Awareness and Acceptance of Nicotine-free Smoking Intervention Methods (Acetium^® Lozenge) Increased Among Health Care Professionals by Targeted E-training as Confirmed by Post-training Surveys

Discussion

At present, the global markets of smoking intervention methods are dominated by devices based on the NRT concept (17). As compared to the most effective special medications, however, the efficacy of NRT is only moderate (15, 16). Importantly, NRT is associated with a wide variety of severe side effects, as recently disclosed in a systematic review and meta-analysis of 120 studies including 177,390 smokers (31). The report concludes that the patients should be clearly informed of all potential side effects of NRT (31). Given these concerns on NRT, the side effect-free Acetium^® lozenge recently introduced by Biohit Oyj (Helsinki) appears as a logical choice to assist in nicotine-free smoking cessation (18, 28, 29).

As compared with the NRT products, Acetium^® lozenge has several indisputable advantages (18, 19, 28, 29, 31). The most important of these are: 1) no nicotine-dependence and side effects of NRT; 2) no upper daily dose (one lozenge for each smoked cigarette); 3) the efficacy is equivalent to NRT; 4) tolerability is superior to NRT; 5) extremely high user compliance; 6) favorable effect achieved within 3-4 months (among the responders); 7) total costs of a quit attempt are significantly lower (no need to continue after successful smoking cessation); 8) improving oral hygiene by its xylitol component; 9) a nicotine-free alternative to quit smoking without transferring the nicotine addiction from cigarette to an NRT device; 10) protected by European Patent; EP 2 197 436 B1 (19); 11) other bonus effect is harm reduction: L-cysteine binds carcinogenic acetaldehyde in the saliva. Accordingly, Acetium^® lozenge represents a major breakthrough in the development of smoking intervention methods.

Because one cannot anticipate achieving adequate dissemination of the awareness of this novel tool among health care professionals exclusively by the original reports on the RCTs (28, 29), the company decided to take advantage of the modern applications of E-Learning. As a joint effort between the experts of Biohit Oyj and Success Clinic Oy, a set of E-Training was repeated three times (2018, 2020 and 2023), distributed to the responders by e-mail. The target groups in the three surveys were slightly different (Table I). Nurses and physicians were invited to all three surveys, whereas pharmacy staff were surveyed twice and other professionals only once (2018). This difference in the targets of these surveys precludes a direct comparison of the responses at a level of the profession. Such a direct comparison is possible, however, for medical doctors and nurses who are included in all three surveys. Similarly, the number of participants varied between the three surveys, the first one receiving the highest number of responders (n=1,008), followed by the last one (n=582). The explanation is to be found in the length of the data collection period (2018: 5 months; 2020: 1.5 months; 2023: 2 months) which was positively related to the number of responders in the survey. Another factor in favor of the 2018 survey is the annual season when the data were collected (late autumn to mid-winter), as compared to early and late springtime in the two others.

Another feature that makes the three surveys non-identical is the content of the included questions (Table II). As a natural development of the process, the contents of the–E-Training materials were modified by the feedback from the preceding survey. The most comprehensive in its content is the last survey that was realized only recently (data collection between March 30, 2023-June 5, 2023). With the added important questions on smoking and pregnancy, including false/true statements, this latest survey provides the most comprehensive information on the responders’ recognition of this important subject. Furthermore, some of the questions that received almost unanimous correct responses in the 2018 survey were omitted from the two subsequent E-training sets as redundant.

Three core questions tracking the awareness, importance and acceptance of the new device were included in all three surveys (Table III). The response patterns in the three surveys, respectively, were significantly (p<0.001; p=0.004; p<0.001) different, implicating the effect achieved by the E-Training. Starting from responder’s awareness on Acetium^® lozenge, the proportion of responders who had never heard about the device decreased from 50% (in 2018), and 62.4% (in 2020) down to 39.4% in the last survey. This increased awareness was mostly contributed by the responders who knew the product but had not yet recommended it for their patients: from 32.4% (in 2020) to 47.9% (in 2023). However, the proportion of responders who have already recommended Acetium^® (11.4%) or who regularly recommend it (1.3%) for their smoking patients is still too low to support a widespread nationwide acceptance of this device. However, because the first survey was done only a year after the last RCT was published (29), the proportion of responders who already knew Acetium^® lozenge (50.0%) in 2018 can be regarded unexpectedly high.

As to the responders’ attitude to nicotine-free intervention methods, all three surveys must be considered reassuring. In the 2023 survey, above 90% of the responders consider nicotine-free smoking intervention methods highly interesting or at least moderately interesting, and only 3% consider them “not interesting”. Also, the proportion of those with no opinion has declined to one half (4.7%) form the 2018 survey (9.3%). This development certainly reflects an increased awareness among the health care professionals on i) the many side effects of NRT (31) and ii) the fact that these products only transfer the nicotine-dependence from cigarette smoking to NRT-products. Highly unfortunate, these attitudes do not yet parallel the acceptance of nicotine-free intervention methods among smokers, as evidenced by the ever-increasing global sales of the NRT products (17).

Regarding the expected future acceptance of Acetium^® lozenge, the responses are most rewarding (Table III). In all three surveys, over 80% up to 96% of the responders reported that the E-Training increased (either substantially or to some extent), their readiness to recommend Acetium^® lozenge to their smoking patients. Only very few responded the contrary (i.e., not increased at all), and even fewer had no opinion on the subject. These results indicate that the information given in the E-Training sets was well taken by the participants whose responses implicate that the vast majority are ready to endorse Acetium^® lozenge to their smoker patients who are motivated to stop smoking.

Between the groups of professionals, interesting differences in these key responses were noticed in the 2023 survey (Figure 1, Figure 2, Figure 3). This was not unexpected, given the differences between these groups particularly in their contact with the patients. Starting with the awareness of Acetium^® lozenge (Figure 1), the highest degree of awareness was reported by the pharmacy staff (>85%) whereas the vast majority (95%) of nurses reported having never heard about the product. The awareness among the physicians (56%) was intermediate between these two extremes. These results implicate pharmacists’ high degree of familiarity of the new products on sale in their pharmacy, including Acetium^®. Additional efforts are still needed to increase the awareness of the device among physicians, of whom a substantial proportion was not yet aware of Acetium^® lozenge in the 2023 survey.

As to the attitudes towards nicotine-free smoking intervention methods, most of the responders among each profession considered those either very interesting or moderately interesting (Figure 2). Interestingly, the nurses reporting very low awareness on Acetium^® lozenge, did express the highest interest in nicotine-free methods, 58% considering these “very interesting”, which is roughly 20 percent points more than that among doctors and 30 percent points more than that among pharmacy staff. This is another indication of the usefulness of these E-Training sets, which clearly succeeded in arousing the interest in nicotine-free intervention methods among those who were least aware of this novel method in advance.

This increased interest in nicotine-free methods (Figure 2) closely parallels the responders’ readiness to recommend Acetium^® lozenge (Figure 3). The difference in the response pattern between the profession categories was no longer highly significant but only slightly different (p=0.025). Again, the increase in the willingness to recommend the method to motivated smokers was highest among the nurses, of whom 56% responded “substantial increase”. This is >10 percent points more than reported by doctors (45%), and 20 percent points more than among the pharmacy staff (36%). The almost similar response rates were received for the category “increased to some extent” leaves few for whom this E-Training was not useful or stimulating.

This E-Training focused on increasing the awareness, interest and acceptance of a novel nicotine-free smoking intervention method (Acetium^® lozenge) among health care professionals working in Finland was well received among the responders. The training-accompanied surveys repeated three times at 2-year intervals confirmed the great potentials of E-Training in promoting this type of professional information, as an additional tool to the company website (18) and original research reports (28, 29). The response rates are clearly related to the length of the data collection period, and also the annual season seems to have an effect. When repeated at regular intervals, the survey was constantly updated by omitting the questions that received almost unanimous responses, i.e., are too obvious to respond. The repeated surveys also offer an opportunity to follow-up the trends in awareness, interest and acceptance of the target method (Acetium^® lozenge in this case).

Taken together, as determined from the three surveys, the E-Training sets had a favorable effect 1) on the responders interest in nicotine-free smoking intervention method in general, 2) in increasing the awareness of Acetium^® lozenge as a novel innovative method to quit smoking nicotine-free, as well as 3) in substantially increasing the responders’ (doctors, nurses, pharmacy staff) readiness to introduce the new device to their smoking patients who are motivated to stop smoking nicotine-free. Widespread adaptation of any new method necessitates continuous dissemination of the expert information to medical professionals, and modern E-Training has major potential in reaching the right target groups and adequate number of responders.