June 27, 2024 • 50 mins
In this episode, we dive into the complex narrative of electronic cigarettes and their role in smoking cessation. Join Josh and Adam as they review research showing e-cigarettes as safer than traditional cigarettes in terms of chemical exposure while also examining the risks for non-smokers.
We present evidence that nicotine e-cigarettes may outperform traditional nicotine replacement therapies like patches and gums. Supported by sources such as the American Journal of Public Health and Cochrane, we compare e-cigarettes with Chantix (varenicline) for smoking cessation. We highlight clinical outcomes and the under-researched long-term side effects of e-cigarettes.
Engage with us on social media and share your thoughts and suggestions for future episodes. Thank you for joining the Doctor Journal Club podcast!
Learn more and become a member at www.DrJournalClub.com
Check out our complete offerings of NANCEAC-approved Continuing Education Courses.
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Introducer (00:02):
Welcome to the Dr Journal Club podcast, the show
that goes under the hood ofevidence-based integrative
medicine.
We review recent researcharticles, interview
evidence-based medicine thoughtleaders and discuss the
challenges and opportunities ofintegrating evidence-based and
integrative medicine.
Continue your learning afterthe show at www.
(00:24):
drjournalclub.
com.
Dr. Joshua Goldenberg (00:31):
Please bear in mind that this is for
educational and entertainmentpurposes o nly.
Talk to your doctor beforemaking any medical decisions,
changes, etc.
Everything we're talking aboutthat's to teach you guys stuff
and have fun.
We are not your doctors.
Also, we would love to answeryour specific questions on
drjournalclub.
com.
You can post questions andcomments for specific videos,
(00:55):
but go ahead and email usdirectly at josh at
drjournalclub.
com.
That's josh at drjournalclub.
com.
Send us your listener questionsand we will discuss it on our
pod.
Hello everyone, this is DrJoshua Goldenberg and Dr Adam
Sadowski.
Josh and Adam, your buddies forevidence evaluation and
(01:18):
critical eval of the medicalliterature.
And today, for God knows whatreason, A adam has us reviewing
an electronic cigarettesresearch article.
I think this is the secondelectronic cigarettes research
article you had us do.
I think we did one a coupleyears ago.
Dr. Adam Sadowski (01:34):
So what do you mean?
For God knows what reason
Dr. Joshua Goldenberg (01:41):
Are people still smoking?
Dr. Adam Sadowski (01:43):
A lot of people still smoke.
Dr. Joshua Goldenberg (01:45):
People still can't be smoking.
Dr. Adam Sadowski (01:47):
Yes, J osh, not only are a lot of people
still smoking, but the youths,the youths are smoking.
Dr. Joshua Goldenberg (01:55):
The youths, yeah, the youths.
Dr. Adam Sadowski (01:58):
These crazy millennials.
These dag nabbit.
Dr. Joshua Goldenberg (02:02):
That can't be a thing.
Dr. Adam Sadowski (02:04):
These dag nabbit Gen Zersers
Dr. Joshua Goldenberg (02:06):
They're not smoking.
No one's smoking anymore.
Dr. Adam Sadowski (02:09):
They're smoking e-cigs.
Dr. Joshua Goldenberg (02:12):
Oh, e-cigs?
Dr. Adam Sadowski (02:13):
It's like they're like pacifiers.
Man, I'm not even joking.
Dr. Joshua Goldenberg (02:20):
Well, I think the last one we did was on
on the potential dangers ofe-cigs.
I think, for these concernsthat people are going to smoke
that instead of smokingsomething else.
Dr. Adam Sadowski (02:32):
It was a Dr.
Journal Club video.
People should check it outactually, because a lot of
people are kind of like.
Dr. Joshua Goldenberg (02:38):
Oh, it was pre-pod.
It was pre-pod, that's right.
Dr. Adam Sadowski (02:41):
It was pre-pod.
Yeah, yeah, it was pre-pod.
I think people should check itout.
It was a good video.
I liked the article a lot.
Basically with that article youknow too long didn't read Spark
notes of that study was thate-cigs apparently appear to be
safer from a quote-unquotetoxicity standpoint like regards
(03:04):
to chemicals you're exposed tothan than cigarettes.
Dr. Joshua Goldenberg (03:06):
Right.
Dr. Adam Sadowski (03:07):
I mean we still.
They're still new, right.
There's still a lot to learnfrom them.
Dr. Joshua Goldenberg (03:12):
Right.
Dr. Adam Sadowski (03:12):
But the data is so clear that cigarettes are
not good for you.
Dr. Joshua Goldenberg (03:16):
Well, but it's like this, interesting.
Okay, so it's been years andand, Michele, um, we're going to
get you the link so you couldput it in the show notes to that
Dr Journal Club review.
But I kind of remember adiscussion about if it's
compared to regular cigarettesyeah, safer, but the fear is
(03:36):
well, what if people are pickingup the habit from doing nothing
?
That's not good.
And then to look at that net,how does that?
How does that net out, I guess,across society?
Dr. Adam Sadowski (03:46):
Yeah, and that the A american academy
pediatrics, way back when, didhave an article on this as well.
Where they come basically?
Uh, you know they were lookingat at adolescents who had no
motivation or, you know, anyinterest in actually picking up
cigarette smoking, and I thinkit was a cohort study, if I'm
(04:12):
not mistaken, cohort orcross-sectional, I think it was
cohort and basically whathappened was those who were not
ever motivated to start smokingcigarettes but did use the
e-cigarettes.
Again, this is in adolescentswho aren't using e-cigarettes
for smoking cessation.
It's a different topicaltogether.
There was, I think, a fourfoldincreased risk in the then going
(04:40):
on to actually picking up asmoking habit.
Dr. Joshua Goldenberg (04:42):
Yeah, so that's interesting that's
interesting.
Dr. Adam Sadowski (04:44):
So you know, if you're not doing it, don't do
this, don't start if you'redoing it.
But if you're smokingcigarettes and the question is,
hey, doc, you know, should I?
Yeah, because this was thiscame up all the time of hey,
should I go from smokingcigarettes to you know, uh,
(05:07):
these vapes and there were somany people who were saying like
no, smoking cigarettes is safer, which is the dumbest thing
I've ever heard.
Dr. Joshua Goldenberg (05:13):
What oh, because it's quote, unquote,
natural or something like that.
Is that the idea?
Dr. Adam Sadowski (05:18):
I don't know, but I don't know, but it really
annoyed me and there's reallyhigh-level evidence in Cochrane
papers that support thetransition from cigarettes to
e-cigarettes.
Now, granted, ideally you comeoff of e-cigarettes, but the
whole goal is to get people tostop smoking.
Dr. Joshua Goldenberg (05:38):
It's interesting.
Have you ever smoked?
No, I smoked for a while.
Really, I smoked a while when Iwas 18.
I remember thinking I'm goingto be cold.
Were you the?
Dr. Adam Sadowski (05:50):
Marlboro man, did you walk around with a
cowboy hat?
Dr. Joshua Goldenberg (05:54):
I was Marlboro Lights.
They were gold or something.
Dr. Adam Sadowski (06:01):
So they were safer for you.
Dr. Joshua Goldenberg (06:03):
I remember people having that
conversation when I was hangingout with the hippies.
They'd be like, well, I onlysmoke.
I can't remember the name ofthe.
There's like a native americanbrand or something.
It's like all natural americanspirits, american spirits, and
that was the theory.
Is that, like that was thehealthy cigarette?
I'm like you've got to bekidding, you realize.
Like we're all lying toourselves, right?
Um, anyway, but so you knowwhat actually got me to quit
(06:25):
smoking.
I was thinking about this whenI was reading the paper.
I was like it was so freakinghard, right, like I knew how.
First of all I was like why arewe doing this?
No one smokes anymore.
And then I was like, well, itwas really kind of hard to quit.
Dr. Adam Sadowski (06:36):
Like I can see how it would be helpful I
think you need to dip back intoprimary care and get a little
dose of reality.
Dr. Joshua Goldenberg (06:42):
I know that's that's I were going to
say that you knew you were goingto say that You're going to be
like, well, you have to stopdealing with folks with SIBO all
the time, and that's all yousee, because you're right.
I have no sense of what realityis, but anyway, I've got pretty
good self-control, but it wasimpossible to quit.
It was so freaking hard and Iremember like um, I remember
(07:05):
like getting so frustrated withmyself and like breaking the
cigarettes and throwing them inthe trash and then, like you
know, not making this up thenlighting a trash on fire and
having a big old bonfire ofcigarettes I should have,
because I would go back.
I and I taped them together,adam, like it was.
So such a powerful addiction itit's crazy.
And the only thing that workedis I did my little hippie trip
(07:29):
off to Central America for likeI don't know.
I think I was gone a half yearor something like that and I was
on a farm in Costa Rica with noaccess to anything, miles from
the town.
You couldn't go and there wasno store and I ran out of
cigarettes and I couldn't doanything for like a number of
weeks and that's how I quit.
(07:50):
Right, it was like youphysically need to be in a
jungle somewhere and have noaccess to cigarettes, Josh,
because apparently that's thelevel of self control that you
have and that I mean that wasreally telling to me.
This is powerful addictionstuff that we're talking about
here.
Dr. Adam Sadowski (08:06):
Yeah, yeah.
No, it's very tough.
I've, you know, I've workedwith people who use pretty
intense illicit substances andthey, you know, they say that
the hardest thing to quit forthem was the cigarettes.
Dr. Joshua Goldenberg (08:20):
That's crazy.
I've heard that before, butthat's like crazy that
anecdotally you've been hearingthat as well like poor Josh back
in the day, have tried to quitsmoking, even did a clinical
trial to quit smoking and failedwere unsuccessful, and now
(08:50):
we're like trying yet again.
So these are people who aredesperate to stop and they need
help, and that was therecruitment goal for this one.
Dr. Adam Sadowski (08:58):
Yeah, and it's also very clinically
relevant because, you know,oftentimes people have tried
more than once to try quittingtobacco use, and so this is it's
not an unreasonable inclusioncriteria or population that
we're dealing with, like themain thing is like okay, this is
relatively homogenous patientpopulation in that it's people
(09:21):
from Finland and that it'speople from Finland.
The fact that these are peoplewho have tried to quit in the
past and failed, and are readyto go again is very much
clinically relevant.
Dr. Joshua Goldenberg (09:32):
I thought so too.
I'm trying to remember.
The inclusion criteria Wassomething like 30-pack year
history.
They had to be moderate orsevere level nicotine addiction.
Dr. Adam Sadowski (09:41):
Yeah, they were smoking on a daily basis
and willing to quit, and theseare people who were recruited
back from 2003 to 2009 in thatprevious trial and basically, if
they were still smoking, werethen allowed to come into this
trial, and they had to bebetween the ages of 25 to 75
years of age, smoking daily forlonger than 10 years with at
(10:05):
least 10 cigarettes per day.
There's 20 cigarettes in a pack, so they're smoking at least a
half a pack a day.
Introducer (10:10):
Wow.
Dr. Adam Sadowski (10:11):
And they had to have been smoking at least a
half a pack a day for the pastfive years and they had to have
a carbon monoxide level of 15parts per million or greater
when they were doing exhale likeexhale testing.
And the reason for that isbecause the primary outcome was
not only self-reported smokingcessation success but also parts
(10:33):
per million of the carbonmonoxide and basically, if it
was like under a certainthreshold, then you can say like
yes, you have been, you havenot been smoking.
We can confirm biologicallythat that what you're saying is
truthful.
Dr. Joshua Goldenberg (10:46):
Yeah, it's always nice to have that
objective marker.
Um, well, let's, let's zoomback out again.
I mean we're we're kind ofjumping in a little bit, but we
did a pretty decent job.
So so that was the.
I think we did a good job withthe inclusion criteria.
So these are, like you said,very clinically relevant
population.
Um, and then, yeah, yeah, let'stalk about the arms.
There was some, it was a cooldesign.
Dr. Adam Sadowski (11:06):
There is a three-arm trial well, before we
get into that.
Dr. Joshua Goldenberg (11:09):
I mean I I did read the introduction to
this just always assume youdidn't and move on, but go ahead
yeah well.
Dr. Adam Sadowski (11:16):
I mean again, sometimes I like to read it if
it's an interesting topic orsomething that like, if, if the
introduction reads well, I willkind of pay attention to it.
Sometimes they're just like wayout there and I'm like, okay,
this is, this is going somewhereI don't want to get involved
with.
But basically what they'resaying is that you know, they
cited previous evidence thatthere is high certainty evidence
(11:38):
that uh, e-cigarettes thatcontain nicotine are associated
with increased conventionalcigarette smoking abstinence
rates compared with nicotinereplacement therapy.
So that would be like yournicotine gums, your nicotine
lozenges, patches, etc.
Etc.
Dr. Joshua Goldenberg (11:53):
So hold on pause on that, like that's
crazy to me.
So you've got.
Let me just like.
Let's just highlight that.
First of all, very, very, veryfew things in medicine have high
certainty evidence like that'salready very, very rare and
that's that's like grade levelhigh.
And so nicotine.
So these are e-cigarettes withnicotine and they have increased
(12:14):
, first of all, your increasedabsence from cigarettes.
So that's even surprising to me, and even more so than nicotine
replacement therapy.
Dr. Adam Sadowski (12:22):
That's great, that's impressive yeah, and the
evidence they cited was fromthe American Journal of Public
Health and Cochrane, so not likelittle tiny trials, but pretty
reputable journals, so that'simpressive.
Dr. Joshua Goldenberg (12:34):
Okay, so we know that these e-cigarettes
with nicotine are excellent forabstinence from regular
cigarette smoking.
Okay Deal, keep them going.
Dr. Adam Sadowski (12:45):
Yep.
And then they, you know,continue to say like, hey,
there's not a lot of, there's noreported short-term adverse
effects with it.
But we do know that adverseeffect reporting in clinical
trials is miserable, and thesejust haven't been around long
enough to develop, you know, asolid database of long-term side
effect profile of e-cigarettes.
(13:07):
And so what they said was inthis study the one that we're
going to be podcasting about wasbasically a 52-week follow-up
where they looked at botheffectiveness and harms of
electronic cigarettes forsmoking cessation, compared to
varenicline, which is brand nameChantix, in adults who were
(13:29):
long-term smokers ofconventional cigarettes and for,
basically, for people who don'tknow.
Typically, when it comes tomedical therapy for smoking
cessation, there aren't verymany options.
You have the nicotinereplacement therapy, which can
be like gums, lozenges, patches,a combination of those.
You have bupropion, which canbe used, and then you also have
(13:53):
varenicline, which is a brandname Chantix.
Chantix is known for causingvivid dreams and there used to
be concern.
Dr. Joshua Goldenberg (14:02):
Oh yeah.
Dr. Adam Sadowski (14:02):
There used to be concern that it could cause
or, you know, induce or resultin psychosis, and so it kind of
had this like oh.
Yeah, For a second there.
It had a black box warning.
Dr. Joshua Goldenberg (14:15):
That's not good.
Dr. Adam Sadowski (14:16):
But then after the Eagles trial, which
actually looked to investigatethis, the FDA then subsequently
removed that psychosis black boxwarning.
They showed that there wasactually no significant
increased risk in thedevelopment of that with Chantix
used compared to placebo.
So then they removed that label.
Dr. Joshua Goldenberg (14:37):
Good background Okay.
Dr. Adam Sadowski (14:38):
Yeah, so that's just some background
information with regards to that
Dr. Joshua Goldenberg (14:45):
I think this is right.
It's a partial ag likenicotinic receptor agonist,
right?
Who cares?
Well, I think that's themechanism.
Well, well, just with thisthought,
who cares?
I knew you were gonna say thatno, no, but seriously.
Dr. Adam Sadowski (14:57):
No, no but seriously.
Who, who cares?
Dr. Joshua Goldenberg (15:00):
well, I mean, it kind of makes sense.
You sort of like agonize,agonize.
You sort of like tickle thenicotine receptor and it's gonna
hey, josh, josh cool, are youstill smoking?
Nobody cares, nobody cares,stop, you know we have people on
this pod who care aboutmechanism of action.
(15:20):
Thank you very much.
That's the problem.
Problem.
Dr. Adam Sadowski (15:25):
Stop.
Yeah, cool we have.
We have mechanisms of actionsand like we can use that and be
nerdy and like, yes, it isimportant, but clinically I want
you to stop smoking.
Dr. Joshua Goldenberg (15:40):
Okay, that's fair.
That's fair especially withlike high level evidence, like I
don't know what the evidencelevel is for shantix.
But you know, you know it's onething to say, okay, we've got
like this one tiny little trial,like we're hanging our hat too
much on or too little onmechanism of action to to
explain it.
But if it is solid evidence,like yeah, you're right at the
end of the day who right, okay,um, okay, and so then basically
(16:11):
what they what they did in theprior trials was looking, I'm
gonna have all these benchtopscientists come after us.
Yeah, go ahead all right.
Dr. Adam Sadowski (16:15):
So come after us, give us your again.
Come after us give us your,give us your data you don't want
to mess with rat people.
Dr. Joshua Goldenberg (16:22):
Rat people are serious.
I mean, let me tell you I don'tknow about we could take the
elijah people, but you know ratscientists, I'm not sure.
I'm not sure.
Dr. Adam Sadowski (16:32):
All right, keep on going as good as, as
good as the rat from uh teenage,uh mutant ninja turtles so this
has been killing me.
Dr. Joshua Goldenberg (16:40):
Is that shredder, or there's shredder
and there's um?
No sure, I thought shredder wasthe bad dude okay, so that's
why I couldn't remember therewas a bad dude and a's no.
Dr. Adam Sadowski (16:49):
I thought Shredder was the bad dude.
Okay, so that's why I couldn'tremember there was a bad dude
and a good dude.
Yeah, the good one takes in theTeenage Mutant.
Dr. Joshua Goldenberg (16:52):
Ninja Turtles Right, but that's not
Shredder.
It was Shredder, but there wasanother S name, it wasn't
Sadowski.
That's what we'll call you,adam the Shredder Sadowski.
You, adam the shredder Sadesk.
Talk to Adam the shredderSadesk.
Dr. Adam Sadowski (17:06):
Okay, we're going on a tangent.
We're going on a tangent, okay.
Dr. Joshua Goldenberg (17:12):
I hit the tangent.
Did you like that?
Normally we tangent at thebeginning.
This is an interpod tangent tofool our listeners.
Okay, go ahead, keep on going,okay.
Dr. Adam Sadowski (17:20):
So the primary outcome of that last
trial where they recruited thesepatients from, the primary
outcome was seven-day smokingabstinence.
So self-reported of hey, Ihaven't smoked in the past week,
which is great.
And then they also confirmed itwith carbon monoxide on
exhalation and that was at the26-week mark.
(17:42):
So basically after six months offollow, follow-up so solid,
solid outcomes yeah, and thenfor for this trial, because
there was no previous randomizedcontrolled trials that looking
at e-cigarettes compared tochantix or varenicline and we
don't get any sort ofcompensation for for saying it.
(18:03):
It's just easier to say chantixand that's what most people
know it by yeah.
So we're not, we're not gettinguh sponsored by by big chantix
here we're not part of thechantix lobby and so what they
hypothesized in this trial wasthat if veroniclean or chantix
therapy were to be combined withmotivational interviewing, um,
then the success rate of smokingcessation would increase
(18:26):
compared to nicotine-containinge-cigarettes combined with
motivational interviewing.
So they're kind of comparingChantix plus motivational
interviewing to e-cigarettesplus motivational interviewing.
Dr. Joshua Goldenberg (18:37):
Which is standard of like I would imagine
you tell me you're the primarycare doc, but like that would be
standard, right?
Like we know, motivationalinterviewing technique works, I
assume, and that's sort of likeyou add that to whatever other
intervention you're doing.
So it's not like they weretrying to get this thing to win,
they were like setting it up asit would be in real life.
Dr. Adam Sadowski (18:55):
Yeah, yeah, and and again, because they're
they're really trying tomaximize therapeutic benefit
here.
So, uh, ideally you're doingmotivational interviewing with
your patients, but reality setsin and sometimes you can't.
Dr. Joshua Goldenberg (19:09):
Wait, wait.
Did the placebo groups also getthe motivational interviewing?
Dr. Adam Sadowski (19:13):
Yeah, they got.
Dr. Joshua Goldenberg (19:14):
Oh, they got it too Okay.
Dr. Adam Sadowski (19:16):
Yep, they got placebo in this trial.
They got placebo Chantix,placebo e-cigarettes, plus
motivational interviewing.
Dr. Joshua Goldenberg (19:24):
Okay.
So they're maximizing thebenefit, but they're not trying
to juice the difference of thestudy, because even the placebo
group got maximum potentialplacebo effects and motivational
interviewing.
Dr. Adam Sadowski (19:33):
Okay, gotcha, I'm with you now yeah, and so
and so, to go back to yourearlier point, what were the
three groups in this trial?
You had the e-cigarette groupplus placebo, chantix, plus
motivational interviewinge-cigarette, placebo, chantix
and motivational interviewing.
Okay, yep the chantix group hadplacebo e-cigarette.
(19:56):
So that was an e-cigarettewithout any nicotine content but
looked exactly like the actuale-cigarette with nicotine Plus.
They got motivationalinterviewing and then, as we
just said, placebo had placeboeverything but real motivational
interviewing.
Dr. Joshua Goldenberg (20:15):
Yeah, so like double dummy we would
sometimes call that plusmotivational interviewing Okay,
awesome, I like those, I likethose groups Very nice.
Dr. Adam Sadowski (20:22):
Yes, and the people who were using the
e-cigarettes were allowed to touse it out of libidum, which I
liked, because basically theysaid here is your e-cigarette
supplies, do what you will withit.
Right, because that's how,that's how people are doing it
in in real life.
Dr. Joshua Goldenberg (20:37):
No one's really like oh, you can only
smoke two milliliters of liquid,well, and that's also kind of
like an intervention in and ofitself, right, like sort of like
a taper or something like that.
Dr. Adam Sadowski (20:47):
Yeah, yeah, yeah, and the study design was
really cool.
I liked it.
It was aninvestigator-initiated,
randomized, placebo-controlled,single-center clinical trial.
So they're very clear here andI really liked how they reported
this.
So it's a randomized,placebo-controlled trial.
We all know what that isSingle-centered, meaning it was
(21:07):
only done at one university, andthen investigator-initiated,
meaning basically theseinvestigators all got together
and were like, hey, we should doa trial on this.
And they were like, yes, weagree, let's go do it.
And it's independent ofindustry sponsorship, right,
it's not an e-cig study, correct?
Now, that being said, they diddisclose and they were very
(21:29):
clear about this that the trialwas funded by grand um, which
was, uh, which was a um, a grant, and with financial support
from pfizer okay however, uh,the funding organization, ie
pfizer, had no role in thedesign conduct, conduct of the
study collection, management,analysis, interpretation of the
(21:50):
data preparation, review,approval of the manuscript
decision to submit.
So basically they just gave themmoney and supplies and said,
like here you go, like figure itout.
Dr. Joshua Goldenberg (22:00):
So they so, just to clarify, they make
Shantix, so they did have anincentive, but, like you said,
they crossed their T's, dottedtheir I's.
Dr. Adam Sadowski (22:07):
As far as their involvement, yeah, but
also, even though they had anincentive, should the data show
that Chantix was terrible andgot blown out of the water, that
was a risk that they werewilling to take.
Dr. Joshua Goldenberg (22:20):
Yeah, I'm cool with that.
Dr. Adam Sadowski (22:24):
So for everyone who's kind of like, oh,
industry sponsorship is bad,not really like read through the
details, not these days.
Dr. Joshua Goldenberg (22:31):
It's clean.
These it's cleaner.
These days.
You have to be careful.
I think supplement industry isstill a bit of a mess, but oh,
it's terrible.
Dr. Adam Sadowski (22:38):
Yeah, yeah, um, but they're getting better
and then the e-cigarettes werepurchased, uh, with the grant.
Dr. Joshua Goldenberg (22:44):
Okay, uh, so yeah, okay, so cool all
right, I'm with you, keep ongoing so very low risk of bias
there for anyone uh payingattention or interested well,
let's talk about risk, aboutsuper fast.
So, um, everybody was blinded,the only the design said it was
good.
But just, they did have amention about masking, and I was
just thinking about that.
Like it seems, it would seempretty obvious to me.
(23:05):
I would imagine, if you'resmoking an e-cigarette and you
don't taste the nicotine rightLike that, I feel like that
would feel different and soeverything.
Dr. Adam Sadowski (23:13):
I thought everything was identical, so in
flavor and everything.
Dr. Joshua Goldenberg (23:16):
Yeah, but you're smoking.
You're smoking non-nicotine.
I mean it's going to bedifferent.
I mean it looks the same, butthen you start smoking it.
And.
But then you start smoking it.
And if you're used to nicotine,are you not going to notice
that it doesn't taste likenicotine?
I don't know, I just feel like.
I've never smoked nicotine, so Idon't know Well this is why I
bring my deep knowledge base tothis pod, these important
(23:37):
matters.
I feel like it would be obvious.
And they do mention thepotential risk of unmasking.
So it was blinded.
But you can always be unmasked,right if, like you just like,
wait, this is, there's no way,this is nicotine or like we've
talked about.
If you you're blinded and thenyou start having lavender
flavored burps, you're likethere's no way, this isn't the
lavender pills.
But what they noted is thatthere was no difference in
(24:00):
dropout rates and so they werekind of using that as a proxy,
like if you, uh, if you feltlike, okay, I was getting the
placebo cigarette, maybe youwould drop out more, right?
so I don't know well that thatwas something that they brought
up but they didn't seem tooconcerned about just because you
know they they didn't seeunequal dropout, I guess yeah, I
(24:21):
feel like it's a bit of a reachtoo yeah, I'm, I'm all right
with it, I'm totally right, andit's also more realistic, right,
right, because I mean, this isdesigned to show efficacy, not
effectiveness, but in real life,like you're going to know if
you're having an e-cigarettewithout nicotine.
Introducer (24:35):
Okay.
Dr. Joshua Goldenberg (24:38):
Look, the thing is we don't do this for
money.
This is pro bono and, quitehonestly, the mothership kind of
ekes it out every month or so,right, so we do this because we
care about this, we think it'simportant, we think that
integrating evidence-basedmedicine and integrative
medicine is essential and therejust aren't other resources out
there the moment.
(24:58):
We find something that does itbetter, we'll probably drop it.
We're busy folks, but right nowthis is what's out there.
Unfortunately, that's it, andso we're going to keep on
fighting that good fight.
And if you believe in that, ifyou believe in intellectual
honesty in the profession, inintegrative medicine and being
an integrative provider andbringing that into the
integrative space, please helpus, and you can help us by
(25:20):
becoming a member on Dr JournalClub.
If you're in need of continuingeducation credits, take our
NANSEAC-approved courses.
We have ethics courses,pharmacy courses, general
courses.
Interact with us on socialmedia, listen to the podcast,
rate our podcast, tell yourfriends.
Dr. Adam Sadowski (25:40):
These are all ways that you can sort of help
support the cause.
And so, yeah, they randomizedthe participants with
computer-generated randomizationscheme.
Everyone was one-to-one-to-one.
And then participants, nursesmaking personal contact, people
providing the motivationalinterviewing, and then the
researchers assessing theoutcomes and analyzing the data
were all masked, meaning theywere blinded.
(26:02):
And then an externalstatistician from a different
university did the uhrandomization scheme.
Dr. Joshua Goldenberg (26:09):
So super clean all good, very kosher,
yeah, very clean what exactly dothey do?
Dr. Adam Sadowski (26:14):
each, each group went through 12-week
intervention, which makes sensebecause chantix is uh prescribed
for a 12-week course.
Dr. Joshua Goldenberg (26:23):
Oh, okay, yeah, and then um in
observation period of up to 52weeks, so for a 12-week course.
Dr. Adam Sadowski (26:27):
Oh, okay, yep .
And then an observation periodof up to 52 weeks, so for a year
.
Dr. Joshua Goldenberg (26:31):
Really nice, really nice.
Dr. Adam Sadowski (26:33):
Yeah, and then the primary outcome was
essentially assessed at thesix-month mark and then the
secondary outcome was assessedat the one-year mark.
When it came to motivationalinterviewing, it was eight
sessions of individualizedcounseling for 30 minutes.
Dr. Joshua Goldenberg (26:52):
Seems reasonable to me.
Yeah, and it's balanced acrossgroups anyway.
Dr. Adam Sadowski (26:55):
Yep.
And then with that primaryoutcome, it was seven-day
abstinence that wasself-reported and confirmed via
exhaled carbon monoxide levelsof less than 10 parts per
million.
And then they basically did thesame thing at the 52 week mark.
Dr. Joshua Goldenberg (27:15):
Oh, and that helps us with unmasking.
If it was unmasked and thatinfluence?
Well, let me think this throughfor a second.
It's an objective outcome.
So well, I guess it would belike if you're lying about, yeah
, never mind, keep on going,we're still good, we're still
good.
Dr. Adam Sadowski (27:30):
Yeah, and then secondary outcomes were
viewed as exploratory.
So really it's mostly about theprimary outcome at the
six-month mark, not the 52-weekmark.
Dr. Joshua Goldenberg (27:39):
But it's nice that they have that
follow-up yeah.
Dr. Adam Sadowski (27:42):
Yep, and then everyone was randomized to the
group they were assigned in.
So the intention to treatprotocol, which we love to see,
and then that was really it froma method standpoint.
Dr. Joshua Goldenberg (27:58):
I really like the way that this study was
conducted and reported.
Yeah, one thing I wanted to addwhich makes it even better is
so it's one thing to say likeintention to treat principle
like what does that mean for thepeople that actually are
missing outcome?
Like intention to treatprinciple like what does that
mean for the people thatactually are missing outcome?
So for losses to follow up,they assume they kept on smoking
, which is great.
So they basically had a worstcase assumption about missing
outcome data or loss to followup, which is a very conservative
(28:19):
way to do it, as opposed tomultiple imputation or coming up
with all sorts of differentsensitivity analyses, which is
what we usually do.
They actually just assumed theworst and if they were missing
the outcome, they just asmissing the fallout.
They just assumed they werestill smoking.
So very good.
So any difference that youwould see would be a
conservative difference there,yep.
Dr. Adam Sadowski (28:37):
Okay, do you want to jump over to what the
baseline, like demographics wereof the trial?
Dr. Joshua Goldenberg (28:43):
Yeah, let's do some baseline stuff
briefly and then let's jump intothe results.
So, baseline we've got a prettyeven split between male and
female, more female than male.
Dr. Adam Sadowski (28:57):
Nominally yeah, nominally more female than
male, which I thought wasreally interesting, surprising,
right.
Dr. Joshua Goldenberg (29:03):
You would think the opposite, or maybe
not, I don't know.
By about 10%.
Yeah, 55% versus 45%, mm-hmmmm-hmm.
Dr. Adam Sadowski (29:06):
Yep right, you don't.
You would think the opposite,or maybe not.
I don't know by about 10.
Dr. Joshua Goldenberg (29:08):
Yeah, 55 versus 45 yep, so um, mostly
female, but not like crazy skew.
Average age about 50 years ofage.
Average bmi 26, 27, 28, so youknow overweight.
And average years of smoking3334 years of smoking.
(29:31):
So balance, that's a lot,that's a lot.
Dr. Adam Sadowski (29:34):
That's a really hard group to to then get
smoking.
Cessation with.
Dr. Joshua Goldenberg (29:38):
That's right, 30.
Yeah, let's just take a secondthere.
That's three decades of smoking.
That's a strong addiction and,like you pointed out earlier,
they've tried multiple times toquit.
They've even been involved inclinical trials to quit before
and failed.
So they're very motivated.
They're showing up again toquit.
Dr. Adam Sadowski (29:54):
Yep.
And then about 64% have smokedat least half a pack, so 11 to
20 cigarettes per day.
And then about a third, 30% orso, smoked even more than the
pack, so about a pack and a half, 21 to 30 cigarettes.
And then you have some who aresmoking even more than that, and
(30:17):
that was about four to fivepercent of people smoked at
least 30 cigarettes per day yeah, okay, good, so that's our
population.
Dr. Joshua Goldenberg (30:24):
Um, like you said, a said only maybe
concerned with homogeny becauseit's all from Finland, but still
it's a really good trial and Ilike the population, it seems
very appropriate for primarycare.
Good, okay, I think the onlyother thing I want to mention
about that was the use of whatthey call snus.
(30:46):
That's like snuff, that's likechewing tobacco.
Okay, okay, that's what Ithought.
I had to Google it because Iwas like, is that different than
the little pouches?
So it is the little pouches,and I think that's so relevant
because essentially, like, theyhave this objective marker of
carbon dioxide level, but ifyou're getting your nicotine
another way, you could basicallybe making up for it, and your
(31:09):
nicotine another way, you couldbasically be making up for it,
and, and it would appear as ifyou had quit, when still you're
just as addicted to nicotine.
So I thought it was great thatthey were so cautious about that
and it did not seem toinfluence results one way or
another.
Dr. Adam Sadowski (31:18):
Yeah, and the Gen Zers love to use what's
called Zyn pouches Z-Y-N.
Dr. Joshua Goldenberg (31:23):
Oh, is that a?
Thing?
Dr. Adam Sadowski (31:24):
It's, it's just nicotine pouches.
They seem to be prettyaddictive, yeah.
Dr. Joshua Goldenberg (31:31):
So that's a thing that's so interesting.
I was like Josh, you're so outof touch, I know, doesn't it
cause like holes in your gums orsomething like that?
I just remember.
Anyway, the whole thing's notgood.
Don't start smoking, okay.
So let's, can we talk aboutresults?
Can we jump into results yet?
Yeah, okay, cool.
So here we go.
(31:53):
So the main outcome here.
So we're talking aboutconfirmed abstinence at six
months.
So the e-cigarette group wehave so this is like true
nicotine e-cigarettes withplacebo, shantix and the
motivational interviewing 40.4%were abstinent at six months.
That's remarkable.
I would think 40% of this toughpopulation is abstinent at six
(32:17):
months.
That's outstanding.
The Shantix group was 43.8, so alittle bit higher, also
outstanding.
And the placebo group was 19.7.
So one in five people on justwell, it's say just placebo.
Remember they had motivationalinterviewing as well.
20% of them essentially quit,which is amazing at six months.
(32:40):
And then you had double thatessentially with the e-cigs with
nicotine or the shantix, whichis pretty cool.
There was a statisticallysignificant difference, clearly,
with those numbers, between theShantix, which is pretty cool.
There was a statisticallysignificant difference clearly
with those numbers between theE-SIGs versus placebo and the
Shantix versus placebo, but notbetween Shantix and E-SIGs.
The difference was too close.
(33:00):
So we can't say statisticallythat even though Shantix
nominally had a higherabstinence rate, that may just
kind of be random error whencompared to e-cigs, but both
seem to be very effective versusplacebo or motivational
interviewing alone.
Dr. Adam Sadowski (33:17):
Yeah, you might even argue that this is a
negative trial for Pfizer.
Dr. Joshua Goldenberg (33:23):
Why.
Dr. Adam Sadowski (33:24):
In the sense that, you know, e-cigarettes may
be as effective as Chantix.
Dr. Joshua Goldenberg (33:31):
Oh, that's true.
Yeah, so not only better butright.
Maybe statistically the same ase-cigs.
That's right, but definitelyreinforces this idea that it
doubles the response rate versusplacebo.
Yeah, good point, okay.
Dr. Adam Sadowski (33:46):
But it's really important because I mean
it's important clinically,because now it's like, hey,
here's a fourth option that wecan consider.
Dr. Joshua Goldenberg (33:52):
Yes, yeah , that's right, that's right.
Love that.
Okay, what else did I want tosay?
I think that's it for thesix-month outcome.
Should we talk about the oneyear?
Dr. Adam Sadowski (34:03):
Yeah, let's talk about the one year which
remember was a secondary outcomeand viewed as exploratory and
it was a little bit upsetting.
Yeah, 50% reduction, like a Idon't know 30% reduction in the
(34:30):
number of people from thesix-month mark who were
abstinent at 52.
So remember, confirmedabstinence was biological, in
addition to self-report.
And at the 52-week mark we have28% in the nicotine electronic
cigarette group versus 38% inthe Chantix, versus 20% in the
(34:57):
placebo.
So placebo basically wentunchanged.
The Chantix group dropped offfrom 44% to 38%, rounding up,
and then the nicotine groupdropped off from 40% to 28%,
yeah, so, so Chantix did alittle bit better.
Dr. Joshua Goldenberg (35:17):
Yeah, and was statistically significant
still at one year, wherease-cigs were not.
Introducer (35:26):
Yeah.
Dr. Joshua Goldenberg (35:27):
Barely Interesting one year, whereas
e-cigs were not, yeah, barelyinteresting.
Um, so we have the at sixmonths.
They're about equivalent, bothdouble the placebo response and
at one year.
Uh, we see that, yeah, theshantix has held most of the
benefits, still statisticallysignificant, whereas the e-cigs
have dropped no longerstatistically significant when
(35:48):
compared to placebo I love howthey reported the absolute um
change in the difference too.
Dr. Adam Sadowski (35:55):
Uh, within on the bottom of table two.
Yeah, so yeah at at the um atthe self-reported and confirmed
abstinence.
When you look at the confidenceintervals for the e-cigarettes,
it went from negative one to18%.
So so no difference there.
And then for the Chantix groupit was 8.4, let's say 8%.
(36:19):
Let's round up 8% to 28% wasthe 95% confidence interval
there.
So that remains statisticallysignificant.
And then placebo was also minus1% to 20%.
So across that threshold of nosignificance.
Dr. Joshua Goldenberg (36:36):
Yes, and the other interesting thing,
just about the snuff or zing orzang or whatever you call it
even when you look at that atone year, the results are
analogous where it's barely notstatistically significant with
e-cigs, still statisticallysignificant for shantix, and
then the difference between thetwo is not statistically
(36:59):
significant at the one year mark.
Now, remember, it's the sixmonth mark.
E-cigs are still doing well,but yeah, they kind of lose
there.
Um, e-cigs are still doing well, but yeah, they kind of lose
their.
It's interesting that thee-cigs would lose their benefits
, some of their benefits, at oneyear, whereas shantix would not
, because if it's just a 12 week, were they taking shantix all
the way through or just forthose 12 weeks?
Dr. Adam Sadowski (37:18):
just for those 12 weeks is my
understanding interesting, veryinteresting now, perhaps this is
where the the, the benchscientists come out from their
gremlin hole and start talkingto me about.
This is why mechanism of actionmatters.
It's because perhaps there'ssomething here that would
explain that, perhaps, but again, I don't care.
Dr. Joshua Goldenberg (37:40):
Oh, man Beautiful.
I thought it was a very clearstudy.
Dr. Adam Sadowski (37:47):
I don't think Wait, we're not done, we're not
done, yeah Well what else wasthere to talk about?
Dr. Joshua Goldenberg (37:51):
Side effects?
Adverse effects?
Yes, no adverse effects, noadverse effects.
I guess that's something totalk about.
Some people died, not many.
Oh my God.
Dr. Adam Sadowski (38:17):
Oh, dear listener, when, when you receive
, when we see josh in in the uhlawsuit and they say they say,
dr goldenberg, you have killedsome patients, and dr
goldenberg's response will beyeah, but not many it's all
about the absolute effects hereit's not statistically
significant.
Your honor yeah yeah, yourhonor.
It was a non-statisticallysignificant increased number of
(38:38):
participants who died under mikeair well, that's essentially
what happened here.
Um, we see a couple people die,each group, yeah four people
died in total two in the isagroup, two in the placebo.
Neither were related tointervention.
There were really nosignificant side effects.
Uh, for all of these, with theexception of chantix, had nausea
(39:01):
.
That was statisticallysignificant and that was
basically it.
Dr. Joshua Goldenberg (39:06):
Well, so one other thing.
I didn't catch this before.
Look at the part.
So we're in table threelisteners Adverse events leading
to discontinuation of a studytreatment.
The Shantix group was doublethe amount in the e-cig or
placebo.
That's interesting.
Dr. Adam Sadowski (39:25):
But they also had higher success success
rates overall, which was alsointeresting which is also
interesting.
So you're explaining that benchscientist so you're.
Dr. Joshua Goldenberg (39:36):
You're more likely to get side effects
significant enough that youwould stop your treatment if
you're taking shantix, butoverall you are still more
likely to benefit, particularlyat one year and just as likely
at six months.
Interesting, Okay.
So we might expect higher sideeffect rates with the shantix.
(39:57):
That's useful information.
Whereas the e-cig.
I mean I'm not surprised thatthe e-cig is the same as placebo
.
I mean, they've been smokingcigarettes and now they're just
smoking electronic cigarettes.
Like I would be surprised ifthere was much of a difference.
I mean, maybe you get shockedby this e-cigarette.
Dr. Adam Sadowski (40:11):
I don't know if that's a thing, but, um,
probably not well, there was,there were e-valley concerns, um
, uh, so I forget what e-valleytotally stands for, but it's
like e-valley yeah, it's likee-cigarette vaping associated
lung injury, something like that.
Oh, um these were earlyconcerns back when e-cigarettes
firsting associated lung injury,something like that.
(40:32):
Oh um, these were earlyconcerns back when e-cigarettes
first came to market and a lotof it had to do with with people
tampering with um, thecombustible oh and so a lot of
people were getting like intolike icu admits for um pretty
severe pulmonary injury from thee-cigarette tampering.
Dr. Joshua Goldenberg (40:49):
Okay, so that would be a good thing to
look here.
We're not seeing an increasewith these.
Okay, beautiful, what else?
Anything else you want to talkabout?
Dr. Adam Sadowski (40:58):
I thought discussion was interesting.
I kind of agreed with them thatthey showed that they said not
only was Chantix helpful but sowas the e-cigarettes at six
months.
And then they just kind oftalked about the lack of
evidence that kind of existslooking at e-cigarettes and
whatnot, but that kind ofthey're off to a good start with
(41:20):
this.
You know what's available rightnow and the direction that the
research is heading in.
Dr. Joshua Goldenberg (41:26):
Yeah, you know it's interesting in
actually looking at the dataversus what they said.
I'm actually more impressedwith Shantix the second time
through here because of the oneyear mark.
But it's funny because, like,apparently Pfizer gave them a
bunch of funding but you don'tget that sense from reading
their article.
They just make them seem likethey're equivalent, which is
(41:48):
interesting.
So clearly they didn't have anoverly impressive influence on
the on the authors, if anything.
It seems the opposite.
They kind of downplay theShantix benefits.
Interesting, okay, cool, I likeit.
Now, just to reinforce the bigdebate, I think, is what is the
population that you're givinge-cigs to right?
Like if you're giving it, likeyou said in that first study you
(42:10):
were talking about, wherepeople that had no initial
interest and they're young andnow they're going to start
smoking, whatever, it's not goodcompared to nothing.
But if they're like hardcoresmokers for 30 years and have
tried everything to quit, likeyeah, it's kind of an obvious
no-brainer, so it really doesmatter.
Like it seems like these thisdebate gets at least a couple
(42:37):
years ago it was like a bigdebate like is are these e-cig
things brilliant or harmful?
Dr. Adam Sadowski (42:39):
and horrible and it really depends on the
population, I think is thetake-home context.
Yeah, context matters a lotcontext matters.
Dr. Joshua Goldenberg (42:43):
Yeah, yep , yep, yep.
So if you're in finland andyou've been smoking for 30 years
and you've tried a bunch ofother stuff, you might try
e-cigs or shantix and you mightdouble your chance of abstinence
, which is super cool.
All right, I like that littlestudy it was.
It was not that little, it'sabout 500 people, 150 in each
group.
Um, nice job, adam.
Thanks for recommending thatone.
Dr. Adam Sadowski (43:04):
Any last minute words of wisdom to our
listeners, sir well, yeah,although it was a small study,
given Small study, 500 peopleRelative to other studies that
are large, right, it was along-term.
It was relatively long-term ayear.
Dr. Joshua Goldenberg (43:21):
Yeah, year outcomes.
Dr. Adam Sadowski (43:24):
Very well conducted.
Dr. Joshua Goldenberg (43:26):
Yep Agreed.
Dr. Adam Sadowski (43:27):
Seems like we've now got two high-level
evidence papers.
Introducer (43:33):
Mm-hmm.
Dr. Adam Sadowski (43:35):
Do we need another study?
Dr. Joshua Goldenberg (43:36):
I mean, I don't think so.
Dr. Adam Sadowski (43:38):
If we did it, you know, if we repeated it in,
let's say, a different patientpopulation, even if it was like
a homogenous patient population.
Let's say, like in Australia,right.
Or let's say we did another onein the States.
Introducer (43:50):
Mm-hmm.
Dr. Adam Sadowski (43:55):
And we get the same results, would you?
Would you be like, hey, I thinkwe're done here, or would you
want to continue beating thislike crazy, like a vitamin d
trial?
Dr. Joshua Goldenberg (44:04):
I mean I don't even know that they needed
this one.
So they had high level evidencefor what they had high
certainty evidence that nicotinecontaining e-cigarettes are
associated with an improvedsmoking abstinence.
So I mean they already hadbefore this was even done.
There was high level gradeevidence that you're going to
increase your abstinence withe-cigarettes compared to
(44:24):
nicotine replacement therapy.
So so the debate is okay.
Well, what about compared toShantix, which is not nicotine
replacement?
But I guess, like for the pointof, should you try e-cigs?
They already have that data.
Like grade high by definition,literally means that any future
study is extremely unlikely tochange the overall result.
Dr. Adam Sadowski (44:44):
And it's really cool.
It's cool to see that confirmedhere.
Dr. Joshua Goldenberg (44:47):
Yeah.
Dr. Adam Sadowski (44:48):
Hey, yeah.
Dr. Joshua Goldenberg (44:49):
That's true, I think that's cool.
Dr. Adam Sadowski (44:52):
Yeah that's the idea, because you, you read
about that.
Yeah, that's the idea of like,hey, if it's high level of
evidence, really nothing shouldchange.
But you always wonder, but Ihaven't seen.
Yeah, you always wonder andlike I haven't yeah I haven't
really seen like, okay, likethey say it's high level, but
we're gonna do another trial andthen confirming that like I
just haven't stumbled upon it,whereas this was like, hey,
(45:13):
there's high level of evidence,we're going to repeat it.
And yeah, we found the samething.
Dr. Joshua Goldenberg (45:19):
Yeah, it is interesting, like when they
were setting up the rationale inthe introduction.
You know, when you already havehigh level evidence of
something, it's like, well,what's your rationale?
And their spin was in the likehaving this additional arm for
shantix.
But yeah, as far as actuale-cigs, yeah, it's already there
.
And to your point like I thinkwe don't see that a lot because
a in theory, you shouldn't berunning extra trials and wasting
(45:39):
resources if you already knowit's high level evidence.
But also very few things arehigh level evidence right, Like
we've done some papers like that.
I can't remember what thepercentage is, but it's in the
low single digits, isn't it?
Like things that are effectiveand high level evidence in
medicine.
Dr. Adam Sadowski (45:54):
Probably.
We're probably like 4% best.
Dr. Joshua Goldenberg (45:56):
Yeah right, it was something.
I remember that somewherebetween four and seven, I can't
remember, but like absurdly low.
And so this is one of thoserare things where e-cigs
apparently are in that fancygroup of high level evidence and
efficacious.
So I am impressed, but don'tstart if you're a little kid who
has no interest in starting tosmoke, only if you're finished
(46:19):
and have 30 years of smoking.
E-cigs and viagra, well, what'sthe what's the evidence on
viagra?
Dr. Adam Sadowski (46:25):
it's high level the number needed to treat
is like two is it so?
Dr. Joshua Goldenberg (46:31):
yeah, okay, that's interesting and
it's uh, and the evidence levelis high.
Dr. Adam Sadowski (46:36):
It works for yeah okay, interesting, all
right I I'm assuming, I I'mpretty sure it is you're
assuming I'm assuming they havea good, they have a good lobby
apparently.
Dr. Joshua Goldenberg (46:46):
Um, it's interesting.
I, I, I would love to see alist of the stuff, of the
interventions that are highlevel and efficacious.
At high level, efficacious anda large effect size, like here
we we double the, the responserate, right, like I would love.
That's got to be a rarefiedlist.
It's like it's like three itemscigarettes and viagra.
What's the third?
(47:07):
I wonder what the semaglutideglp1 oh it would?
Dr. Adam Sadowski (47:16):
it would probably be suboxone am I is?
Dr. Joshua Goldenberg (47:19):
is the evidence?
Is the level of evidence highfor suboxone?
Dr. Adam Sadowski (47:24):
don't quote me on that, I don't.
I I'm going to assume.
Yes, I know the number neededto treat is very low with
suboxone oh, that's interestingbut it's likely high level of
evidence.
Huh, very curious.
I'm assuming.
Don't quote me, it's notmedical advice, don't?
I don't know.
Dr. Joshua Goldenberg (47:42):
I'm telling you outwardly I do not
know if you're a listener, and,oh, you know what.
There's another one.
Um, mark's always talking aboutit.
It's probiotics for Ulcerativecolitis, some, no, not even for
some pediatric oh my God,necrotizing something or other.
I think that has high levelevidence.
(48:02):
Mark's always like it's one ofthe few things that has high
level evidence, and it's true.
Okay, so we got Viagra,probiotics in that one pediatric
population and e-cigs.
And then, listeners, if you'vegot any others, please send it
our way.
That would be cool to kind ofmake a list and maybe do a
series of papers where we talkabout the things that actually
(48:22):
work, since we're alwaysfetching about the things that
don't work and how most thingsdon't.
So it might be a nice littletweak.
Yeah, little tweak.
Yeah, our two episode series,things that work in medicine.
We've already covered them,right?
Yeah, all right.
Well, uh, we're not jaded, okay.
Well, talk to you laterlisteners.
Thank you, adam, good paper atthe end of all my complaining.
Um, it was a good paper and itwas interesting to know that we
(48:45):
have high level evidence forthat.
So cool man.
Yeah, step back into primarycare and never.
Dr. Adam Sadowski (48:50):
The world is your oyster.
Dr. Joshua Goldenberg (48:53):
All right , talk to y'all later.
Bye, if you enjoy this podcast,chances are that one of your
colleagues and friends probablywould as well.
Please do us a favor and letthem know about the podcast and,
if you have a little bit ofextra time, even just a few
seconds, if you could rate usand review us on Apple Podcast
or any other distributor.
It would be greatly appreciated.
(49:14):
It would mean a lot to us andhelp get the word out to other
people that would really enjoyour content.
Thank you, hey y'all.
This is Josh.
You know we talked about somereally interesting stuff today.
I think one of the things we'regoing to do that's relevant.
There is a course we have on DrJournal Club called the EBM
Boot Camp.
That's really meant forclinicians, to sort of help them
understand how to criticallyevaluate the literature, etc,
(49:36):
etc.
Some of the things that we'vebeen talking about today.
Go ahead and check out the shownotes link.
We're going to link to itdirectly.
I think it might be of interest.
Don't forget to follow us onsocial and interact with us on
social media at Dr JournalClubClub DRJournalClub on
Twitter.
We're on Facebook, we're onLinkedIn, etc.
Etc.
So please reach out to us.
We always love to talk to ourfans and our listeners.
(49:58):
If you have any specificquestions you'd like to ask us
about research, evidence, beinga clinician, etc.
Don't hesitate to ask.
And then, of course, if youhave any topics that you'd like
us to cover on the pod, pleaselet us know as well.
And, of course, if you have anytopics that you'd like us to
cover on the pod, please let usknow as well.
Introducer (50:13):
Thank you for listening to the Doctor Journal
Club podcast, the show that goesunder the hood of
evidence-based integrativemedicine.
We review recent researcharticles, interview
evidence-based medicine thoughtleaders and discuss the
challenges and opportunities ofintegrating evidence-based and
integrative medicine.
Be sure to visit www.
d wwwdoctorjournalclubcom tolearn more.
Welcome to the Dr Journal Club podcast, the show
that goes under the hood ofevidence-based integrative
medicine.
We review recent researcharticles, interview
evidence-based medicine thoughtleaders and discuss the
challenges and opportunities ofintegrating evidence-based and
integrative medicine.
Continue your learning afterthe show at www.
(00:24):
drjournalclub.
com.
Dr. Joshua Goldenberg (00:31):
Please bear in mind that this is for
educational and entertainmentpurposes o nly.
Talk to your doctor beforemaking any medical decisions,
changes, etc.
Everything we're talking aboutthat's to teach you guys stuff
and have fun.
We are not your doctors.
Also, we would love to answeryour specific questions on
drjournalclub.
com.
You can post questions andcomments for specific videos,
(00:55):
but go ahead and email usdirectly at josh at
drjournalclub.
com.
That's josh at drjournalclub.
com.
Send us your listener questionsand we will discuss it on our
pod.
Hello everyone, this is DrJoshua Goldenberg and Dr Adam
Sadowski.
Josh and Adam, your buddies forevidence evaluation and
(01:18):
critical eval of the medicalliterature.
And today, for God knows whatreason, A adam has us reviewing
an electronic cigarettesresearch article.
I think this is the secondelectronic cigarettes research
article you had us do.
I think we did one a coupleyears ago.
Dr. Adam Sadowski (01:34):
So what do you mean?
For God knows what reason
Dr. Joshua Goldenberg (01:41):
Are people still smoking?
Dr. Adam Sadowski (01:43):
A lot of people still smoke.
Dr. Joshua Goldenberg (01:45):
People still can't be smoking.
Dr. Adam Sadowski (01:47):
Yes, J osh, not only are a lot of people
still smoking, but the youths,the youths are smoking.
Dr. Joshua Goldenberg (01:55):
The youths, yeah, the youths.
Dr. Adam Sadowski (01:58):
These crazy millennials.
These dag nabbit.
Dr. Joshua Goldenberg (02:02):
That can't be a thing.
Dr. Adam Sadowski (02:04):
These dag nabbit Gen Zersers
Dr. Joshua Goldenberg (02:06):
They're not smoking.
No one's smoking anymore.
Dr. Adam Sadowski (02:09):
They're smoking e-cigs.
Dr. Joshua Goldenberg (02:12):
Oh, e-cigs?
Dr. Adam Sadowski (02:13):
It's like they're like pacifiers.
Man, I'm not even joking.
Dr. Joshua Goldenberg (02:20):
Well, I think the last one we did was on
on the potential dangers ofe-cigs.
I think, for these concernsthat people are going to smoke
that instead of smokingsomething else.
Dr. Adam Sadowski (02:32):
It was a Dr.
Journal Club video.
People should check it outactually, because a lot of
people are kind of like.
Dr. Joshua Goldenberg (02:38):
Oh, it was pre-pod.
It was pre-pod, that's right.
Dr. Adam Sadowski (02:41):
It was pre-pod.
Yeah, yeah, it was pre-pod.
I think people should check itout.
It was a good video.
I liked the article a lot.
Basically with that article youknow too long didn't read Spark
notes of that study was thate-cigs apparently appear to be
safer from a quote-unquotetoxicity standpoint like regards
(03:04):
to chemicals you're exposed tothan than cigarettes.
Dr. Joshua Goldenberg (03:06):
Right.
Dr. Adam Sadowski (03:07):
I mean we still.
They're still new, right.
There's still a lot to learnfrom them.
Dr. Joshua Goldenberg (03:12):
Right.
Dr. Adam Sadowski (03:12):
But the data is so clear that cigarettes are
not good for you.
Dr. Joshua Goldenberg (03:16):
Well, but it's like this, interesting.
Okay, so it's been years andand, Michele, um, we're going to
get you the link so you couldput it in the show notes to that
Dr Journal Club review.
But I kind of remember adiscussion about if it's
compared to regular cigarettesyeah, safer, but the fear is
(03:36):
well, what if people are pickingup the habit from doing nothing
?
That's not good.
And then to look at that net,how does that?
How does that net out, I guess,across society?
Dr. Adam Sadowski (03:46):
Yeah, and that the A american academy
pediatrics, way back when, didhave an article on this as well.
Where they come basically?
Uh, you know they were lookingat at adolescents who had no
motivation or, you know, anyinterest in actually picking up
cigarette smoking, and I thinkit was a cohort study, if I'm
(04:12):
not mistaken, cohort orcross-sectional, I think it was
cohort and basically whathappened was those who were not
ever motivated to start smokingcigarettes but did use the
e-cigarettes.
Again, this is in adolescentswho aren't using e-cigarettes
for smoking cessation.
It's a different topicaltogether.
There was, I think, a fourfoldincreased risk in the then going
(04:40):
on to actually picking up asmoking habit.
Dr. Joshua Goldenberg (04:42):
Yeah, so that's interesting that's
interesting.
Dr. Adam Sadowski (04:44):
So you know, if you're not doing it, don't do
this, don't start if you'redoing it.
But if you're smokingcigarettes and the question is,
hey, doc, you know, should I?
Yeah, because this was thiscame up all the time of hey,
should I go from smokingcigarettes to you know, uh,
(05:07):
these vapes and there were somany people who were saying like
no, smoking cigarettes is safer, which is the dumbest thing
I've ever heard.
Dr. Joshua Goldenberg (05:13):
What oh, because it's quote, unquote,
natural or something like that.
Is that the idea?
Dr. Adam Sadowski (05:18):
I don't know, but I don't know, but it really
annoyed me and there's reallyhigh-level evidence in Cochrane
papers that support thetransition from cigarettes to
e-cigarettes.
Now, granted, ideally you comeoff of e-cigarettes, but the
whole goal is to get people tostop smoking.
Dr. Joshua Goldenberg (05:38):
It's interesting.
Have you ever smoked?
No, I smoked for a while.
Really, I smoked a while when Iwas 18.
I remember thinking I'm goingto be cold.
Were you the?
Dr. Adam Sadowski (05:50):
Marlboro man, did you walk around with a
cowboy hat?
Dr. Joshua Goldenberg (05:54):
I was Marlboro Lights.
They were gold or something.
Dr. Adam Sadowski (06:01):
So they were safer for you.
Dr. Joshua Goldenberg (06:03):
I remember people having that
conversation when I was hangingout with the hippies.
They'd be like, well, I onlysmoke.
I can't remember the name ofthe.
There's like a native americanbrand or something.
It's like all natural americanspirits, american spirits, and
that was the theory.
Is that, like that was thehealthy cigarette?
I'm like you've got to bekidding, you realize.
Like we're all lying toourselves, right?
Um, anyway, but so you knowwhat actually got me to quit
(06:25):
smoking.
I was thinking about this whenI was reading the paper.
I was like it was so freakinghard, right, like I knew how.
First of all I was like why arewe doing this?
No one smokes anymore.
And then I was like, well, itwas really kind of hard to quit.
Dr. Adam Sadowski (06:36):
Like I can see how it would be helpful I
think you need to dip back intoprimary care and get a little
dose of reality.
Dr. Joshua Goldenberg (06:42):
I know that's that's I were going to
say that you knew you were goingto say that You're going to be
like, well, you have to stopdealing with folks with SIBO all
the time, and that's all yousee, because you're right.
I have no sense of what realityis, but anyway, I've got pretty
good self-control, but it wasimpossible to quit.
It was so freaking hard and Iremember like um, I remember
(07:05):
like getting so frustrated withmyself and like breaking the
cigarettes and throwing them inthe trash and then, like you
know, not making this up thenlighting a trash on fire and
having a big old bonfire ofcigarettes I should have,
because I would go back.
I and I taped them together,adam, like it was.
So such a powerful addiction itit's crazy.
And the only thing that workedis I did my little hippie trip
(07:29):
off to Central America for likeI don't know.
I think I was gone a half yearor something like that and I was
on a farm in Costa Rica with noaccess to anything, miles from
the town.
You couldn't go and there wasno store and I ran out of
cigarettes and I couldn't doanything for like a number of
weeks and that's how I quit.
(07:50):
Right, it was like youphysically need to be in a
jungle somewhere and have noaccess to cigarettes, Josh,
because apparently that's thelevel of self control that you
have and that I mean that wasreally telling to me.
This is powerful addictionstuff that we're talking about
here.
Dr. Adam Sadowski (08:06):
Yeah, yeah.
No, it's very tough.
I've, you know, I've workedwith people who use pretty
intense illicit substances andthey, you know, they say that
the hardest thing to quit forthem was the cigarettes.
Dr. Joshua Goldenberg (08:20):
That's crazy.
I've heard that before, butthat's like crazy that
anecdotally you've been hearingthat as well like poor Josh back
in the day, have tried to quitsmoking, even did a clinical
trial to quit smoking and failedwere unsuccessful, and now
(08:50):
we're like trying yet again.
So these are people who aredesperate to stop and they need
help, and that was therecruitment goal for this one.
Dr. Adam Sadowski (08:58):
Yeah, and it's also very clinically
relevant because, you know,oftentimes people have tried
more than once to try quittingtobacco use, and so this is it's
not an unreasonable inclusioncriteria or population that
we're dealing with, like themain thing is like okay, this is
relatively homogenous patientpopulation in that it's people
(09:21):
from Finland and that it'speople from Finland.
The fact that these are peoplewho have tried to quit in the
past and failed, and are readyto go again is very much
clinically relevant.
Dr. Joshua Goldenberg (09:32):
I thought so too.
I'm trying to remember.
The inclusion criteria Wassomething like 30-pack year
history.
They had to be moderate orsevere level nicotine addiction.
Dr. Adam Sadowski (09:41):
Yeah, they were smoking on a daily basis
and willing to quit, and theseare people who were recruited
back from 2003 to 2009 in thatprevious trial and basically, if
they were still smoking, werethen allowed to come into this
trial, and they had to bebetween the ages of 25 to 75
years of age, smoking daily forlonger than 10 years with at
(10:05):
least 10 cigarettes per day.
There's 20 cigarettes in a pack, so they're smoking at least a
half a pack a day.
Introducer (10:10):
Wow.
Dr. Adam Sadowski (10:11):
And they had to have been smoking at least a
half a pack a day for the pastfive years and they had to have
a carbon monoxide level of 15parts per million or greater
when they were doing exhale likeexhale testing.
And the reason for that isbecause the primary outcome was
not only self-reported smokingcessation success but also parts
(10:33):
per million of the carbonmonoxide and basically, if it
was like under a certainthreshold, then you can say like
yes, you have been, you havenot been smoking.
We can confirm biologicallythat that what you're saying is
truthful.
Dr. Joshua Goldenberg (10:46):
Yeah, it's always nice to have that
objective marker.
Um, well, let's, let's zoomback out again.
I mean we're we're kind ofjumping in a little bit, but we
did a pretty decent job.
So so that was the.
I think we did a good job withthe inclusion criteria.
So these are, like you said,very clinically relevant
population.
Um, and then, yeah, yeah, let'stalk about the arms.
There was some, it was a cooldesign.
Dr. Adam Sadowski (11:06):
There is a three-arm trial well, before we
get into that.
Dr. Joshua Goldenberg (11:09):
I mean I I did read the introduction to
this just always assume youdidn't and move on, but go ahead
yeah well.
Dr. Adam Sadowski (11:16):
I mean again, sometimes I like to read it if
it's an interesting topic orsomething that like, if, if the
introduction reads well, I willkind of pay attention to it.
Sometimes they're just like wayout there and I'm like, okay,
this is, this is going somewhereI don't want to get involved
with.
But basically what they'resaying is that you know, they
cited previous evidence thatthere is high certainty evidence
(11:38):
that uh, e-cigarettes thatcontain nicotine are associated
with increased conventionalcigarette smoking abstinence
rates compared with nicotinereplacement therapy.
So that would be like yournicotine gums, your nicotine
lozenges, patches, etc.
Etc.
Dr. Joshua Goldenberg (11:53):
So hold on pause on that, like that's
crazy to me.
So you've got.
Let me just like.
Let's just highlight that.
First of all, very, very, veryfew things in medicine have high
certainty evidence like that'salready very, very rare and
that's that's like grade levelhigh.
And so nicotine.
So these are e-cigarettes withnicotine and they have increased
(12:14):
, first of all, your increasedabsence from cigarettes.
So that's even surprising to me, and even more so than nicotine
replacement therapy.
Dr. Adam Sadowski (12:22):
That's great, that's impressive yeah, and the
evidence they cited was fromthe American Journal of Public
Health and Cochrane, so not likelittle tiny trials, but pretty
reputable journals, so that'simpressive.
Dr. Joshua Goldenberg (12:34):
Okay, so we know that these e-cigarettes
with nicotine are excellent forabstinence from regular
cigarette smoking.
Okay Deal, keep them going.
Dr. Adam Sadowski (12:45):
Yep.
And then they, you know,continue to say like, hey,
there's not a lot of, there's noreported short-term adverse
effects with it.
But we do know that adverseeffect reporting in clinical
trials is miserable, and thesejust haven't been around long
enough to develop, you know, asolid database of long-term side
effect profile of e-cigarettes.
(13:07):
And so what they said was inthis study the one that we're
going to be podcasting about wasbasically a 52-week follow-up
where they looked at botheffectiveness and harms of
electronic cigarettes forsmoking cessation, compared to
varenicline, which is brand nameChantix, in adults who were
(13:29):
long-term smokers ofconventional cigarettes and for,
basically, for people who don'tknow.
Typically, when it comes tomedical therapy for smoking
cessation, there aren't verymany options.
You have the nicotinereplacement therapy, which can
be like gums, lozenges, patches,a combination of those.
You have bupropion, which canbe used, and then you also have
(13:53):
varenicline, which is a brandname Chantix.
Chantix is known for causingvivid dreams and there used to
be concern.
Dr. Joshua Goldenberg (14:02):
Oh yeah.
Dr. Adam Sadowski (14:02):
There used to be concern that it could cause
or, you know, induce or resultin psychosis, and so it kind of
had this like oh.
Yeah, For a second there.
It had a black box warning.
Dr. Joshua Goldenberg (14:15):
That's not good.
Dr. Adam Sadowski (14:16):
But then after the Eagles trial, which
actually looked to investigatethis, the FDA then subsequently
removed that psychosis black boxwarning.
They showed that there wasactually no significant
increased risk in thedevelopment of that with Chantix
used compared to placebo.
So then they removed that label.
Dr. Joshua Goldenberg (14:37):
Good background Okay.
Dr. Adam Sadowski (14:38):
Yeah, so that's just some background
information with regards to that
Dr. Joshua Goldenberg (14:45):
I think this is right.
It's a partial ag likenicotinic receptor agonist,
right?
Who cares?
Well, I think that's themechanism.
Well, well, just with thisthought,
who cares?
I knew you were gonna say thatno, no, but seriously.
Dr. Adam Sadowski (14:57):
No, no but seriously.
Who, who cares?
Dr. Joshua Goldenberg (15:00):
well, I mean, it kind of makes sense.
You sort of like agonize,agonize.
You sort of like tickle thenicotine receptor and it's gonna
hey, josh, josh cool, are youstill smoking?
Nobody cares, nobody cares,stop, you know we have people on
this pod who care aboutmechanism of action.
(15:20):
Thank you very much.
That's the problem.
Problem.
Dr. Adam Sadowski (15:25):
Stop.
Yeah, cool we have.
We have mechanisms of actionsand like we can use that and be
nerdy and like, yes, it isimportant, but clinically I want
you to stop smoking.
Dr. Joshua Goldenberg (15:40):
Okay, that's fair.
That's fair especially withlike high level evidence, like I
don't know what the evidencelevel is for shantix.
But you know, you know it's onething to say, okay, we've got
like this one tiny little trial,like we're hanging our hat too
much on or too little onmechanism of action to to
explain it.
But if it is solid evidence,like yeah, you're right at the
end of the day who right, okay,um, okay, and so then basically
(16:11):
what they what they did in theprior trials was looking, I'm
gonna have all these benchtopscientists come after us.
Yeah, go ahead all right.
Dr. Adam Sadowski (16:15):
So come after us, give us your again.
Come after us give us your,give us your data you don't want
to mess with rat people.
Dr. Joshua Goldenberg (16:22):
Rat people are serious.
I mean, let me tell you I don'tknow about we could take the
elijah people, but you know ratscientists, I'm not sure.
I'm not sure.
Dr. Adam Sadowski (16:32):
All right, keep on going as good as, as
good as the rat from uh teenage,uh mutant ninja turtles so this
has been killing me.
Dr. Joshua Goldenberg (16:40):
Is that shredder, or there's shredder
and there's um?
No sure, I thought shredder wasthe bad dude okay, so that's
why I couldn't remember therewas a bad dude and a's no.
Dr. Adam Sadowski (16:49):
I thought Shredder was the bad dude.
Okay, so that's why I couldn'tremember there was a bad dude
and a good dude.
Yeah, the good one takes in theTeenage Mutant.
Dr. Joshua Goldenberg (16:52):
Ninja Turtles Right, but that's not
Shredder.
It was Shredder, but there wasanother S name, it wasn't
Sadowski.
That's what we'll call you,adam the Shredder Sadowski.
You, adam the shredder Sadesk.
Talk to Adam the shredderSadesk.
Dr. Adam Sadowski (17:06):
Okay, we're going on a tangent.
We're going on a tangent, okay.
Dr. Joshua Goldenberg (17:12):
I hit the tangent.
Did you like that?
Normally we tangent at thebeginning.
This is an interpod tangent tofool our listeners.
Okay, go ahead, keep on going,okay.
Dr. Adam Sadowski (17:20):
So the primary outcome of that last
trial where they recruited thesepatients from, the primary
outcome was seven-day smokingabstinence.
So self-reported of hey, Ihaven't smoked in the past week,
which is great.
And then they also confirmed itwith carbon monoxide on
exhalation and that was at the26-week mark.
(17:42):
So basically after six months offollow, follow-up so solid,
solid outcomes yeah, and thenfor for this trial, because
there was no previous randomizedcontrolled trials that looking
at e-cigarettes compared tochantix or varenicline and we
don't get any sort ofcompensation for for saying it.
(18:03):
It's just easier to say chantixand that's what most people
know it by yeah.
So we're not, we're not gettinguh sponsored by by big chantix
here we're not part of thechantix lobby and so what they
hypothesized in this trial wasthat if veroniclean or chantix
therapy were to be combined withmotivational interviewing, um,
then the success rate of smokingcessation would increase
(18:26):
compared to nicotine-containinge-cigarettes combined with
motivational interviewing.
So they're kind of comparingChantix plus motivational
interviewing to e-cigarettesplus motivational interviewing.
Dr. Joshua Goldenberg (18:37):
Which is standard of like I would imagine
you tell me you're the primarycare doc, but like that would be
standard, right?
Like we know, motivationalinterviewing technique works, I
assume, and that's sort of likeyou add that to whatever other
intervention you're doing.
So it's not like they weretrying to get this thing to win,
they were like setting it up asit would be in real life.
Dr. Adam Sadowski (18:55):
Yeah, yeah, and and again, because they're
they're really trying tomaximize therapeutic benefit
here.
So, uh, ideally you're doingmotivational interviewing with
your patients, but reality setsin and sometimes you can't.
Dr. Joshua Goldenberg (19:09):
Wait, wait.
Did the placebo groups also getthe motivational interviewing?
Dr. Adam Sadowski (19:13):
Yeah, they got.
Dr. Joshua Goldenberg (19:14):
Oh, they got it too Okay.
Dr. Adam Sadowski (19:16):
Yep, they got placebo in this trial.
They got placebo Chantix,placebo e-cigarettes, plus
motivational interviewing.
Dr. Joshua Goldenberg (19:24):
Okay.
So they're maximizing thebenefit, but they're not trying
to juice the difference of thestudy, because even the placebo
group got maximum potentialplacebo effects and motivational
interviewing.
Dr. Adam Sadowski (19:33):
Okay, gotcha, I'm with you now yeah, and so
and so, to go back to yourearlier point, what were the
three groups in this trial?
You had the e-cigarette groupplus placebo, chantix, plus
motivational interviewinge-cigarette, placebo, chantix
and motivational interviewing.
Okay, yep the chantix group hadplacebo e-cigarette.
(19:56):
So that was an e-cigarettewithout any nicotine content but
looked exactly like the actuale-cigarette with nicotine Plus.
They got motivationalinterviewing and then, as we
just said, placebo had placeboeverything but real motivational
interviewing.
Dr. Joshua Goldenberg (20:15):
Yeah, so like double dummy we would
sometimes call that plusmotivational interviewing Okay,
awesome, I like those, I likethose groups Very nice.
Dr. Adam Sadowski (20:22):
Yes, and the people who were using the
e-cigarettes were allowed to touse it out of libidum, which I
liked, because basically theysaid here is your e-cigarette
supplies, do what you will withit.
Right, because that's how,that's how people are doing it
in in real life.
Dr. Joshua Goldenberg (20:37):
No one's really like oh, you can only
smoke two milliliters of liquid,well, and that's also kind of
like an intervention in and ofitself, right, like sort of like
a taper or something like that.
Dr. Adam Sadowski (20:47):
Yeah, yeah, yeah, and the study design was
really cool.
I liked it.
It was aninvestigator-initiated,
randomized, placebo-controlled,single-center clinical trial.
So they're very clear here andI really liked how they reported
this.
So it's a randomized,placebo-controlled trial.
We all know what that isSingle-centered, meaning it was
(21:07):
only done at one university, andthen investigator-initiated,
meaning basically theseinvestigators all got together
and were like, hey, we should doa trial on this.
And they were like, yes, weagree, let's go do it.
And it's independent ofindustry sponsorship, right,
it's not an e-cig study, correct?
Now, that being said, they diddisclose and they were very
(21:29):
clear about this that the trialwas funded by grand um, which
was, uh, which was a um, a grant, and with financial support
from pfizer okay however, uh,the funding organization, ie
pfizer, had no role in thedesign conduct, conduct of the
study collection, management,analysis, interpretation of the
(21:50):
data preparation, review,approval of the manuscript
decision to submit.
So basically they just gave themmoney and supplies and said,
like here you go, like figure itout.
Dr. Joshua Goldenberg (22:00):
So they so, just to clarify, they make
Shantix, so they did have anincentive, but, like you said,
they crossed their T's, dottedtheir I's.
Dr. Adam Sadowski (22:07):
As far as their involvement, yeah, but
also, even though they had anincentive, should the data show
that Chantix was terrible andgot blown out of the water, that
was a risk that they werewilling to take.
Dr. Joshua Goldenberg (22:20):
Yeah, I'm cool with that.
Dr. Adam Sadowski (22:24):
So for everyone who's kind of like, oh,
industry sponsorship is bad,not really like read through the
details, not these days.
Dr. Joshua Goldenberg (22:31):
It's clean.
These it's cleaner.
These days.
You have to be careful.
I think supplement industry isstill a bit of a mess, but oh,
it's terrible.
Dr. Adam Sadowski (22:38):
Yeah, yeah, um, but they're getting better
and then the e-cigarettes werepurchased, uh, with the grant.
Dr. Joshua Goldenberg (22:44):
Okay, uh, so yeah, okay, so cool all
right, I'm with you, keep ongoing so very low risk of bias
there for anyone uh payingattention or interested well,
let's talk about risk, aboutsuper fast.
So, um, everybody was blinded,the only the design said it was
good.
But just, they did have amention about masking, and I was
just thinking about that.
Like it seems, it would seempretty obvious to me.
(23:05):
I would imagine, if you'resmoking an e-cigarette and you
don't taste the nicotine rightLike that, I feel like that
would feel different and soeverything.
Dr. Adam Sadowski (23:13):
I thought everything was identical, so in
flavor and everything.
Dr. Joshua Goldenberg (23:16):
Yeah, but you're smoking.
You're smoking non-nicotine.
I mean it's going to bedifferent.
I mean it looks the same, butthen you start smoking it.
And.
But then you start smoking it.
And if you're used to nicotine,are you not going to notice
that it doesn't taste likenicotine?
I don't know, I just feel like.
I've never smoked nicotine, so Idon't know Well this is why I
bring my deep knowledge base tothis pod, these important
(23:37):
matters.
I feel like it would be obvious.
And they do mention thepotential risk of unmasking.
So it was blinded.
But you can always be unmasked,right if, like you just like,
wait, this is, there's no way,this is nicotine or like we've
talked about.
If you you're blinded and thenyou start having lavender
flavored burps, you're likethere's no way, this isn't the
lavender pills.
But what they noted is thatthere was no difference in
(24:00):
dropout rates and so they werekind of using that as a proxy,
like if you, uh, if you feltlike, okay, I was getting the
placebo cigarette, maybe youwould drop out more, right?
so I don't know well that thatwas something that they brought
up but they didn't seem tooconcerned about just because you
know they they didn't seeunequal dropout, I guess yeah, I
(24:21):
feel like it's a bit of a reachtoo yeah, I'm, I'm all right
with it, I'm totally right, andit's also more realistic, right,
right, because I mean, this isdesigned to show efficacy, not
effectiveness, but in real life,like you're going to know if
you're having an e-cigarettewithout nicotine.
Introducer (24:35):
Okay.
Dr. Joshua Goldenberg (24:38):
Look, the thing is we don't do this for
money.
This is pro bono and, quitehonestly, the mothership kind of
ekes it out every month or so,right, so we do this because we
care about this, we think it'simportant, we think that
integrating evidence-basedmedicine and integrative
medicine is essential and therejust aren't other resources out
there the moment.
(24:58):
We find something that does itbetter, we'll probably drop it.
We're busy folks, but right nowthis is what's out there.
Unfortunately, that's it, andso we're going to keep on
fighting that good fight.
And if you believe in that, ifyou believe in intellectual
honesty in the profession, inintegrative medicine and being
an integrative provider andbringing that into the
integrative space, please helpus, and you can help us by
(25:20):
becoming a member on Dr JournalClub.
If you're in need of continuingeducation credits, take our
NANSEAC-approved courses.
We have ethics courses,pharmacy courses, general
courses.
Interact with us on socialmedia, listen to the podcast,
rate our podcast, tell yourfriends.
Dr. Adam Sadowski (25:40):
These are all ways that you can sort of help
support the cause.
And so, yeah, they randomizedthe participants with
computer-generated randomizationscheme.
Everyone was one-to-one-to-one.
And then participants, nursesmaking personal contact, people
providing the motivationalinterviewing, and then the
researchers assessing theoutcomes and analyzing the data
were all masked, meaning theywere blinded.
(26:02):
And then an externalstatistician from a different
university did the uhrandomization scheme.
Dr. Joshua Goldenberg (26:09):
So super clean all good, very kosher,
yeah, very clean what exactly dothey do?
Dr. Adam Sadowski (26:14):
each, each group went through 12-week
intervention, which makes sensebecause chantix is uh prescribed
for a 12-week course.
Dr. Joshua Goldenberg (26:23):
Oh, okay, yeah, and then um in
observation period of up to 52weeks, so for a 12-week course.
Dr. Adam Sadowski (26:27):
Oh, okay, yep .
And then an observation periodof up to 52 weeks, so for a year
.
Dr. Joshua Goldenberg (26:31):
Really nice, really nice.
Dr. Adam Sadowski (26:33):
Yeah, and then the primary outcome was
essentially assessed at thesix-month mark and then the
secondary outcome was assessedat the one-year mark.
When it came to motivationalinterviewing, it was eight
sessions of individualizedcounseling for 30 minutes.
Dr. Joshua Goldenberg (26:52):
Seems reasonable to me.
Yeah, and it's balanced acrossgroups anyway.
Dr. Adam Sadowski (26:55):
Yep.
And then with that primaryoutcome, it was seven-day
abstinence that wasself-reported and confirmed via
exhaled carbon monoxide levelsof less than 10 parts per
million.
And then they basically did thesame thing at the 52 week mark.
Dr. Joshua Goldenberg (27:15):
Oh, and that helps us with unmasking.
If it was unmasked and thatinfluence?
Well, let me think this throughfor a second.
It's an objective outcome.
So well, I guess it would belike if you're lying about, yeah
, never mind, keep on going,we're still good, we're still
good.
Dr. Adam Sadowski (27:30):
Yeah, and then secondary outcomes were
viewed as exploratory.
So really it's mostly about theprimary outcome at the
six-month mark, not the 52-weekmark.
Dr. Joshua Goldenberg (27:39):
But it's nice that they have that
follow-up yeah.
Dr. Adam Sadowski (27:42):
Yep, and then everyone was randomized to the
group they were assigned in.
So the intention to treatprotocol, which we love to see,
and then that was really it froma method standpoint.
Dr. Joshua Goldenberg (27:58):
I really like the way that this study was
conducted and reported.
Yeah, one thing I wanted to addwhich makes it even better is
so it's one thing to say likeintention to treat principle
like what does that mean for thepeople that actually are
missing outcome?
Like intention to treatprinciple like what does that
mean for the people thatactually are missing outcome?
So for losses to follow up,they assume they kept on smoking
, which is great.
So they basically had a worstcase assumption about missing
outcome data or loss to followup, which is a very conservative
(28:19):
way to do it, as opposed tomultiple imputation or coming up
with all sorts of differentsensitivity analyses, which is
what we usually do.
They actually just assumed theworst and if they were missing
the outcome, they just asmissing the fallout.
They just assumed they werestill smoking.
So very good.
So any difference that youwould see would be a
conservative difference there,yep.
Dr. Adam Sadowski (28:37):
Okay, do you want to jump over to what the
baseline, like demographics wereof the trial?
Dr. Joshua Goldenberg (28:43):
Yeah, let's do some baseline stuff
briefly and then let's jump intothe results.
So, baseline we've got a prettyeven split between male and
female, more female than male.
Dr. Adam Sadowski (28:57):
Nominally yeah, nominally more female than
male, which I thought wasreally interesting, surprising,
right.
Dr. Joshua Goldenberg (29:03):
You would think the opposite, or maybe
not, I don't know.
By about 10%.
Yeah, 55% versus 45%, mm-hmmmm-hmm.
Dr. Adam Sadowski (29:06):
Yep right, you don't.
You would think the opposite,or maybe not.
I don't know by about 10.
Dr. Joshua Goldenberg (29:08):
Yeah, 55 versus 45 yep, so um, mostly
female, but not like crazy skew.
Average age about 50 years ofage.
Average bmi 26, 27, 28, so youknow overweight.
And average years of smoking3334 years of smoking.
(29:31):
So balance, that's a lot,that's a lot.
Dr. Adam Sadowski (29:34):
That's a really hard group to to then get
smoking.
Cessation with.
Dr. Joshua Goldenberg (29:38):
That's right, 30.
Yeah, let's just take a secondthere.
That's three decades of smoking.
That's a strong addiction and,like you pointed out earlier,
they've tried multiple times toquit.
They've even been involved inclinical trials to quit before
and failed.
So they're very motivated.
They're showing up again toquit.
Dr. Adam Sadowski (29:54):
Yep.
And then about 64% have smokedat least half a pack, so 11 to
20 cigarettes per day.
And then about a third, 30% orso, smoked even more than the
pack, so about a pack and a half, 21 to 30 cigarettes.
And then you have some who aresmoking even more than that, and
(30:17):
that was about four to fivepercent of people smoked at
least 30 cigarettes per day yeah, okay, good, so that's our
population.
Dr. Joshua Goldenberg (30:24):
Um, like you said, a said only maybe
concerned with homogeny becauseit's all from Finland, but still
it's a really good trial and Ilike the population, it seems
very appropriate for primarycare.
Good, okay, I think the onlyother thing I want to mention
about that was the use of whatthey call snus.
(30:46):
That's like snuff, that's likechewing tobacco.
Okay, okay, that's what Ithought.
I had to Google it because Iwas like, is that different than
the little pouches?
So it is the little pouches,and I think that's so relevant
because essentially, like, theyhave this objective marker of
carbon dioxide level, but ifyou're getting your nicotine
another way, you could basicallybe making up for it, and your
(31:09):
nicotine another way, you couldbasically be making up for it,
and, and it would appear as ifyou had quit, when still you're
just as addicted to nicotine.
So I thought it was great thatthey were so cautious about that
and it did not seem toinfluence results one way or
another.
Dr. Adam Sadowski (31:18):
Yeah, and the Gen Zers love to use what's
called Zyn pouches Z-Y-N.
Dr. Joshua Goldenberg (31:23):
Oh, is that a?
Thing?
Dr. Adam Sadowski (31:24):
It's, it's just nicotine pouches.
They seem to be prettyaddictive, yeah.
Dr. Joshua Goldenberg (31:31):
So that's a thing that's so interesting.
I was like Josh, you're so outof touch, I know, doesn't it
cause like holes in your gums orsomething like that?
I just remember.
Anyway, the whole thing's notgood.
Don't start smoking, okay.
So let's, can we talk aboutresults?
Can we jump into results yet?
Yeah, okay, cool.
So here we go.
(31:53):
So the main outcome here.
So we're talking aboutconfirmed abstinence at six
months.
So the e-cigarette group wehave so this is like true
nicotine e-cigarettes withplacebo, shantix and the
motivational interviewing 40.4%were abstinent at six months.
That's remarkable.
I would think 40% of this toughpopulation is abstinent at six
(32:17):
months.
That's outstanding.
The Shantix group was 43.8, so alittle bit higher, also
outstanding.
And the placebo group was 19.7.
So one in five people on justwell, it's say just placebo.
Remember they had motivationalinterviewing as well.
20% of them essentially quit,which is amazing at six months.
(32:40):
And then you had double thatessentially with the e-cigs with
nicotine or the shantix, whichis pretty cool.
There was a statisticallysignificant difference, clearly,
with those numbers, between theShantix, which is pretty cool.
There was a statisticallysignificant difference clearly
with those numbers between theE-SIGs versus placebo and the
Shantix versus placebo, but notbetween Shantix and E-SIGs.
The difference was too close.
(33:00):
So we can't say statisticallythat even though Shantix
nominally had a higherabstinence rate, that may just
kind of be random error whencompared to e-cigs, but both
seem to be very effective versusplacebo or motivational
interviewing alone.
Dr. Adam Sadowski (33:17):
Yeah, you might even argue that this is a
negative trial for Pfizer.
Dr. Joshua Goldenberg (33:23):
Why.
Dr. Adam Sadowski (33:24):
In the sense that, you know, e-cigarettes may
be as effective as Chantix.
Dr. Joshua Goldenberg (33:31):
Oh, that's true.
Yeah, so not only better butright.
Maybe statistically the same ase-cigs.
That's right, but definitelyreinforces this idea that it
doubles the response rate versusplacebo.
Yeah, good point, okay.
Dr. Adam Sadowski (33:46):
But it's really important because I mean
it's important clinically,because now it's like, hey,
here's a fourth option that wecan consider.
Dr. Joshua Goldenberg (33:52):
Yes, yeah , that's right, that's right.
Love that.
Okay, what else did I want tosay?
I think that's it for thesix-month outcome.
Should we talk about the oneyear?
Dr. Adam Sadowski (34:03):
Yeah, let's talk about the one year which
remember was a secondary outcomeand viewed as exploratory and
it was a little bit upsetting.
Yeah, 50% reduction, like a Idon't know 30% reduction in the
(34:30):
number of people from thesix-month mark who were
abstinent at 52.
So remember, confirmedabstinence was biological, in
addition to self-report.
And at the 52-week mark we have28% in the nicotine electronic
cigarette group versus 38% inthe Chantix, versus 20% in the
(34:57):
placebo.
So placebo basically wentunchanged.
The Chantix group dropped offfrom 44% to 38%, rounding up,
and then the nicotine groupdropped off from 40% to 28%,
yeah, so, so Chantix did alittle bit better.
Dr. Joshua Goldenberg (35:17):
Yeah, and was statistically significant
still at one year, wherease-cigs were not.
Introducer (35:26):
Yeah.
Dr. Joshua Goldenberg (35:27):
Barely Interesting one year, whereas
e-cigs were not, yeah, barelyinteresting.
Um, so we have the at sixmonths.
They're about equivalent, bothdouble the placebo response and
at one year.
Uh, we see that, yeah, theshantix has held most of the
benefits, still statisticallysignificant, whereas the e-cigs
have dropped no longerstatistically significant when
(35:48):
compared to placebo I love howthey reported the absolute um
change in the difference too.
Dr. Adam Sadowski (35:55):
Uh, within on the bottom of table two.
Yeah, so yeah at at the um atthe self-reported and confirmed
abstinence.
When you look at the confidenceintervals for the e-cigarettes,
it went from negative one to18%.
So so no difference there.
And then for the Chantix groupit was 8.4, let's say 8%.
(36:19):
Let's round up 8% to 28% wasthe 95% confidence interval
there.
So that remains statisticallysignificant.
And then placebo was also minus1% to 20%.
So across that threshold of nosignificance.
Dr. Joshua Goldenberg (36:36):
Yes, and the other interesting thing,
just about the snuff or zing orzang or whatever you call it
even when you look at that atone year, the results are
analogous where it's barely notstatistically significant with
e-cigs, still statisticallysignificant for shantix, and
then the difference between thetwo is not statistically
(36:59):
significant at the one year mark.
Now, remember, it's the sixmonth mark.
E-cigs are still doing well,but yeah, they kind of lose
there.
Um, e-cigs are still doing well, but yeah, they kind of lose
their.
It's interesting that thee-cigs would lose their benefits
, some of their benefits, at oneyear, whereas shantix would not
, because if it's just a 12 week, were they taking shantix all
the way through or just forthose 12 weeks?
Dr. Adam Sadowski (37:18):
just for those 12 weeks is my
understanding interesting, veryinteresting now, perhaps this is
where the the, the benchscientists come out from their
gremlin hole and start talkingto me about.
This is why mechanism of actionmatters.
It's because perhaps there'ssomething here that would
explain that, perhaps, but again, I don't care.
Dr. Joshua Goldenberg (37:40):
Oh, man Beautiful.
I thought it was a very clearstudy.
Dr. Adam Sadowski (37:47):
I don't think Wait, we're not done, we're not
done, yeah Well what else wasthere to talk about?
Dr. Joshua Goldenberg (37:51):
Side effects?
Adverse effects?
Yes, no adverse effects, noadverse effects.
I guess that's something totalk about.
Some people died, not many.
Oh my God.
Dr. Adam Sadowski (38:17):
Oh, dear listener, when, when you receive
, when we see josh in in the uhlawsuit and they say they say,
dr goldenberg, you have killedsome patients, and dr
goldenberg's response will beyeah, but not many it's all
about the absolute effects hereit's not statistically
significant.
Your honor yeah yeah, yourhonor.
It was a non-statisticallysignificant increased number of
(38:38):
participants who died under mikeair well, that's essentially
what happened here.
Um, we see a couple people die,each group, yeah four people
died in total two in the isagroup, two in the placebo.
Neither were related tointervention.
There were really nosignificant side effects.
Uh, for all of these, with theexception of chantix, had nausea
(39:01):
.
That was statisticallysignificant and that was
basically it.
Dr. Joshua Goldenberg (39:06):
Well, so one other thing.
I didn't catch this before.
Look at the part.
So we're in table threelisteners Adverse events leading
to discontinuation of a studytreatment.
The Shantix group was doublethe amount in the e-cig or
placebo.
That's interesting.
Dr. Adam Sadowski (39:25):
But they also had higher success success
rates overall, which was alsointeresting which is also
interesting.
So you're explaining that benchscientist so you're.
Dr. Joshua Goldenberg (39:36):
You're more likely to get side effects
significant enough that youwould stop your treatment if
you're taking shantix, butoverall you are still more
likely to benefit, particularlyat one year and just as likely
at six months.
Interesting, Okay.
So we might expect higher sideeffect rates with the shantix.
(39:57):
That's useful information.
Whereas the e-cig.
I mean I'm not surprised thatthe e-cig is the same as placebo
.
I mean, they've been smokingcigarettes and now they're just
smoking electronic cigarettes.
Like I would be surprised ifthere was much of a difference.
I mean, maybe you get shockedby this e-cigarette.
Dr. Adam Sadowski (40:11):
I don't know if that's a thing, but, um,
probably not well, there was,there were e-valley concerns, um
, uh, so I forget what e-valleytotally stands for, but it's
like e-valley yeah, it's likee-cigarette vaping associated
lung injury, something like that.
Oh, um these were earlyconcerns back when e-cigarettes
firsting associated lung injury,something like that.
(40:32):
Oh um, these were earlyconcerns back when e-cigarettes
first came to market and a lotof it had to do with with people
tampering with um, thecombustible oh and so a lot of
people were getting like intolike icu admits for um pretty
severe pulmonary injury from thee-cigarette tampering.
Dr. Joshua Goldenberg (40:49):
Okay, so that would be a good thing to
look here.
We're not seeing an increasewith these.
Okay, beautiful, what else?
Anything else you want to talkabout?
Dr. Adam Sadowski (40:58):
I thought discussion was interesting.
I kind of agreed with them thatthey showed that they said not
only was Chantix helpful but sowas the e-cigarettes at six
months.
And then they just kind oftalked about the lack of
evidence that kind of existslooking at e-cigarettes and
whatnot, but that kind ofthey're off to a good start with
(41:20):
this.
You know what's available rightnow and the direction that the
research is heading in.
Dr. Joshua Goldenberg (41:26):
Yeah, you know it's interesting in
actually looking at the dataversus what they said.
I'm actually more impressedwith Shantix the second time
through here because of the oneyear mark.
But it's funny because, like,apparently Pfizer gave them a
bunch of funding but you don'tget that sense from reading
their article.
They just make them seem likethey're equivalent, which is
(41:48):
interesting.
So clearly they didn't have anoverly impressive influence on
the on the authors, if anything.
It seems the opposite.
They kind of downplay theShantix benefits.
Interesting, okay, cool, I likeit.
Now, just to reinforce the bigdebate, I think, is what is the
population that you're givinge-cigs to right?
Like if you're giving it, likeyou said in that first study you
(42:10):
were talking about, wherepeople that had no initial
interest and they're young andnow they're going to start
smoking, whatever, it's not goodcompared to nothing.
But if they're like hardcoresmokers for 30 years and have
tried everything to quit, likeyeah, it's kind of an obvious
no-brainer, so it really doesmatter.
Like it seems like these thisdebate gets at least a couple
(42:37):
years ago it was like a bigdebate like is are these e-cig
things brilliant or harmful?
Dr. Adam Sadowski (42:39):
and horrible and it really depends on the
population, I think is thetake-home context.
Yeah, context matters a lotcontext matters.
Dr. Joshua Goldenberg (42:43):
Yeah, yep , yep, yep.
So if you're in finland andyou've been smoking for 30 years
and you've tried a bunch ofother stuff, you might try
e-cigs or shantix and you mightdouble your chance of abstinence
, which is super cool.
All right, I like that littlestudy it was.
It was not that little, it'sabout 500 people, 150 in each
group.
Um, nice job, adam.
Thanks for recommending thatone.
Dr. Adam Sadowski (43:04):
Any last minute words of wisdom to our
listeners, sir well, yeah,although it was a small study,
given Small study, 500 peopleRelative to other studies that
are large, right, it was along-term.
It was relatively long-term ayear.
Dr. Joshua Goldenberg (43:21):
Yeah, year outcomes.
Dr. Adam Sadowski (43:24):
Very well conducted.
Dr. Joshua Goldenberg (43:26):
Yep Agreed.
Dr. Adam Sadowski (43:27):
Seems like we've now got two high-level
evidence papers.
Introducer (43:33):
Mm-hmm.
Dr. Adam Sadowski (43:35):
Do we need another study?
Dr. Joshua Goldenberg (43:36):
I mean, I don't think so.
Dr. Adam Sadowski (43:38):
If we did it, you know, if we repeated it in,
let's say, a different patientpopulation, even if it was like
a homogenous patient population.
Let's say, like in Australia,right.
Or let's say we did another onein the States.
Introducer (43:50):
Mm-hmm.
Dr. Adam Sadowski (43:55):
And we get the same results, would you?
Would you be like, hey, I thinkwe're done here, or would you
want to continue beating thislike crazy, like a vitamin d
trial?
Dr. Joshua Goldenberg (44:04):
I mean I don't even know that they needed
this one.
So they had high level evidencefor what they had high
certainty evidence that nicotinecontaining e-cigarettes are
associated with an improvedsmoking abstinence.
So I mean they already hadbefore this was even done.
There was high level gradeevidence that you're going to
increase your abstinence withe-cigarettes compared to
(44:24):
nicotine replacement therapy.
So so the debate is okay.
Well, what about compared toShantix, which is not nicotine
replacement?
But I guess, like for the pointof, should you try e-cigs?
They already have that data.
Like grade high by definition,literally means that any future
study is extremely unlikely tochange the overall result.
Dr. Adam Sadowski (44:44):
And it's really cool.
It's cool to see that confirmedhere.
Dr. Joshua Goldenberg (44:47):
Yeah.
Dr. Adam Sadowski (44:48):
Hey, yeah.
Dr. Joshua Goldenberg (44:49):
That's true, I think that's cool.
Dr. Adam Sadowski (44:52):
Yeah that's the idea, because you, you read
about that.
Yeah, that's the idea of like,hey, if it's high level of
evidence, really nothing shouldchange.
But you always wonder, but Ihaven't seen.
Yeah, you always wonder andlike I haven't yeah I haven't
really seen like, okay, likethey say it's high level, but
we're gonna do another trial andthen confirming that like I
just haven't stumbled upon it,whereas this was like, hey,
(45:13):
there's high level of evidence,we're going to repeat it.
And yeah, we found the samething.
Dr. Joshua Goldenberg (45:19):
Yeah, it is interesting, like when they
were setting up the rationale inthe introduction.
You know, when you already havehigh level evidence of
something, it's like, well,what's your rationale?
And their spin was in the likehaving this additional arm for
shantix.
But yeah, as far as actuale-cigs, yeah, it's already there
.
And to your point like I thinkwe don't see that a lot because
a in theory, you shouldn't berunning extra trials and wasting
(45:39):
resources if you already knowit's high level evidence.
But also very few things arehigh level evidence right, Like
we've done some papers like that.
I can't remember what thepercentage is, but it's in the
low single digits, isn't it?
Like things that are effectiveand high level evidence in
medicine.
Dr. Adam Sadowski (45:54):
Probably.
We're probably like 4% best.
Dr. Joshua Goldenberg (45:56):
Yeah right, it was something.
I remember that somewherebetween four and seven, I can't
remember, but like absurdly low.
And so this is one of thoserare things where e-cigs
apparently are in that fancygroup of high level evidence and
efficacious.
So I am impressed, but don'tstart if you're a little kid who
has no interest in starting tosmoke, only if you're finished
(46:19):
and have 30 years of smoking.
E-cigs and viagra, well, what'sthe what's the evidence on
viagra?
Dr. Adam Sadowski (46:25):
it's high level the number needed to treat
is like two is it so?
Dr. Joshua Goldenberg (46:31):
yeah, okay, that's interesting and
it's uh, and the evidence levelis high.
Dr. Adam Sadowski (46:36):
It works for yeah okay, interesting, all
right I I'm assuming, I I'mpretty sure it is you're
assuming I'm assuming they havea good, they have a good lobby
apparently.
Dr. Joshua Goldenberg (46:46):
Um, it's interesting.
I, I, I would love to see alist of the stuff, of the
interventions that are highlevel and efficacious.
At high level, efficacious anda large effect size, like here
we we double the, the responserate, right, like I would love.
That's got to be a rarefiedlist.
It's like it's like three itemscigarettes and viagra.
What's the third?
(47:07):
I wonder what the semaglutideglp1 oh it would?
Dr. Adam Sadowski (47:16):
it would probably be suboxone am I is?
Dr. Joshua Goldenberg (47:19):
is the evidence?
Is the level of evidence highfor suboxone?
Dr. Adam Sadowski (47:24):
don't quote me on that, I don't.
I I'm going to assume.
Yes, I know the number neededto treat is very low with
suboxone oh, that's interestingbut it's likely high level of
evidence.
Huh, very curious.
I'm assuming.
Don't quote me, it's notmedical advice, don't?
I don't know.
Dr. Joshua Goldenberg (47:42):
I'm telling you outwardly I do not
know if you're a listener, and,oh, you know what.
There's another one.
Um, mark's always talking aboutit.
It's probiotics for Ulcerativecolitis, some, no, not even for
some pediatric oh my God,necrotizing something or other.
I think that has high levelevidence.
(48:02):
Mark's always like it's one ofthe few things that has high
level evidence, and it's true.
Okay, so we got Viagra,probiotics in that one pediatric
population and e-cigs.
And then, listeners, if you'vegot any others, please send it
our way.
That would be cool to kind ofmake a list and maybe do a
series of papers where we talkabout the things that actually
(48:22):
work, since we're alwaysfetching about the things that
don't work and how most thingsdon't.
So it might be a nice littletweak.
Yeah, little tweak.
Yeah, our two episode series,things that work in medicine.
We've already covered them,right?
Yeah, all right.
Well, uh, we're not jaded, okay.
Well, talk to you laterlisteners.
Thank you, adam, good paper atthe end of all my complaining.
Um, it was a good paper and itwas interesting to know that we
(48:45):
have high level evidence forthat.
So cool man.
Yeah, step back into primarycare and never.
Dr. Adam Sadowski (48:50):
The world is your oyster.
Dr. Joshua Goldenberg (48:53):
All right , talk to y'all later.
Bye, if you enjoy this podcast,chances are that one of your
colleagues and friends probablywould as well.
Please do us a favor and letthem know about the podcast and,
if you have a little bit ofextra time, even just a few
seconds, if you could rate usand review us on Apple Podcast
or any other distributor.
It would be greatly appreciated.
(49:14):
It would mean a lot to us andhelp get the word out to other
people that would really enjoyour content.
Thank you, hey y'all.
This is Josh.
You know we talked about somereally interesting stuff today.
I think one of the things we'regoing to do that's relevant.
There is a course we have on DrJournal Club called the EBM
Boot Camp.
That's really meant forclinicians, to sort of help them
understand how to criticallyevaluate the literature, etc,
(49:36):
etc.
Some of the things that we'vebeen talking about today.
Go ahead and check out the shownotes link.
We're going to link to itdirectly.
I think it might be of interest.
Don't forget to follow us onsocial and interact with us on
social media at Dr JournalClubClub DRJournalClub on
Twitter.
We're on Facebook, we're onLinkedIn, etc.
Etc.
So please reach out to us.
We always love to talk to ourfans and our listeners.
(49:58):
If you have any specificquestions you'd like to ask us
about research, evidence, beinga clinician, etc.
Don't hesitate to ask.
And then, of course, if youhave any topics that you'd like
us to cover on the pod, pleaselet us know as well.
And, of course, if you have anytopics that you'd like us to
cover on the pod, please let usknow as well.
Introducer (50:13):
Thank you for listening to the Doctor Journal
Club podcast, the show that goesunder the hood of
evidence-based integrativemedicine.
We review recent researcharticles, interview
evidence-based medicine thoughtleaders and discuss the
challenges and opportunities ofintegrating evidence-based and
integrative medicine.
Be sure to visit www.
d wwwdoctorjournalclubcom tolearn more.
Popular Podcasts
Fudd Around And Find Out
UConn basketball star Azzi Fudd brings her championship swag to iHeart Women’s Sports with Fudd Around and Find Out, a weekly podcast that takes fans along for the ride as Azzi spends her final year of college trying to reclaim the National Championship and prepare to be a first round WNBA draft pick. Ever wonder what it’s like to be a world-class athlete in the public spotlight while still managing schoolwork, friendships and family time? It’s time to Fudd Around and Find Out!
Crime Junkie
Does hearing about a true crime case always leave you scouring the internet for the truth behind the story? Dive into your next mystery with Crime Junkie. Every Monday, join your host Ashley Flowers as she unravels all the details of infamous and underreported true crime cases with her best friend Brit Prawat. From cold cases to missing persons and heroes in our community who seek justice, Crime Junkie is your destination for theories and stories you won’t hear anywhere else. Whether you're a seasoned true crime enthusiast or new to the genre, you'll find yourself on the edge of your seat awaiting a new episode every Monday. If you can never get enough true crime... Congratulations, you’ve found your people. Follow to join a community of Crime Junkies! Crime Junkie is presented by audiochuck Media Company.
The Breakfast Club
The World's Most Dangerous Morning Show, The Breakfast Club, With DJ Envy, Jess Hilarious, And Charlamagne Tha God!