380 Benjamin Toll: and and continued to vape. 269 00:34:33.750 --> 00:34:34.630 Benjamin Toll: So 270 00:34:35.070 --> 00:34:42.680 Benjamin Toll: what are the next steps for this study? So so Lisa and I have an Mpi. Grant that 271 00:34:42.920 --> 00:34:46.209 Benjamin Toll: proposes a test of this drug asset 272 00:34:46.260 --> 00:34:59.539 Benjamin Toll: versus placebo in a group of 326 mono vapors that would be split evenly between New Haven and Charleston there will be a rigorous 273 00:34:59.550 --> 00:35:02.398 Benjamin Toll: test of several biological 274 00:35:03.230 --> 00:35:06.960 Benjamin Toll: markers like like DNA damage 275 00:35:07.380 --> 00:35:08.830 Benjamin Toll: across time. 276 00:35:09.878 --> 00:35:15.760 Benjamin Toll: We have a plan to examine several possible treatment moderators. 277 00:35:15.860 --> 00:35:24.249 Benjamin Toll: This got a fundable score, so thank you, to the Nci. The funding line was announced yesterday, and we are 278 00:35:24.290 --> 00:35:26.529 Benjamin Toll: below that funding line thankfully. 279 00:35:26.630 --> 00:35:29.230 Benjamin Toll: So here are the summary points. 280 00:35:29.390 --> 00:35:48.189 Benjamin Toll: If an adult that smokes does not succeed through a 1st line treatment from the FDA. Our doctors and providers may consider talking about the relative risks of e-cigarettes, the importance of complete 281 00:35:48.780 --> 00:35:49.900 Benjamin Toll: switching. 282 00:35:50.010 --> 00:35:53.800 Benjamin Toll: and make patients aware of the 23 283 00:35:53.980 --> 00:36:00.169 Benjamin Toll: vapes that are currently authorized by the FDA with an eventual goal of stopping 284 00:36:00.300 --> 00:36:02.050 Benjamin Toll: all product use. 285 00:36:03.714 --> 00:36:06.129 Benjamin Toll: In the near future. 286 00:36:06.270 --> 00:36:10.239 Benjamin Toll: These products would be the dominant form of tobacco use 287 00:36:10.680 --> 00:36:12.140 Benjamin Toll: in this country. 288 00:36:13.470 --> 00:36:18.499 Benjamin Toll: A very high number of people who use e-cigarettes plan to quit 289 00:36:20.630 --> 00:36:24.019 Benjamin Toll: dual energy may have some 290 00:36:24.190 --> 00:36:33.239 Benjamin Toll: use in quitting for mono e-cigarette users. But higher doses of this drug are probably needed for dual users. 291 00:36:33.550 --> 00:36:38.189 Benjamin Toll: The drug varenicline tartrate shows a good treatment 292 00:36:38.290 --> 00:36:39.920 Benjamin Toll: signal for 293 00:36:40.040 --> 00:36:41.710 Benjamin Toll: quitting e-cigarettes. 294 00:36:41.860 --> 00:36:54.599 Benjamin Toll: The field and I can't stress this enough. The field desperately needs high quality, large trials to help people that want to quit E cigarettes 295 00:36:54.850 --> 00:36:56.270 Benjamin Toll: to do so. 296 00:36:56.750 --> 00:36:59.169 Benjamin Toll: And I'm going to close by saying 297 00:36:59.210 --> 00:37:18.459 Benjamin Toll: this, this work we do. It's hard. It's a very, very challenging set of studies. Science is hard preventing. Cancer is hard. These are all opportunities for us as a community to rise up and to help others. 298 00:37:18.500 --> 00:37:20.270 Benjamin Toll: Please do your part. 299 00:37:20.480 --> 00:37:31.269 Benjamin Toll: All these things, all the pressure, all the challenges they are opportunities for our community of tobacco treaters and researchers 300 00:37:31.900 --> 00:37:34.139 Benjamin Toll: to rise. And with that 301 00:37:34.280 --> 00:37:36.820 Benjamin Toll: I say, thank you, and I'll stop there. 302 00:37:38.140 --> 00:37:51.230 Jamie Hartmann-Boyce: Thank you so much, Ben. You've covered a lot in a short amount of time. I really appreciate it. So I'm going to 1st hand over to Dr. Joanna Streck, our discussant. Please do continue adding comments to the Q. And a. And we'll get to as many of them as we can. 303 00:37:52.080 --> 00:38:04.600 Joanna Streck: That was a wonderful presentation. Thank you. And so nice to hear how you're seeing the future of this field and future research that other people, including junior people, may want to get into. Write a K. On that topic. 304 00:38:04.600 --> 00:38:29.430 Joanna Streck: I'm just curious. I'll just ask one of my sets of questions and then let the rest of the time be for all of the questions in the chat. But I'm curious what you think about the kind of nuance around physician and healthcare provider advice on e-cigarettes. So just thinking about like the how, if you have any thoughts or data around how you might advise someone who's exclusively smoking, and 305 00:38:29.430 --> 00:38:32.000 Joanna Streck: wants to try out e-cigarettes to switch 306 00:38:32.000 --> 00:38:53.640 Joanna Streck: the question of gradual or abrupt. And then also that great point that you listed around sharing the relative risks of e-cigarettes with tobacco, cigarettes, and any thoughts or data out there where a provider could look at how to talk about through all the risks, especially in light of what you shared, that some of them actually think the opposite that are more dangerous. 307 00:38:53.640 --> 00:39:19.229 Benjamin Toll: So I'm I'm glad you asked that. So when we when Nature Medicine published that letter that is publicly available, we tried. They they pay wallet, and I'm sorry that they pay wallet, but they pay wallet, and there's no way to unpay wall letters for some reason. But so when Nature medicine published that letter. The FDA 308 00:39:19.580 --> 00:39:30.279 Benjamin Toll: created a suite of websites that talk about relative risks of the of the products. It's a lovely website. It's public. I would encourage 309 00:39:30.430 --> 00:39:37.959 Benjamin Toll: all of our physicians and providers to go to that website. Learn what it says. Take 310 00:39:38.330 --> 00:39:50.900 Benjamin Toll: a look. It's not. It's not challenging to understand. But I think it can be a little challenging to internalize, because many physicians incorrectly think 311 00:39:51.010 --> 00:40:01.370 Benjamin Toll: that smoking is better than vaping, and it's the opposite right? So there's less toxicants and less carciage and less carcinogens 312 00:40:02.490 --> 00:40:14.419 Benjamin Toll: in vapes. So I would encourage your colleagues to go to that that website and and and and just learn about these 313 00:40:14.660 --> 00:40:40.379 Benjamin Toll: products and and have thoughtful conversations. So it may be that the person has asthma, and it's and and it's not a good choice. Or it may be that they tried varenicline. They tried bupropion. They tried patch, and they feel very desperate and hopeless. They could consider maybe an e-cigar 314 00:40:40.430 --> 00:40:58.040 Benjamin Toll: always stress, though the plan is not to stay on the e-cigarette the plan. So for my practice, I never suggest e-cigarettes, but instead, some of my patients, they just come in, and they're and they're vaping. And say, and say, Hey, guess what, Doc. 315 00:40:58.080 --> 00:41:13.169 Benjamin Toll: you're gonna be so proud of me. I quit smoking. So the 1st thing I do is I congratulate them. And the second thing I say is, that's great that you did that. Now we have to talk about trying to get you off of that product. 316 00:41:14.430 --> 00:41:16.029 Joanna Streck: Awesome. Thank you. 317 00:41:16.240 --> 00:41:16.559 Benjamin Toll: Of course. 318 00:41:16.560 --> 00:41:26.370 Joanna Streck: And I see they sent that the relative risk piece in the chat, which is awesome. But yeah, Jamie, if you want to do the chat questions. I know we have a ton. That's all I had. Thank you. 319 00:41:26.370 --> 00:41:38.079 Jamie Hartmann-Boyce: Absolutely. Thank you, Joanna, so, and thank you everyone for keeping these brilliant questions coming in. We'll get to as many of them as we can, and any others will be sent to Ben at the end as well. So if your question isn't asked, don't panic. 320 00:41:38.080 --> 00:41:56.870 Jamie Hartmann-Boyce: so I'll start with one from Gisell Walia, who says, wonderful talk, Ben, you implied or said the endgame was not just tobacco, but nicotine. We generally have accepted that if someone wants to use nicotine gum for years, decades, or even a lifetime is acceptable. Many physicians accept this, although it took many years to get to this point. 321 00:41:56.870 --> 00:42:02.180 Jamie Hartmann-Boyce: Why would this be different for non-medicinal nicotine products, especially nicotine pouches. 322 00:42:03.370 --> 00:42:10.380 Benjamin Toll: So. Hi, jazz! Thanks for the good question. It's a very thoughtful and very learned 323 00:42:10.610 --> 00:42:13.519 Benjamin Toll: question, as usual from jazz. 324 00:42:13.750 --> 00:42:15.460 Benjamin Toll: I would say. 325 00:42:15.920 --> 00:42:29.030 Benjamin Toll: for the vapes that we know have some levels of heavy metals. They have some levels of some chemicals that are not not air. For for those 326 00:42:29.920 --> 00:42:41.759 Benjamin Toll: I would say, unequivocally, we have to stop those. So I have many patients that want to use gum for years, and I say, go for it. And 327 00:42:41.800 --> 00:43:07.779 Benjamin Toll: and what I say is this, if you're going to stop that gum and go back to smoking, keep using that gum your entire life. That's like a blood pressure medicine. It's it's keeping you safe, right? But for for vapes, jazz, I think that's not true, because there are, there is some risk. The exact amount is not yet totally quantified, but there is some risk 328 00:43:07.850 --> 00:43:24.880 Benjamin Toll: for a tobacco free pouch. I think that the jury is still out. We need more pharmacological studies to look and see if there's risk. These are very new products. They're very appealing products. You know. 329 00:43:25.514 --> 00:43:30.770 Benjamin Toll: If Baker Mayfield is taking one on the sidelines of a nationally televised. 330 00:43:30.860 --> 00:43:51.390 Benjamin Toll: of of a huge game. Then, this is a big product that is, that is very popular. So and and frankly, we know very little about these products. So I I think what I would say, jazz is for the vapes. There is some risk, and we must get people to quit those 331 00:43:51.460 --> 00:43:53.140 Benjamin Toll: for the tobacco pet 332 00:43:53.420 --> 00:43:56.410 Benjamin Toll: for the pouches. I'd say that the jury is still out. 333 00:44:00.470 --> 00:44:02.480 Benjamin Toll: Oh, you're you're muted, Jamie. 334 00:44:02.640 --> 00:44:03.829 Jamie Hartmann-Boyce: Sorry about that. 335 00:44:04.250 --> 00:44:07.300 Jamie Hartmann-Boyce: Thank you so much. You'd think, after all these years I'd be used. 336 00:44:09.000 --> 00:44:23.420 Jamie Hartmann-Boyce: Alas! So we have a question from Norbert Zilitron Schmidt asking if there's any solid scientific evidence for significant actual health benefits from quitting, vaping. So what happens to people when they quit vaping? Do we know. 337 00:44:23.610 --> 00:44:27.790 Benjamin Toll: Such a great question. We need data. 338 00:44:27.860 --> 00:44:29.210 Benjamin Toll: There is 339 00:44:29.340 --> 00:44:55.220 Benjamin Toll: very, very scant data. And so in the 2, I've proposed a trial. So the trial that that we hope is gonna get funded is gonna is gonna examine that very, that very issue where we're gonna look across time prospectively. If your health improves. Matt Carpenter and I are proposing a 340 00:44:55.530 --> 00:44:57.249 Benjamin Toll: Pia one, the 4 341 00:44:57.270 --> 00:45:00.639 Benjamin Toll: projects and one project that that 342 00:45:01.140 --> 00:45:19.150 Benjamin Toll: that's led by Alana Rajewski. The entire project is to look prospectively across time for our cohort of a thousand patients to see what are the health improvements of quitting, vaping. 343 00:45:19.200 --> 00:45:20.410 Benjamin Toll: Frankly. 344 00:45:20.440 --> 00:45:36.910 Benjamin Toll: we need data. We don't have data as intelligent people. I think that we can agree that it's likely that there would be some improvements unlike smoking where there's going to be massive improvements. I predict that they're small, but 345 00:45:37.140 --> 00:45:42.199 Benjamin Toll: you know but consistent. But I I just don't know of 346 00:45:43.620 --> 00:45:46.860 Benjamin Toll: of a large body of evidence that has looked 347 00:45:47.000 --> 00:45:49.639 Benjamin Toll: through through this, and we desperately need it. 348 00:45:51.300 --> 00:46:06.870 Jamie Hartmann-Boyce: Thank you. So a question here from Cheryl Olson, there will be multiple heated tobacco products in the Us. Market within the next few years based on use in other countries, such as Japan. Among people who smoke. Are you considering similar studies in Htps. 349 00:46:07.820 --> 00:46:10.049 Benjamin Toll: Well, I would say. 350 00:46:10.773 --> 00:46:15.410 Benjamin Toll: my colleague, Dr. Smith and I have talked about this. 351 00:46:15.902 --> 00:46:28.369 Benjamin Toll: You know, one of the of the big issues is production. And if they're really gonna be here, so a as this community knows there was a battle between people 352 00:46:28.450 --> 00:46:41.940 Benjamin Toll: Pmi and Altria in which they shut down production, and importation of these devices because they had 2 test markets. 353 00:46:42.938 --> 00:46:46.210 Benjamin Toll: And I I believe 354 00:46:46.620 --> 00:46:51.409 Benjamin Toll: I I guess the short answer is that I'm not planning 355 00:46:51.460 --> 00:47:15.929 Benjamin Toll: studies till I see that these products are actually being used in this country. So I mean, I I am planning for my future studies. Obviously, I'll I'll always study smoking. But I'm I'm really doing a lot of vaping treatment studies now, because I think that's our future and if if the so-called heat not burn, comes this 356 00:47:16.160 --> 00:47:22.439 Benjamin Toll: country and takes off. I I think that we like we certainly you should study it. 357 00:47:24.110 --> 00:47:25.290 Jamie Hartmann-Boyce: Thank you. 358 00:47:26.077 --> 00:47:30.450 Jamie Hartmann-Boyce: Moving on to a question from Matthew Bars. He notes that. 359 00:47:30.450 --> 00:47:31.170 Benjamin Toll: Can you. 360 00:47:31.450 --> 00:47:50.830 Jamie Hartmann-Boyce: In your paper evaluating nicotine replacement therapy for vaping cessation. 196 people responded to the Ad. But only 30 people were randomized, which is around 15%. He asked if there's the possibility of any selection bias going on here, and if that might affect conclusions. 361 00:47:51.660 --> 00:47:57.732 Benjamin Toll: Well, you know, Matt, it's a especially. The dual users are, are 362 00:47:58.360 --> 00:47:59.740 Benjamin Toll: an important 363 00:48:00.050 --> 00:48:06.989 Benjamin Toll: group, but they have they have a host of issues. And we did screen out a large number of people. 364 00:48:07.824 --> 00:48:13.155 Benjamin Toll: There's there's certainly always that possibility. I I hope that's not true. 365 00:48:13.610 --> 00:48:16.720 Benjamin Toll: I'm I'm not sure if there's a question behind the 366 00:48:17.360 --> 00:48:35.610 Benjamin Toll: question, but I'll say it's a very highly addicted group, and I think that dual users really like I'm confident in in the finding that dual users need high doses of drugs to feel that they are. 367 00:48:35.760 --> 00:48:39.330 Benjamin Toll: that they are able to get to quitting. 368 00:48:40.950 --> 00:48:42.010 Jamie Hartmann-Boyce: Thank you. 369 00:48:42.310 --> 00:48:53.239 Jamie Hartmann-Boyce: We have a question from Margaret Laplante, which is, are any of the 23 FDA authorized devices authorized for cessation purposes, and she says, Thank you. A very interesting discussion. 370 00:48:53.803 --> 00:49:11.140 Benjamin Toll: They are not. So they are. So there's 2 paths for these products. One is cedar, and that's a safe and effective rule. So that's like what the nicotine patch did. It's shown to be safe and effective for quitting all of the 371 00:49:11.640 --> 00:49:13.430 Benjamin Toll: all the authorized 372 00:49:13.620 --> 00:49:22.380 Benjamin Toll: products are on a public health rule that shows that these, that that these products have 373 00:49:22.400 --> 00:49:35.930 Benjamin Toll: a scientifically measurable, that that they have a lower amount of risk than a combusted product. So they are not shown to be safe and effective. I wish 374 00:49:35.970 --> 00:50:01.469 Benjamin Toll: if I had, like a 1 that could make things happen, I wish that we could have a bunch of E cigarettes that go the safe and effective route. I think that'd be great. So far, I've heard whispers that one company was maybe gonna do one product that way, and so far it's been crickets. I I would love for for us to go the cedar route. I I don't see that happening. But it's certainly possible. 375 00:50:02.550 --> 00:50:05.730 Jamie Hartmann-Boyce: Can I just ask a follow up question from my own curiosity? Ben. 376 00:50:05.730 --> 00:50:06.090 Benjamin Toll: Yeah. 377 00:50:06.090 --> 00:50:19.080 Jamie Hartmann-Boyce: Given our current state of affairs, and the fact that this might continue with no e-cigarettes going through the cedar safe and effective route. Where does that leave clinicians if they're talking about e-cigarettes for quitting smoking? Does that put them in a difficult position. 378 00:50:19.780 --> 00:50:38.429 Benjamin Toll: I I mean, I think the fact that it's authorized by the FDA makes at least the providers that I've talked to. It makes them a little more comfortable. But what you're asking, I think, is true. They're still not totally comfortable, so it makes them a bit more comfortable. But it's not. I mean. 379 00:50:38.920 --> 00:50:56.319 Benjamin Toll: obviously, if you're a physician that is going to tell a patient to take a product, you want it to be entirely safe. Now, if your patient is, say, pregnant and is smoking, and they've tried 380 00:50:57.120 --> 00:50:59.880 Benjamin Toll: Veronica and Patch 381 00:51:00.250 --> 00:51:10.610 Benjamin Toll: Bupropion, and they're desperate. Then maybe you're okay doing that. But it's still a hard sell to have a license healthcare 382 00:51:10.950 --> 00:51:12.300 Benjamin Toll: Provider 383 00:51:12.510 --> 00:51:16.260 Benjamin Toll: fully recommend a product that they know has some risk. 384 00:51:18.300 --> 00:51:19.553 Jamie Hartmann-Boyce: Thank you. 385 00:51:20.440 --> 00:51:28.049 Jamie Hartmann-Boyce: We have another question here from Norbert Zilatan. Schmidt. What 386 00:51:28.380 --> 00:51:36.979 Jamie Hartmann-Boyce: if you know, is the assumption of people who say they want to quit vaping about the danger level of vaping compared to smoking. So this is about perceptions. 387 00:51:36.980 --> 00:51:45.810 Benjamin Toll: Oh, that's a really good question. So what is their perception? My understanding is that they perceive that it has high risk. 388 00:51:46.336 --> 00:51:51.470 Benjamin Toll: And they want to quit. We we looked at Pathway 389 00:51:51.490 --> 00:52:04.790 Benjamin Toll: 4 and 5, and it was going up. We're gonna look again at at 6 and 7. It's a really important question. My UN. Understanding is that most people in the country 390 00:52:04.830 --> 00:52:08.340 Benjamin Toll: think that that e-cigarettes are 391 00:52:08.360 --> 00:52:09.620 Benjamin Toll: quite dangerous. 392 00:52:11.580 --> 00:52:12.260 Benjamin Toll: Yeah. 393 00:52:12.780 --> 00:52:15.770 Jamie Hartmann-Boyce: And quite dangerous, related to smoking. 394 00:52:15.770 --> 00:52:20.070 Benjamin Toll: Yes, that that they're that they're either the same, or worse 395 00:52:20.210 --> 00:52:26.219 Benjamin Toll: than than combusted smoking, which we we all know in in the field, and 396 00:52:26.740 --> 00:52:35.079 Benjamin Toll: and I'm from the FDA. There's there's measurably less risk for for vapes. But that that is not well known. 397 00:52:36.350 --> 00:52:36.734 Benjamin Toll: Yeah. 398 00:52:37.120 --> 00:52:38.960 Jamie Hartmann-Boyce: Same with many places in the world. I think. 399 00:52:38.960 --> 00:52:39.360 Benjamin Toll: Right. 400 00:52:39.760 --> 00:52:40.506 Jamie Hartmann-Boyce: That's problem 401 00:52:41.700 --> 00:52:46.110 Jamie Hartmann-Boyce: great. So some more questions coming in. 402 00:52:47.170 --> 00:52:57.530 Jamie Hartmann-Boyce: Nicole Krebs has asked e-cigarette users are still a small percentage of the population for your studies with e-cigarette users that want to quit. Is it hard to identify those people for your trials. 403 00:52:58.090 --> 00:52:59.619 Benjamin Toll: Can I tell you 404 00:53:00.470 --> 00:53:30.010 Benjamin Toll: it was so fast to get mono vapors like I was shocked. It felt like the old tea Tark days. So in the old tea Tark days, in the late nineties and early 2 thousands, we would fill up a giant room at Yale like like 40 people. I mean, they were just calling, calling, calling, and then like, now it's gotten much harder to find people that want to quit smoking. And we did this Mono vaping study 405 00:53:30.010 --> 00:53:45.319 Benjamin Toll: with Chantex or or Veronica, and we had loads of patients coming loads. I mean, it was really very I I was surprised. And I will say, having done 406 00:53:45.760 --> 00:53:48.340 Benjamin Toll: both. Now, I found that 407 00:53:48.885 --> 00:53:56.160 Benjamin Toll: just in in the Charleston market, a lot of interest in the Mono vapors in 408 00:53:56.260 --> 00:54:11.420 Benjamin Toll: quitting and interest, but a little bit lower for the dual user. So it's there. But it's not. It's not as much as I mean these amount of vapors. It I mean, this study was a pleasure, because they just kept coming. I mean, really easy. Yeah. 409 00:54:11.420 --> 00:54:13.300 Jamie Hartmann-Boyce: Yeah, interesting. 410 00:54:13.420 --> 00:54:25.539 Jamie Hartmann-Boyce: Thank you. A question here from Cheryl Olson. Given your focus on cancer, at what point do you anticipate? We might have useful data on e-cigarettes and cancer risk. 411 00:54:25.940 --> 00:54:44.980 Benjamin Toll: Well, I mean, we're gonna in our study. Certainly. We're going to look at DNA damage inflammatory markers. So there's obviously like a chain of events that leads to cancer. We're going to look at those various markers and see if 412 00:54:45.020 --> 00:54:48.060 Benjamin Toll: those markers go down upon 413 00:54:48.080 --> 00:54:55.590 Benjamin Toll: quitting vaping, and that that'll be a strong signal. And I I'm just I I 414 00:54:55.840 --> 00:55:05.170 Benjamin Toll: the main goal of me doing this and of me doing these talks is to try to encourage our colleagues to conduct these trials. 415 00:55:05.840 --> 00:55:07.469 Benjamin Toll: Do the trials 416 00:55:07.950 --> 00:55:18.849 Benjamin Toll: I would love you to help people to quit and to measure biological risk along the way. It's so important that the new trials have great markers of 417 00:55:19.610 --> 00:55:21.320 Benjamin Toll: of inflammation. 418 00:55:21.390 --> 00:55:21.965 Benjamin Toll: of 419 00:55:22.800 --> 00:55:27.048 Benjamin Toll: of DNA damage, and all of the things. 420 00:55:28.590 --> 00:55:29.250 Jamie Hartmann-Boyce: Great. 421 00:55:29.390 --> 00:55:40.699 Jamie Hartmann-Boyce: Thank you. A question from Skip Murray. Is anyone doing? Follow up studies to see if people who quit smoking with vapor products are still able to stay smoke free for a long period of time, as in years. 422 00:55:40.700 --> 00:55:41.866 Benjamin Toll: Yep. Hello! 423 00:55:42.730 --> 00:55:44.940 Benjamin Toll: You know I 424 00:55:45.910 --> 00:55:47.880 Benjamin Toll: there are so few studies. 425 00:55:48.418 --> 00:55:54.850 Benjamin Toll: I do not know of any. I think that's a great idea. Obviously our goal 426 00:55:54.850 --> 00:56:18.850 Benjamin Toll: is to stop smoking. Obviously our goal is for people to stay smoke free. One of my fears that was thankfully not borne out in the pilot studies that we've done that I presented is that you quit vaping and go back to smoking. I think that's a reasonable fear that has to be mitigated 427 00:56:18.850 --> 00:56:42.700 Benjamin Toll: for us to feel comfortable, so we don't want. So there's there's a continuum of harm. This is air, and this is smoking and vaping's in here. I'd like people to quit and go to no risk not to quit and to go to higher risk. That's not what we're going for, and we really need good studies 428 00:56:42.800 --> 00:56:45.010 Benjamin Toll: that have those long term follow ups. 429 00:56:46.140 --> 00:57:07.430 Jamie Hartmann-Boyce: Thank you. A question from George Coledner and George apologies. If I've mispronounced your last name, I'm finding that my vaping and pouch, using patients routinely use continuously similar to chain smoking cigarette smokers. Can you comment on the possibility that e-cigarettes and pouches cause less disease, but are more addictive than tobacco cigarettes. 430 00:57:07.430 --> 00:57:16.980 Benjamin Toll: I can. And and can I tell you this is a very polarizing subject in which I've been yelled at by people. I think I think 431 00:57:17.090 --> 00:57:24.230 Benjamin Toll: that in a way, if you think about vaping versus smoking, and and it's by the way. 432 00:57:24.320 --> 00:57:36.339 Benjamin Toll: a lot of my data comes from my live patients who I speak with, and they and they tell me what they do. So the thing about a vape is this, if you smoke cigarettes, it's 433 00:57:36.340 --> 00:57:57.209 Benjamin Toll: 20 to a box right, and then you have to light it right? And then and then, when the 20 cigarettes are done, you crush it and you throw it out. That's a that's a very nice stopping point, right? If you have a 5,000 puff, kang vape, you can just go and go and go, and there's no fixed stopping point. 434 00:57:57.610 --> 00:58:13.480 Benjamin Toll: The other thing is, there's no fire for vapes. So I have patients that take their vape. They hit it. They put it under their pillow, and then they sleep, and they wake up, maybe through the night. And certainly 1st thing they take it and hit it 435 00:58:13.830 --> 00:58:14.969 Benjamin Toll: straight away 436 00:58:15.810 --> 00:58:29.810 Benjamin Toll: with smoking. There's a few other steps right? Because it burns. You gotta like get the cigarette out. You gotta light it. You might want to sit up like, it's just harder. Frankly, so I I think. 437 00:58:29.920 --> 00:58:41.709 Benjamin Toll: And we have data from, you know, one of the pathways that shows that it may be that that vapes are slightly more addictive because of continuous 438 00:58:42.120 --> 00:59:00.980 Benjamin Toll: your use. But that that's emerging data. I'm not saying that that's definitely true. But I do think it's possible. There's no pouch data that I know of. I do know that the pouches are highly addictive. I have patients that use them 439 00:59:01.010 --> 00:59:09.800 Benjamin Toll: through the night. And that use many, many tents. So I mean it is an addictive substance in a different vessel. 440 00:59:10.570 --> 00:59:17.189 Jamie Hartmann-Boyce: Wonderful. Thank you so much. That's all we have time for today. That was a brilliant talk, and thanks for dealing with all the rapid fire questions. 441 00:59:17.190 --> 00:59:17.770 Benjamin Toll: Of course. 442 00:59:17.770 --> 00:59:21.859 Jamie Hartmann-Boyce: We didn't get to yours, and I'm gonna hand over to Rachel to close us out. 443 00:59:24.310 --> 00:59:36.709 Rachel Rosen: We are out of time. Thank you to our presenter moderator and discussant, and finally, thank you to our audience of 172 people for your participation today. Hope you have a top snotch weekend. 444 00:59:37.720 --> 00:59:39.049 Benjamin Toll: Great. Thank you. Everyone.