Poor communication between general practitioners (GPs) and medical specialists can lead to poorer quality, and continuity, of care. Our study aims to assess patients’ perceptions of communication at the interface between primary and secondary care in 34 countries. It will analyse, too, whether this communication is associated with the organisation of primary care within a country, and with the characteristics of GPs and their patients.We conducted a cross-sectional survey among patients in 34 countries. Following a GP consultation, patients were asked two questions. Did they take to understand that their GP had informed medical specialists about their illness upon referral? And, secondly, did their GP know the results of the treatment by a medical specialist? We used multi-response logistic multilevel models to investigate the association of factors related to primary care, the GP, and the patient, with the patients’ perceptions of communication at the interface between primary and secondary care.In total, 61,931 patients completed the questionnaire. We found large differences between countries, in both the patients’ perceptions of information shared by GPs with medical specialists, and the patients’ perceptions of the GPs’ awareness of the results of treatment by medical specialists. Patients whose GPs stated that they ‘seldom or never’ send referral letters, also less frequently perceived that their GP communicated with their medical specialists about their illness. Patients with GPs indicating they ‘seldom or never’ receive feedback from medical specialists, indicated less frequently that their GP would know the results of treatment by a medical specialist. Moreover, patients with a personal doctor perceived higher rates of communication in both directions at the interface between primary and secondary care.Generally, patients perceive there to be high rates of communication at the interface between primary and secondary care, but there are large differences between countries. Policies aimed at stimulating personal doctor arrangements could, potentially, enhance the continuity of care between primary and secondary care. In modern health care systems, patients frequently visit both their general practitioner (GP) and multiple medical specialists. According to the ‘Health for All’ database, in 2013, each European citizen had, on average, an estimated seven primary care and/or ambulatory specialist care contacts . It is iPrevious studies demonstrated that all actors in the referral process, the GPs, medical specialists, and patients, are aware of the importance of good communication between GPs and medical specialists , 7. PatiHigh rates of communication between GPs and medical specialists as reported by GPs. Patients usually carry paper referral letters and feedback from the medical specialist to their GP. Therefore, patients are more likely to be aware of when a GP communicates with a medical specialist. We hypothesise that there is a positive correlation between GPs’ and patients’ perceived rates of communication at the interface between primary and secondary care.High rates of personal continuity of care. Personal continuity of care is defined as “having a personal care provider in every separate care setting who knows and follows the patient” [patient” . Studiespatient” , 11. AlwHigher GP job satisfaction. Several studies demonstrated that job satisfaction among physicians is associated positively with their quality of care [ of care –26. Low  of care . A recen of care  is correWe also hypothesise that there is a correlation between the patients’ perception of communication from GPs to medical specialists and that from medical specialists to GPs. Our hypothesis is that when a patient is aware of the GP sending letters to a medical specialist upon referral, this will enhance the patients’ perceptions about the GP being informed by the medical specialist after treatment. Variations among countries, in the communication perceived by the patient at the interface between primary and secondary care, are influenced by the above-mentioned features . In Turkey, Spain, Belgium, and Canada, larger samples were taken in order to enable comparisons between regions. A total of 61,931 patients filled out the questionnaires. Details about the study protocol, questionnaire development, and sampling of GPs, have been published elsewhere [To analyse patients’ perceptions of communication at the interface between primary and secondary care in 34 countries, we used data from the QUALICOPC study . In this study, patients in 31 European countries , plus in Australia, Canada, and New Zealand, were surveyed between October 2011 and December 2013. The study is co-funded by the European Commission, and, therefore, initially included only European countries. Research teams from Australia, Canada, and New Zealand joined the study on their own initiative, and with their own funding. This was due to their interest in an international comparison of primary care in their country. In each country, a target number of 200 GPs were asked to participate by filling out a questionnaire and allowing their patients to be interviewed. Only one GP could participate per practice. Fieldworkers were instructed to invite, consecutively, patients, aged 18 years or older, in the waiting room of each GP practice participating. Patients, who had had a face-to-face consultation with the GP participating, were invited to complete a questionnaire, anonymously, until nine patient questionnaires were collected in each practice. A target response of 2000 patients was required for each country, with the exception of Cyprus, Iceland, Luxembourg and Malta  and legal requirements in each country. Ethical approval for the QUALICOPC study was acquired in accordance with the legal requirements in each country .‘When I am referred, my GP informs the medical specialist about my illness’;‘After treatment by a medical specialist, my GP knows the results’.To assess the patients’ perceptions of communication between GPs and medical specialists, we used the patients’ responses to the following statements:Patients were asked whether they agreed with these statements. Possible answers to both questions were: ‘yes’; ‘no’; ‘don’t know’, and; ‘not applicable’. The questionnaire did not include a question on whether, or when, a patient had a referral from their GP to a medical specialist. We excluded patients who had never been referred (and therefore answered ‘not applicable’), and those who were not sure or not recently referred . We only included ‘yes’ and ‘no’ answers, to ensure that data represented patients who remembered a referral to a medical specialist. We excluded a total of 14,283 respondents answering ‘don’t know’, and 3189 ‘not applicable’, for the first statement, and 9023 ‘don’t know’, and 2479 ‘not applicable’, for the second statement.For the purpose of the analyses, we organised the independent variables of primary interest according to our hypotheses:‘To what extent do you use referral letters  when you refer patients to a medical specialist?’‘To what extent do medical specialists inform you after they have finished the treatment or diagnostics of your patients?’To measure communication at the interface between primary and secondary care from the GPs’ perspectives, we used two questions from the questionnaire completed by GPs within the QUALICOPC study . GPs werPossible answers for the first question were: ‘for all patients whom I refer’; ‘for most patients whom I refer’; ‘for a minority of patients whom I refer’, and; ‘seldom or never’. Possible answers for the second question were: ‘Always, or nearly always’; ‘Usually’; ‘Occasionally’, and; ‘Seldom or Never’. The answers to both the above-mentioned questions were dichotomised as follows: ‘seldom or never’ versus the other three possible answers .We used measures of personal continuity of care at the country level and at the patient level. To estimate the level of personal continuity of care at the country level, we listed the countries in which it is mandatory for a patient to be registered to a specific GP or practice (‘list system in place’). For 30 countries , we derived these data from the PHAMEU  study , 33. DatWe measured the job satisfaction of GPs through a continuous score derived from a combination of six statements from the questionnaire addressed to GPs within the QUALICOPC study. A higher score measures higher job satisfaction. The development of the score was described in detail in another paper .Age and gender of GPs;Self-reported urbanisation of the practice location. Possible locations were ‘big (inner)city’, ‘suburbs’, ‘ town’, ‘mixed urban-rural’, and ‘rural’;Self-reported employment status of GPs ;Age and gender of patients;Self-reported income of patients, compared to the average of the country ;patients perception of their health status gained through answers to the question: ‘How would you describe your own health in general?’ ; and,If patients had one or more self-reported longstanding diseases .We included the following potentially confounding factors in our analyses:p < 0.05. We used Stata version 13.0  for the descriptive statistics, and MLwiN, version 2.25  for the multi-response logistic multilevel models.The distributions of answers to the two outcome statements: ‘When I am referred, my GP informs the medical specialist about my illness’, and: ‘After treatment by a medical specialist, my GP knows the results’, were calculated for each country. Next, multi-response logistic multilevel models were used, firstly, to calculate odds ratios in order to analyse the relationship between the dependent and independent variables. Then they were used to analyse the correlation between patients’ perceptions of GPs’ communication to medical specialists, firstly about their illness when they are referred, and, secondly, on receipt of results by GPs of treatment carried out by medical specialists. The country, GP, patient, and response levels were included in our models. We estimated an initial model that included only confounders. These were: age and gender of GPs; practice location; employment status of GPs; age and gender of patients; income of patients; perceived health status of patients; and presence of at least one longstanding disease. We applied three cumulative models, in which we added variables that assessed: 1) the rates of referral letters sent, and feedback communication received by GPs, as declared by GPs; 2) job satisfaction of GPs; 3) personal continuity of care at the patient and country level. We only present the final model in the results section as the odds ratios only change slightly over the subsequent models. For each of the two outcome variables, we calculated the percentage of reduction of variance in the final model at the country and GP levels. The level of statistical significance was set at Table Figures Tables Patients with GPs who indicate they ‘seldom or never’ receive feedback from medical specialists are less likely to state that their GPs are informed about the results of the specialists’ treatments. On the other hand, patients with a personal doctor have a higher likelihood of stating that their GP knows about the results of the specialist’s treatment. Higher job satisfaction among GPs is associated with higher perceived rates of feedback received by GPs, although, here too, the association is not significant. The ICC of the final model at the country level is 17%, while the ICC at the GP level is 28%. The variance only decreased slightly from the variance of the null model applying only confounders. For this outcome measure, the final model provides a reduction of variance of 12% at the country level and 0.5% at the GP level.There is a strong correlation at the country level and at the GP level between our two outcome measures (the correlation coefficients are 0.65 and 0.46 respectively). The correlation coefficients only change slightly after adjusting for all the covariates (0.69 at the country level and 0.46 at the GP level) (data not shown).This study aimed to investigate factors correlating to the rates of communication perceived by the patient at the interface between primary and secondary care. We found that these rates correlate positively with the personal continuity of care experienced, and with the rates of communication at the interface between primary and secondary care, as reported by GPs.In line with our first hypothesis, we found that there is a positive association between the communication perceived by the patient at the interface between primary and secondary care, and the rates of sending referral letters and receiving feedback communication reported by GPs. This means that when a GP sends a referral letter to and/or receives feedback from a medical specialist, the patients are usually aware of that. This is easily understandable when the patient is the carrier of the paper letter, that is when the GP and/or a medical specialist gives the letter directly to the patient. But it is less obvious when the GP and the medical specialist communicate through electronic means. However, a previous study found that the use of electronic systems to communicate did not affect the perception by patients of this communication .Our second hypothesis was partially confirmed. Indeed, patients with a personal doctor were more likely to state that their GPs send referral letters to medical specialists and receive feedback. This means that higher ‘personal continuity of care’ is positively associated with patients’ perceived ‘cross-boundary continuity of care’ , 8. ThusUnexpectedly, and in contrast with our third hypothesis, job satisfaction among GPs is not significantly correlated with our two main outcome measures. In a previous paper, using data from the same QUALICOPC study, Schäfer et al. demonstrated that high job satisfaction among GPs is related positively to patients’ perceived quality of care . Moreover, a recent study demonstrated that subjective workload might affect communication between GPs and medical specialists negatively during referrals .The results of the multi-response analysis demonstrated that there is a strong correlation at country level between the answers to the two outcome statements. As there is a positive association between a patient’s perception of communication and rates of communication reported by GPs, this means that there are countries that perform better in the area of communication between GPs and medical specialists in both directions. Notably, the three non-European countries, together with Switzerland, are in the top five countries in both outcome statements. With the exception of Switzerland, these countries have a strong primary care system and, in particular, in the area of continuity of care, there is little room for improvement, according to patients . The couIt should be noted that the final explanatory model provides only a relatively small reduction of variance at the country and at the GP levels for the two outcomes considered. This means that there are other factors that potentially influence patients’ perception of communication at the interface between primary and secondary care which were not measured in our study. Examples of these might include the implementation and use of personal health records, , 37 and/As patients positive perceptions of communication between primary care physicians and medical specialists improve health outcomes, , 14 the The main strength is the number of countries studied. Patients from 34 countries were surveyed, and this gave us the opportunity to investigate whether differences in health care systems were related to communication as perceived by the patient at the interface between primary and secondary care. Moreover, we were able to assess whether the characteristics of GPs and patients affect the perception of patients about communication at this interface, independent of the national health care system. The use of multilevel regression analysis is another strength of this study. Multilevel analysis allowed us to examine, at the same time, the associations with variables at the group and individual levels, in order to account for the dependence of observations within groups, and to examine both variation within individuals and groups .A limitation of this study is that it is only patients who visited a GP who were included. Therefore, the sample is not representative of the general population of each country. Moreover, in several countries, patients tend to visit a medical specialist without consulting a GP first. Our sample does not represent this group of patients. In our analyses, we also excluded all patients who answered, “don’t know”, to the two outcome questions about communication between GPs and medical specialists. These patients were excluded however, because they may have been referred some time ago and/or don’t remember what happened around a specific referral. Another limitation is that we could not assess whether the characteristics of medical specialists are associated with the patients’ perspective on communication at the interface between primary and secondary care. Finally, the study does not include data about how patients perceived the quality of this communication. The Qualicopc study was designed covering a broad range of topics and not as a study into referral processes and communication. We were therefore restricted in the nature and amount of questions we could use. The patient perceived quality and the referral process more broadly should be further explored in international research.This study revealed large differences among countries in patients’ perceptions of communication at the interface between primary and secondary care, However, personal continuity of care can improve this perception, independent of the health care system in which this occurs. The results also indicate the need for further studies to investigate other factors potentially associated with patients’ perception of communication at the interface between primary and secondary care.


To explore the understandings of and engagement with e-cigarettes, of young adults from disadvantaged backgrounds, and how these may have an impact on existing smoking identities.Twenty-two small group and 11 individual qualitative interviews were conducted in Central Scotland with 72 16–24 year olds between September 2015 and April 2016. Participants were mostly smokers and ex-smokers from socioeconomically disadvantaged backgrounds.Although most participants had tried e-cigarettes, they generally held ambivalent views about e-cigarettes and vaping. Two overarching themes were identified which helped in understanding this. Firstly, e-cigarettes were understood by the participants in relation to their existing smoking identities. Vaping was viewed as less controllable and more addictive than smoking, which did not fit with their self-identity as controlled smokers. Secondly, they felt that vaping could not replace the social and cultural importance that smoking had in their lives.This study suggests that though young adults from disadvantaged areas are trying e-cigarettes for various reasons, vaping is rarely sustained. Through their own experiences of vaping and their observations of others vaping, the participants perceive the behavior as endangering an existing acceptable and controlled smoking identity. Additionally, e-cigarettes were considered to be a jarring presence in existing social situations where smoking was valued. This study, therefore, provides insights into how young adults may be rationalizing their continued smoking in the face of potentially less harmful alternatives.As new and novel nicotine delivery devices, and due to their similarity to smoking, e-cigarettes have the potential to help smokers in their quit attempts. However, the findings from this study raise questions about whether e-cigarettes are regarded as having this potential by young adult smokers from disadvantaged socioeconomic environments where smoking is more commonplace and acceptable. Recent data from England indicates that though rates of trying e-cigarettes are similar across age groups, 16–24 years olds have the lowest use of nicotine replacement therapies (NRTs).19 This suggests that there is less interest in quitting smoking among this age group, which is consistent with findings from Scottish national surveys20 and qualitative evidence.21 However, it also shows that young adults are trying e-cigarettes as much as older age groups who have more interest in quitting. Using e-cigarettes is an increasingly popular method to help in quitting smoking in England,22 but recent research suggests that e-cigarettes are being used by young adults for reasons other than cessation. These reasons include circumventing smoking bans,24 as fashion accessories,25 attractive flavors, and perceptions of vaping as “cool.”15–18These qualitative studies were undertaken before the emergence of e-cigarettes. Recent qualitative studies have focused on how these devices may be affecting smoking behaviors and identities among young adults,26 Indeed, in Scotland in 2015, adults living in the most deprived areas had over three times the smoking prevalence of those living in the most affluent areas (35% vs. 11%).20 With the relatively high prevalence of smoking in deprived areas and public health campaigns promoting smoking cessation and protecting others from second-hand smoke, smoking has become associated with class-based stigma.27 This stigma can be internalized by disadvantaged young smokers who are aware of how their smoking and class status interplay when they are perceived and/or judged by others.29 This leads some smokers to rationalize their smoking: for example emphasizing their “responsible” approach to smoking, such as keeping the behavior out of the sight of young children.26 This paper, therefore, considers how e-cigarettes are affecting the smoking identities of young adults, especially among those from disadvantaged socioeconomic backgrounds, who are more likely to be smokers.Smoking is often clustered into “islands” of marginalized populations where the behavior is considered almost inevitable.31 Current policy and practice directions in the United Kingdom are leaning towards “e-cigarette friendly” stop-smoking services and the devices are seen as important to harm reduction strategies.32–34 Opinions diverge in the United States, however, with the US Surgeon General’s recent report recommending that young adults be discouraged from any type of nicotine use.35 Recent qualitative research with British smokers reflects the uncertainty of policy-makers and practitioners about e-cigarettes’ potential role in quitting smoking. Concerns include replacing a smoking addiction with a vaping addiction36 or reverting to cigarettes because of the similarities between smoking and vaping.21 This paper builds on these recent qualitative studies by exploring the perceptions of smoking and vaping among disadvantaged young adults.Although the debate around e-cigarettes and their potential for smoking cessation is ongoing, in the United Kingdom a consensus seems to be emerging that e-cigarettes could provide a safer alternative to smoking.37 Most participants chose to be interviewed in friendship pairs (n = 16), triads (n = 33), or groups of four (n = 12). Eleven participants chose to be interviewed alone. Participants were purposively selected to represent a range of ages, employment status , and gender. Smokers and ex-smokers were included in order to explore how e-cigarettes were being considered in relation to cigarettes. Ethical approval was obtained from the Ethics Committee at the School for Health in Social Science at the University of Edinburgh.Twenty-two friendship group interviews and 11 individual interviews were conducted with 72 young adults aged 16–25 years. Friendship groups, where participants are asked to invite one or two friends to take part in the interview, have proven effective in previous studies as they can create a more naturalistic setting for young participants when talking about tobacco issues; for example, challenging and/or supporting each other’s accounts.Participants were not questioned directly about their socioeconomic status in order to avoid offense or embarrassment, over the disclosure of such information, which could have interrupted establishing rapport between the researcher and participant. However, to ensure that the sample came from predominantly disadvantaged backgrounds, participants were recruited mostly from community organizations in Central Scotland, which assist disadvantaged young people through skills and employability training. Interviews were arranged with the help of gatekeepers at these organizations. To obtain a spread of participants including those in work and education, other organizations including workplaces and educational institutions were contacted. Adverts were also placed on the skills exchange website Gumtree to increase recruitment of college students and those in employment. Potential participants who contacted the author conducting the fieldwork [ML] were not invited to take part, if they indicated that they came from more affluent backgrounds, identified, for example, by type of employment or educational institution. Although these markers are not always indicators of disadvantage, this screening of participant details ensured that those from more affluent backgrounds were not recruited. Recruitment material explained that the study was exploring young adults’ views about e-cigarettes, and participants were offered a £15 gift voucher. Potential participants were provided with information and consent materials and offered the opportunity to ask questions; consent forms were signed. Interviews took place mostly in community venues between September 2015 and April 2016.The semistructured topic guide was used flexibly and explored what participants thought of e-cigarettes in relation to smoking. Interviews began with general questions about the participants’ lives and experiences of smoking and vaping. Further questions covered where and who the participants had seen vaping and/or whether and where they themselves had vaped. Questions about what participants had seen, in terms of advertising and marketing, were also covered. Accompanying the questions, the interviewer used props of four different types of e-cigarette, representing a range of disposable “cigalikes,” re-usable cigalikes ; vaporizers, which resemble marker pens; and small-box shaped devices which can be personalized and modified (commonly referred to as “box mods” by participants), to stimulate discussion. Participants used multiple terms for e-cigarettes interchangeably. In the quotes employed in this paper, “e-cigarette” generally referred to cigalikes, whereas “vaporizer” and “box mods” referred to their aforementioned descriptions. Pictures of e-cigarette advertisements and of e-cigarettes being vaped in various places were also shown to participants. These were originally included to help trigger thoughts and discussion, but this proved not to be their actual function in the interviews as most participants had seen similar devices and scenarios in their everyday life. However, the props and pictures did facilitate more natural interactions, as participants relaxed into informal conversational exchange when handling devices and leafing through pictures.38 an open coding of the data was conducted, to identify recurring themes across the interviews. A sample of transcripts was similarly independently coded by another author [AA], and there was broad agreement on the identified codes. Secondly, thematic coding39 was employed, informed by existing literature about young adults and smoking identities. At regular meetings, the authors discussed and refined the identified codes. The thematic coding allowed the initial open-codes to be grouped into clearer overarching codes. Thirdly, focused coding38 enabled a nuanced identification of codes pertaining to the overarching themes. The initial coding was undertaken as data were being collected and data saturation was reached, when no new themes were identified from the initial open coding of later interviews. All participants have pseudonyms, with their smoking status, vaping status, and age given in brackets.The interviews were recorded, transcribed to verbatim, and imported into Nvivo V.10 to facilitate analysis. Three rounds of coding were undertaken primarily by ML but informed at crucial junctures by all authors. Initially, and informed by a grounded theory approach,Nearly half (31) of the participants were not in education, employment, or training (NEET) . Those iSmoking was an almost ubiquitous behavior in the lives of all participants. Some of the smokers noted very young ages at which they began (8 or 9 years old) and others noted being introduced to cigarettes by parents, grandparents, other family members, and peers. This paper considers the accounts of smoking and nonsmoking participants together as the few nonsmoking participants described their difficulties in refraining from smoking in the face of smoking family and friends, and reflected on the ubiquity of smoking in their everyday environment. As such, there was little difference between the opinions of the smokers and nonsmokers towards smoking and vaping. The following two main result sections present two of the overarching themes identified in the first and second stage of the coding process: the participants’ situating of their smoking identity in the light of e-cigarettes’ emergence and their appreciation of the social value of smoking compared to vaping. Each of these themes is unpacked by subthemes, identified in the third stage of focused coding.Although smokers recognized the potential of e-cigarettes compared to existing NRT methods for quitting, many situated themselves in a transitional phase between adolescence and adulthood, where they felt that e-cigarettes were not for them. Rather they were regarded as being for older people (over 24 years) who wanted to quit, and younger people (under 16 years) prompted into trying e-cigarettes by flavors, marketing, and peer pressure. An exchange between Malcolm and Laura  demonstrated this attitude:Malcolm: Maybe, like, older people that smoke. They probably have more patience to smoke one of them [an e-cigarette]. But I dinnae [do not] think younger people … very many of them [will use e-cigarettes].Laura: You get all the wee [young people] jumping about, reckon they’re cool, they’re an ex-smoker and all that.Malcolm: Like, young ones running about playing with them.Other participants felt vaping to be initiating a new addiction and some, like Heather , expressed a sense of maturity having already experienced becoming addicted to smoking: “I don’t think kids realise the effect. They must think: well it’s not a real cigarette, so it’s not that bad … I probably won’t get addicted to that. But it’s still got the nicotine in it, so...” Most participants continued to smoke, however, and Andrew , using a common slang Scottish term for a cigarette—a fag—demonstrated how, despite this sense of maturity, many participants felt that they were not ready to adopt an even more responsible and mature approach by quitting smoking altogether:A lot of people when they get to a certain age are more scared; they want to look after their body … I don’t know if it’s just a thing with me or young people …some people are just arrogant. … But, truly the only people that I’ve heard that have benefitted from these [e-cigarettes] are people that are smoking, like, 60/70 fags a day.Smokers often rationalized their smoking identities in the interviews. Alice , for example, felt that she had control over how many cigarettes she consumed and, thereby, resisted an identity of being “addicted”: “I’m not addicted to cigarettes. I can smoke for, say, like a year, like consistently, every day, have a fag … I don’t get addicted.” Although smoking was considered controllable, vaping was less so, as Kevin  and William  discussed:Kevin: Like you’re constantly doing it [vaping] because you can smoke it indoors.William: And there isn’t an ending point, the only ending point is when the liquid runs out.Kevin: Just keep puffing it …William: It’s not like, that’s … five minutes and put it down … it still goes if it’s got a charge … I was hazed [affected by vaping] in work all the time which would never happen with a cigarette … I think that’s why I’ve kinda fallen back into smoking a bit more now cause I did have like a situation where I was like I’ve totally just [vaping too much].Feeling in control of their smoking led participants to present their smoking as acceptable and not that “bad,” especially when other aspects of their health were positive, as Adam  explained, “I think moderation is a good way to say how I smoke. Like I don’t power through my fags or anything I will be conservative … I think if you smoke in moderation and keep somewhat fit you shouldn’t do too bad.” In contrast to this view on smoking, many participants had observed apparently constant use of e-cigarettes amongst others. For example, Ruth  said:A lot of people I’ve seen using these just sort of seem to have them hanging out their mouth the whole time … It’s so easy to pick these up … you don’t even need to go outside … I think I’d probably be … smoking more than I usually do but just through not noticing, not actively trying to smoke more.Interestingly, Ruth did not differentiate “smoking” and “vaping” in the above quote. This was similar for many of the participants and demonstrates their attitude towards vaping as doing little to change existing smoking behaviors and identities. However, a few participants had found controlling vaping to be straightforward. Although Ellen  also saw a seemingly increased addiction in other e-cigarette users, she was bemused at this behavior as she was able to equate vaping duration with a cigarette: “You kinda reach a natural end of … ‘right, I’ve been using this for four minutes, that’s like a fag, I’m going to put this away now’, so it was weird to see someone just sitting constantly [vaping].”Many participants felt that they would be able to quit smoking, given their “acceptable” level of smoking and relative young age. The ability to quit vaping was seen as less certain. Participants such as Jane  were often puzzled as to why people appeared not to cut down vaping and try to stop altogether: “anybody that I’ve heard has stopped smoking with them they’ve been on them since they stopped smoking for like however many years, they’ve been on them since … they’ve just constantly stuck to that.” Likewise, David  described losing his confidence to quit using an e-cigarette after observing the seeming failure to do so among friends:I was going to try completely stop smoking normal cigarettes and then after a while come off the e-cigarette but I know plenty people that have been on the e-cigarette for over two years now, so they’re just as addicted to that as they are normal cigarettes.Contrary views to the addictiveness of vaping were present among a few participants. For example, Steven  described successfully transitioning from smoking to vaping using a box mod e-cigarette, and his ongoing process of lowering the nicotine content of his e-liquids to eventually reach zero nicotine and stop vaping. Steven was one of four participants to report having quit smoking with the use of an e-cigarette and, along with the other three, reported a specific personal motivation for quitting. For Steven, this was a sudden realization of a drop in fitness. For the others, it involved reaching a milestone age, impending parenthood, and a diagnosis with Type 1 diabetes. Three of these four participants used a box mod e-cigarette. However, few others noted having tried a box mod, and so their experiences of e-cigarettes mostly lay with cigalikes and vaporizers. The high up-front cost and what many perceived as extravagant features, compared to the more affordable and accessible e-cigarette models, were reasons given for avoiding box mods. Conversely, the few users of box mods referred positively to the long-term cost-effectiveness, sophisticated features, and personalization of the devices, and believed them to be the most effective for smoking cessation.Smoking while drinking alcohol was an almost unquestioned necessity among the participants, and quit attempts using e-cigarettes often collapsed when drinking:Graham : I tried to stop [smoking] with a vapouriser but it only went so far … It doesn’t work when you go out drinking.Gregory : It really doesn’t … Used a vapouriser to try and stop. It wasn’t good enough. Like Graham said, when you’re going out for a drink it just doesn’t do it.Participants also mentioned e-cigarettes being left behind when preparing for a night out or being neglected while out. Indeed, smoking was an important social interaction for participants and some lamented the more individualized behavior of using e-cigarettes:Julia : Well it was a big social thing, when you had a fag, and you went out for a drink and a quick fag.Kate : You’d be like, ‘excuse me, have you got a light’? And now, it’s like, you just keep [to] yourself, you don’t see people speaking.Interviewer: And do you think the e-cigarettes and the vapourisers have contributed to that?Kate: Probably.Julia: Aye.Kate: It must’ve, ‘cause you can’t go to someone, ‘can I charge one?’! … ‘Have you got a spare battery’? You know what I mean, it’s gone really weird.Though sharing cigarettes and lighters could start conversations, sharing e-cigarettes was perceived to be a conversation ender. A few participants did note positive aspects of the individuality of e-cigarettes. For example, Daniel  felt that personalizing devices meant they were less likely to be shared and so it was easier to avoid social smoking cues as he maintained his attempt at quitting smoking. Some participants had integrated vaping more successfully into their lives. William and Kevin had become friends through a common enthusiasm for vaping. However, both still smoked and were not intending to quit in the near future. Several others mentioned the likelihood of “going back to fags,” at times of drinking and stress, should they try to quit using e-cigarettes.Just as cigarettes were synonymous with drinking alcohol, they were also often understood as important stress relievers for the participants. Many described the everyday stress of their lives, usually due to their precarious working and living circumstances. For instance, one group mentioned that just living in a deprived area made them want to smoke, whereas others noted that smoking, along with other substance use, was just part of what they encountered in their daily lives. Fred  provided a specific insight into this stress when he talked about being nervous before a job interview: “so I’ll have a fag, and stand outside for ten minutes … but I try and not use the e-cig ‘cause it doesn’t help with the nerves … A fag kind of helps you a wee [small] bit there.” Fred did not like smoking before an interview, aware that the smell of smoke on his body and clothes served to stigmatize him to interviewers, however, he felt unable to escape this felt stigma, as for him there was no effective replacement for a cigarette.Reinforcing the idea of smoking as more controllable than vaping, participants often explained their smoking in terms of taking a break to relieve stress. Smoking a cigarette was often described as merely something to do while having their break—as opposed to being driven by nicotine addiction. Jane  and Karen  worked in the same office. They described taking three or four smoking breaks a day. They compared their break schedule with the much more frequent vaping breaks of a colleague who they felt was more addicted to vaping than he had been to smoking, and so, to them, the frequency of his vaping breaks seemingly diminished their value. A 5-min break outside with a cigarette therefore retained value for Jane and Karen, as the prospect of switching to e-cigarettes meant that control over their addiction would be lost.17 Nonetheless, the participants also distanced themselves from even more mature, older people, who might use e-cigarettes as cessation aids. This form of identity work builds on the findings of Thomson et al.26 that in response to perceived moral imperatives to demonstrate some compliance with smoking disapproval, smokers attempt to craft identities as “responsible” or “considerate.”40 The participants in this study stressed their continued smoking as a more responsible option than transitioning to vaping. This raises the possibility that negative attitudes towards e-cigarettes and vaping may be entrenching existing justifications for continued smoking among young adults from disadvantaged areas.A key finding of this study is that e-cigarettes and vaping did not fit into the lives of most of the participants as possible smoking cessation aids or as replacements for cigarettes and smoking. Smoking had come to be acceptable and manageable in many participants’ lives and identities. E-cigarettes were perceived as endangering this, threatening to lull them into an identity of less control characterized by an even greater addiction than that of smoking. Participants, therefore, stressed their self-identity as “controlled smokers” rather than “out-of-control vapers.” Avoiding e-cigarettes could be a marker of maturity among these participants, relative to the immaturity of younger people who they felt were unable to make informed decisions about potentially addictive behaviors. This finding is contrary to some other qualitative studies on young adults and e-cigarettes which find that the ability to perform “smoke tricks” and other markers of “vaping trendiness” were important factors for use.12 In contrast, the use of e-cigarettes in social settings was perceived to impede social interaction. Stress was normal for these young adults, as they attempted to secure employment and establish more stable routines. As has been found in previous studies of disadvantaged smokers,42 smoking was experienced and valued as a stress reliever. In contrast, participants found that vaping rarely offered an effective alternative. Other research has indicated that young adult smokers believed e-cigarettes to be effective replacements for cigarettes;18 however, the disadvantaged circumstances of the participants in this study, seemingly increased the “resilience” of smoking,43 so that vaping was unsustainable. Some participants formed social practices around a shared enthusiasm for vaping. However, several of these participants were dual users of cigarettes and e-cigarettes, and recent research has suggested that dual use may be a lasting behavior in itself rather than a stage of quitting smoking.44 Type of e-cigarette may also have affected the participants’ views. The more expensive and sophisticated box mods were financially inaccessible to many, but users did note their greater potential as smoking cessation aids. Future research should consider examining the different models of e-cigarettes and their uses, independently, rather than treating e-cigarettes as homogenous devices.45Nonetheless, e-cigarettes were used by some participants in attempts to quit smoking. These attempts were generally short-lived as e-cigarettes and vaping failed to adequately replace the important social aspects of smoking, which remained an important social “lubricant.”47 The participants’ attitude to e-cigarettes and vaping was influenced by their living in disadvantaged areas of Central Scotland, where smoking is more of a social norm. More research is needed to explore the variable meanings of e-cigarettes and vaping by socioeconomic status.The evidence base around e-cigarettes is constantly developing and so these findings are limited to a specific geographical context and the time when they were gathered and analyzed. These qualitative data from a small purposive sample cannot be used to generalize to the Scottish or UK population. Access to and attitudes towards e-cigarettes and uptake of vaping may differ by socioeconomic status and so have an impact on health inequalities.48 Although there is yet no clear consensus on the health equity impact of e-cigarettes,46 there remain fears that e-cigarettes will be less accessible to those on lower incomes and exacerbate existing health inequities related to smoking.49 Additionally, the fact that the participants’ attitudes towards e-cigarettes were being informed by their perception of addiction is supported by evidence from another qualitative study15 that finds young adults used their own embodied experiences of vaping to inform their opinions. Prevailing public health views that e-cigarettes are likely to be less harmful than combustible tobacco products26–28 are, perhaps, not well disseminated among young adults and this lack of information may well be exacerbated by circumstances of disadvantage. Indeed, many of the participants noted limited access to technology and social media. The findings in this study highlight the importance of exploring the social context of disadvantaged young smokers, as the health inequity impact of e-cigarettes cannot be reduced to only matters of cost, pricing, and access. The participants’ decisions to reject e-cigarettes were based on ideas of addiction, identity, and stigma, along with existing social relations in which cigarettes and smoking were necessary and irreplaceable. Therefore, e-cigarettes should not distract from continued efforts to tackle the underlying social and cultural reasons for smoking among disadvantaged young adults.These findings are particularly pertinent to understand how e-cigarettes are being understood among a population with particular attitudes of disapproval towards smoking with simultaneously high rates of smoking. The fact that participants felt switching to e-cigarettes did little to alleviate an identity of being “addicted” confounds recent commentaries that e-cigarettes offer a route to denormalize smoking without stigmatization.This work was supported by a Cancer Research UK (CRUK) Tobacco Advisory Grant (TAG) award. The reference for the award is C3721/A19466.None declared.


Our guest this evening is once again Dr. Anastasia Noitall‐MostDr. Noitall‐Most: Good evening Abi; it is always a pleasure to be here.Ms. Repor‐Tastory: Ani, this evening we will continue the discussion we began in the last episode about the results of the most ambitious human microbiome survey to date, the Global Phenotype‐Genotype Survey, or GLOPS.Dr. Noitall‐Most: Yes, Abi: GLOPS taught us that each human being has a unique genotype‐phenotype, determined by its integrated human and microbiome metagenome, but that certain human:human behavioural activities lead to the sharing of some of the microbiota and a resulting short term or, more rarely, longer term changes in metagenotype‐phenotypes, including voice quality and diction.GLOPS concerning non‐human, environmental mediators of what we might call microbiome diversification and diversity maintenance. Of course, most people by now have heard that subways are environments where spectacular microbiota exchanges can take place, in the case of the Hong Kong subway, where cross border exchanges, including the sharing of antibiotic resistant bugs and genes, are effected.This evening, I'd like to explore some fascinating findings of Ms. Repor‐Tastory: Gosh, yes, that was a bombshell at the time!Dr. Noitall‐Most: Indeed! And of course there are other activities, outside of subways, that do the job, including money handling.,GLOPS provided ample confirmation of the widely‐held belief that domestic animals, particularly pet dogs, significantly boost intestinal microbiota diversity.Ms. Repor‐Tastory: Yes, this led to an amazing increase in the sale of pets, especially dogs, in families with young children: it was impossible to keep up with demand in the months following this finding, despite an extortionate increase in prices! And the stocks of manufacturers of pet food and accessories became the favorites of the tipsters and went through the roof!Dr. Noitall‐Most: Yes, unfortunately, I missed that train when it started to roll. But, a totally unexpected finding by GLOPS and its subsequent causality trials is that it is not only changes in our microbiota composition that affect us. It has now become clear that new microbes that pass through/over us, but fail to set up home in our resident microbiome, can have significant consequences for us. In other words, microbial transients also play an important role in our health and behavior.Ms. Repor‐Tastory: But if they don't take up residence, how can they possibly affect us?Dr. Noitall‐Most: Yes, that is a surprise and I will come to the likely explanation shortly. What is clear is that regular exposure to a richly diverse external microbial flora can have a major positive influence on our health and robustness. In terms of microbiome enrichment from the environment, the majority of us who do not have pet dogs that devotedly lick our faces all the time acquire new microbes principally by eating/drinking and breathing. And, since much of the food we eat is cooked, and drinks tend to have low numbers of microbes, our main source of microbial augmentation is in the air we take in by nose and mouth. Of course, the particulate content of air ‐ solids like dust and water droplets/aerosols – and the microbiota they transmit, as well as individual microbes on a float‐about, vary enormously in time and place, with high levels experienced for example in the path of a dust storm, downwind of a composting plant, during a fog, etc.Ms. Repor‐Tastory: Gosh, yes: taking the air along the edge of a rapeseed field in full bloom in early Summer, with the nasal passages succumbing to a spirited pollen assault, and the air thick with insects, gives the feeling of breathing lentil soup!Dr. Noitall‐Most: Yes, and of course pollen is a major component of the non‐nitrogen, non‐oxygen part of air that we inhale during the tree reproductive season and, at specific times in the farming calendar, like the one you mention. Interestingly, pollens have their own specific microbiomes,mucked out, and near mixed farming land where pig slurry is periodically sprayed on the fields.In any case, the newly‐appreciated beneficial effects on our health of microbially‐laden aerosols has led to unexpected and explosive price increases in city houses near waste treatment plants, municipal composting facilities, well‐tended leafy parks subjected to a weekly blower coiffeur that collects vegetable and other matter into nice small piles and creates a miasma of microbially‐laden dust for locals to respire and ingest, airport runways and helicopter pads, and in country properties downwind of domestic animal residences, like dogs' homes and horse stables, farm husbandry buildings, including poultry houses, farm animal markets, etc., that are regularly Ms. Repor‐Tastory, wrinkling her nose disapprovingly: Yes, this trend is now the major topic of conversation at cocktail parties, but the prevailing odour after the slurry cart has been out and about can be overwhelming and promptly drives inside everyone enjoying cocktails on the terrace.Dr. Noitall‐Most: Of course but, with time, our senses get accustomed to such stimulations and relegate them into our perception background. And, dare I say it, we then start to appreciate such smells as key ingredients of good country air!Anyway, at this juncture, I might also mention that it has recently been shown that a large fraction of microbes in the gut microbiota are spore‐formers,and other stress‐resistant forms, and an important conclusion drawn from this finding is that it is such forms that are preferentially shared between people.Ms. Repor‐Tastory: Hhmm: I must confess that I hold my breath when passing someone creating a dust storm with one of those leaf blowers!Dr. Noitall‐Most: Yes, Abi: this is a normal reaction ‐ the stuff they suspend in the air is not particularly appetizing, given that it contains all sorts of animal gifts and, anyway, one can always have too much of a good thing.On the other hand, as is well known, we humans do not make all the vitamins and other metabolites we absolutely need for good health, nor are they present in adequate quantities in the food we consume.in entero so to speak, but rather from the lysis of microbes in the gut,It has always been assumed that our gut microbes supply us with all the essential nutrients we do not make ourselves, in exchange for the privilege of the nice warm and cosy, food‐rich accommodation we provide. However, there is an increasing indication that some of our microbial supply of vitamins and other micronutrients does not come from microbial synthesis and release on site, ,A good example of this is vitamin B12, which is not made by plants and animals and only by a limited number of microbes, and apparently not released in sufficient quantities by our growing gut microbes to satisfy our needs. So the question is: how do we acquire enough? Interestingly, carnivorous predators, especially hyaenas, vultures, etc., often prefer the delights of the entrails of the prey, rather than its juicy meat, and many animals, like rodents, rabbits, dogs and even primates and, to some extent, piglets and foals, practice coprophagy – the eating of faeces. According to a world‐renowned expert,Ms. Repor‐Tastory: Coprophagy? Uuhhh: how disgusting! …………………..Primates, you say?Dr. Noitall‐Most: Yes, but obviously in the case of human primates, recognition of the importance of the oral‐faecal route for transmission of infectious diseases has somewhat dampened our enthusiasm for coprophagy – in fact we have become coprophobic, and developed other supply chains over time. One may be a high meat diet; another may be co‐evolution of humans and our microbiota, resulting in our microbiota containing sufficient numbers of those bugs able to produce B12 which, after careful cultivation, we sacrifice to extract their vitamin content. And a third may be a regular intake of a goodly quantity of microbial bounty from the environment. So perhaps when you pass a nice fella wielding a leaf blower, instead of holding your breath, you might consider the possibility that his efforts to herd leaves may concomitantly be unwittingly herding vitamin‐rich microbes in your direction to supplement your diet, and which may reduce your need to continuously pop vitamin pills.Ms. Repor‐Tastory: Gosh: that is interesting! I spend a small fortune on vitamin supplements which otherwise could be used to upgrade my gym subscription.Dr. Noitall‐Most: Exactly, but let's move from microbes as food supplements back to microbes as agents of human microbiota diversity. In addition to the aforementioned sources, there are other provenances of transient microbe immune stimulation. Most of us, when we exit from the built environment, breathe in significant quantities of frass particles – insect excreta – with heavier doses delivered in certain settings, like near beehives, wasps nests, etc., which provide a steady stimulation of the lung immune system, as well as sometimes contributing to the development of asthma.Ms. Repor‐Tastory: Oh absolutely! Most of the gardeners and plumbers I know are rather earthy folk, but all the nicer  for it. I vividly remember the explosive sneezing attack I experienced after diving into a haystack with a cute, rosy‐cheeked farm boy one harvest time……..……(angry noises emanating from the in‐ear headphone)…Oh, sorry, I did not mean to interrupt…Dr. Noitall‐Most: Yes: a sneezing attack can be distracting, even downright awkward, in some situations.Ms. Repor‐Tastory: But anyway, why does exposure to lots of different bugs that fail to incorporate in our microbiome have such a positive effect?Dr. Noitall‐Most: Well, we do not yet have definitive information on this score but, according to the GLOPS consultant, Professor Tim Kennis of the Queenton Institute of Advanced Studies, a primary duty of our mucosal immune defenses is a sort of guard duty: to maintain surveillance of our mucosal surfaces, in order to recognize the arrival of pathogens and their establishment in our microbiota, and to promptly attack them to ward off an imminent infection. However, when the microbiota composition does not change much, the duty guards relax, get bored and become lazy. Current lifestyles, which are increasingly dominated by work‐at‐home flexi‐employment, entertainment consisting more of computer games, streamed music and movies, rather than of microbe‐enriching activities like soccer, rugby, cross‐country running, etc., and remote social interactions by social media, home delivery of all essentials, and only infrequent surreptitious sorties from the home to replenish cigarette supplies or visit the local school on parent‐teacher days, have enormously reduced our exposure to new bugs and are leading to progressive atrophy of our immune systems, a good example of the maxim if it is not used it withers. This is consistent with the fact that the severity of typical infections regularly experienced by chair‐bound people, like colds and flu, seems to be increasing, not only because of pathogen evolution to greater virulenceMs. Repor‐Tastory: Oh: that would explain why Winter colds seem to hang on longer and longer each year, sometimes one bronchitis merging with the next cold, as if the bugs were treating us like a baton, always to be handed over to the next!Dr. Noitall‐Most: On the other hand, continual exposure to new bugs results in regular microbial altercations on epithelial barrier surfaces, involving exploitation of physical, chemical and informational weaponry, as the new bugs try to displace resident bugs and gain traction, and in a marked perturbation in the microbe:mucosa communication traffic. All of these mucosal battles keep the immune system awake and primed, and prevents it from atrophying, hence the health benefits of lifestyles and situations that continually expose us to high doses of diverse bugs. Of course, having good immune defenses results in milder infection episodes, reduced development of co‐morbidities, reduced need for antibiotic therapy, and hence a reduced burden of antibiotic resistant bugs in the microbiomes of such people. An exception to this generalization is the acquisition of pavement bounty – the rich diversity of bugs on pavements – by individuals who get pickledMs. Repor‐Tastory, screwing up her fact contritely: Yes, this only happened to me once and was soooo embarrassing that I vowed never to indulge like that again, at least outside the privacy of my own home. But you are quite correct: the world, as viewed from the floor looks very different!Dr. Noitall‐Most: Ah: you bring up an important point! When we consider microbial intake via air, we implicitly assume air at a level of about 1.6m, the average nose‐mouth height of adults…… a bit more for the Dutch, Montenegrins and Scandinavians.to‐be‐explored floor,DustMs. Repor‐Tastory, with a thoughtful expression on her face: Yes, and it is not only the dust on the floor: all the stuff we bring in on our shoes, drop/spill on the floor, the dog's hairs; oh my goodness, and what about when Fido get an itchy bottom and drags himself along the floor on his rear end!Dr. Noitall‐Most: Erm…yes: and this is only what they vacuum up indoors; just imagine what they sample outside, where the title of the book: Let them eat dirt comes into operationAnyway: to return to the usual situation, 1.6m up, where the microbe‐laden air delivers its microbial diversity bounty to our airways and GI tract.Ms. Repor‐Tastory, looking vaguely doubtful: Yes, well, I suppose having cocktails on the terrace while surveilling the approaching air sparger‐generated haze of microbially‐saturated vapour wafting over from the waste treatment plant, and surrounded by the hunt pack going crazy, racing between people's legs, might have its compensations…..But anyway, didn't I read somewhere that compost heaps and the like contain pathogenic bugs?Dr. Noitall‐Most: Aahh, I'm very glad you raised this issue, Abi! In fact, there is a plethora of publications attesting to the presence in all sorts of environments, including shower curtains, of microbes which belong to species which contain representatives that sometimes cause infections.nosocomial or hospital‐acquired infections.opportunistic pathogens,potential to cause infections, mostly in immunocompromised hosts. Moreover, such bugs in the environmental samples are almost always only detected by metagenomic sequencing, almost never isolated and, where they are, almost never tested for their ability to cause disease in some standard infection model or other. Typical publications, mostly in the Journal of Terribly Important Studies,throw over the fence‐type research.Ms. Repor‐Tastory: Well, that is most unsporting!Dr. Noitall‐Most: Absolutely! And: most studies are only qualitative: a bug is shown to be present in the sample. But as all microbiologists know, an infection requires an infective dose,Shigella may be a single bacterium, whereas an infective dose of Vibrio cholera may be as high as ten million. And, switching from an environmental lifestyle to a pathogenic lifestyle is very resource costly,Jekyll and HydeLegionella,Vibrio,Leptospira,In fact, public health agencies have pretty much defined real sources and routes of environmental infections, like water supply lines and cooling systems for things like Ms. Repor‐Tastory: Oh, well, that is a relief!Dr. Noitall‐Most: And, to put all of this into context, our own microbiome contains these types of bugs, both potential and real pathogens, and we live with them in perfect harmony most of the time. I wonder how many authors of papers exposing the dangers of compost heaps and the like are aware of the bugs with pathogen potential on and in their own bodies, and those of their children and pet cats and dogs, what conclusions they would draw from such information and, importantly, what concrete measures they would undertake in response?Ms. Repor‐Tastory: Well, yes, but I must admit to a certain aversion to dribbling babies and slobbery dogs that have just returned from walkies.Dr. Noitall‐Most: Talking about dogs, I must share with viewers new information about how they distribute their microbial bounty to us. A fascinating aspect of the influence of dogs as family pets that was explored by the renowned mathematician, Professor Fidget Jones,GLOPS, was the importance of slobber, you know, the frothy stuff decorating and dripping from the mouths of excited dogs that is periodically centrifugally jettisoned by vigorous flicks of the head, especially when a flea in the ear decides to go on a walkabout to make sure her canine friend is awake and paying attention. The force and trajectory of which may be modulated by Fido's tongue. Well, it turns out that slobber is a perfect growth medium for many microbes that end up in the mouth, especially the vast array acquired during daily walkie sampling campaigns, so is chock‐a‐block with an amazing diversity of bugs. Anyone within range of the head flick shower is immediately gifted substantial numbers of all sorts of exotic microbes originating from the varied local flora and fauna inhabiting or visiting the walkie routes.Ms. Repor‐Tastory, indicating intense distaste: Uuhhh! You mean that I need to be sprayed by that disgusting stuff in order to keep my immune system alert?Dr. Noitall‐Most: Sorry Abi: at least two books by famous microbiomologists carefully document the issue of why dirt is good for us.slobber index, or SLIND,SLIND value, Fidget is able to accurately predict the diversity, the so‐called α diversity, of skin microbiota and, with slightly less precision, that of the gut microbiota, of dog‐owning individuals. The α diversity value is then employed as a key parameter in a new allergy susceptibility model which generates personalized predictive allergy susceptibility indices.From a Ms. Repor‐Tastory: Well, I never: so slobber production can be an important contribution to the health of our microbiota and may influence our susceptibility to hay fever in the Spring!Dr. Noitall‐Most: Yes, and it was this that induced the Imaging Group of Mabriella Golinari and Ranfredy Mohde of the Walpur Gisnacht Institute for Cellular Pathology in Bad Hurzbarg in Northern Germany,GLOPS study, to explore the possibility that slobber production was influenced by buccal microbes.Slobbercopius paintballa and S. jettisona, which they nicknamed Slop and Sloj.And indeed they were able to isolate two closely related bacteria that were abundant in slobber‐super dogs but undetectable in slobber‐poor dogs. When these bugs were given to slobber‐poor dogs in a commercial dog food, they caused the subjects to produce so much slobber that they left a trail wherever they went in the house – more or less like a snail‐slug trail, but rather more impressive. Unfortunately, one dog quickly ruined a rather expensive oriental rug in the house of its house‐proud owner, and another made a bit of a mess of the linen on the children's bed on which it slept. AND, crucially, both ruined the best shoes of the ladies of the households, so the trial was aborted because the dogs were suffering unnecessarily from the unhappiness of their usually happy owners, and all the screaming going on. Nevertheless, the new bacteria were unambiguously shown to play a major role in slobber production and were given the names SlopMs. Repor‐Tastory: Oh, poor dogs!Dr. Noitall‐Most: Quite! Anyway, initial studies to determine how Slop and Sloj induce slobber flow suggests that they produce both a hormone‐like compound they designated canine slobber‐inducing compound, or CSIC, that turns up production of saliva by the dog, and a new biosurfactantSLOSH, that acts like soap, turning all that extra saliva into a soapsud‐like slobber full of microbes growing in the buccal cavity.Ms. Repor‐Tastory: Wow: so slobber is microbially‐triggered!GLOPS investigation?Ok, so finally, let me come to my traditional closing question: are there any applications of this part of the Dr. Noitall‐Most: Yes, of course, Abi! Firstly, there is the key issue of maintaining diversity of our microbiomes. While some folks are able to have pets and live next to the municipal waste treatment facility, many are not, so all the major food companies are developing so‐called microbiota diversity enhancement treatments, usually bug‐packed capsules that can be taken with a cup of cocoa, or a single malt and water, just before retiring. The capsule fillings are mostly spores of a wide range of microbes found in the environment.The earliest to come to market will be based on microbes washed from crop plants, because regulatory approval is a simple process, since we already consume such bugs in our diet and the treatment does not represent anything fundamentally new. However, these microbe mixes are not exceptionally diverse, so other sources are being explored, including compost, but these will have to undergo rigorous safety testing before they will be authorised.Ms. Repor‐Tastory: Oh: I am not sure I would want to swallow compost last thing at night…..Dr. Noitall‐Most: Well: there is always the option of mucking out the stables……. But, seriously: I have heard on the grapevine that the public health department of one state that is rather wealthy and technologically advanced will soon carry out a limited trial involving the mass feeding of an aerosol loaded with a highly diverse but well characterised microbial flora into its metro system. Apparently, there has been a high level of uptake of an offer of lifelong free healthcare for regular metro‐users in exchange for regular detailed monitoring over a 10‐year period, so this trial will be exceptionally well documented and will show whether or not environmental engineering for microbial diversity is helpful for our health and, if so, in what ways. And….this trial without doubt marks the beginning of a new era of pro‐active environmental engineering interventions by public health agencies for microbiota delivery for different health objectives.Ms. Repor‐Tastory: Gosh! But, then, such public health environmental engineering campaigns are not in principle different from the practice of adding iodide to table salt to eliminate iodine deficiency in the population,Dr. Noitall‐Most: Yes, Abi, you are right. But the thing is: while the effectiveness of microbe transmission in semi‐enclosed spaces is bad news for transmission of pathogens, it is good news for the transmission of healthy bugs. And, of course, one might be forgiven for considering the possibility that there may be additional, undeclared reasons for this trial, such as removal of the motivation to live all on top of one another near waste treatment facilities, etc., and the unnecessary and unsustainable rises in accommodation prices in such areas.Ms. Repor‐Tastory: Oh, yes: it would be soooo nice to abandon the pig slurry and hound pack in favour of a quiet garden smelling of roses!Dr. Noitall‐Most: Mind you: subways are not a particularly efficient means of distributing anything, because of the enormous dilution effect, the total volume:personal space volume ratio. So, if the practice of public health environmental engineering, or PHEE, really gets going, for example for annual mass immunization against prevalent flu strains, or to distribute vaccines against the usual childhood infections, it will more probably involve people walking through a sort of dosed air bladeMs. Repor‐Tastory: Gosh, how interesting: this is sort of PHEE would be equivalent to a sheep dip.Dr. Noitall‐Most: Errr, yes: thank you Abi!But perhaps the most exciting application of these findings is being enthusiastically explored by the Lorenzo von Syntech High Security Institute for Artificial Life in Madrid, headed by the world‐renowned Professor Vic Torde, is the use of synthetic biology approaches to engineer an undisclosed super gut coloniser producing high levels of micronutrients we cannot make ourselves, starting with vitamin B12.Ms. Repor‐Tastory: Oh, this sounds like an even more promising development to allow me to abandon my vitamin pills in favour of a gym upgrade!Dr. Noitall‐Most: Another application results from the finding that the SLOSH biosurfactant is exceptionally effective at removing wine stains from cotton and other fabrics, and hence is being developed as an upmarket bio‐stain remover – this will undoubtedly go like a bomb with organitarian wine enthusiasts. However, it turns out that production levels of SLOSH by Slop and Sloj grown in fermenters are so low that it cannot yet be commercialised.Pseudomonas KT2440 chassisSLOSH. Interestingly, as viewers can see on the image now being shown,SLOSH in the form of micropearls.SYBSLOSMPSR (pronounced sib‐slos‐empeser), although the company involved in its commercial exploitation has intimated that this name may not be outstandingly attractive for marketing purposes.The researchers at LvS have given this form of the surfactant the name synthetic biology soap‐like oral substance micropearl stain remover, or Ms. Repor‐Tastory: Gosh: they really do look like pearls! But how do the LvS researchers get the pearls out of the bacteria?Dr. Noitall‐Most: Excellent question, Abi. In fact, this is a fundamental problem of some microbial biotechnology processes – the extraction of intracellular products – that has occupied researchers for some years now.Bdellovibrio, to lyse the cells and release their contents,SLOSH chemical skeleton. The first variant created has been shown to act as an emulsifier at ambient temperatures and to become irreversibly rigid at high temperatures, and moreover has a flavour of chocolate. Because a brief whipping of solutions containing this variant gives a mousse‐like product which becomes perfectly stabilised during cooking, Vic is exploring its use to create the perfect chocolate mousse.In fact, the KT2440 cell factory has worked out so amazingly well that Vic and his associates are now introducing into it biochemical pathways for the creation of new variants by modification of the SLOSH molecule yields all sorts of new flavours, reminiscent of raspberry, artichoke, fermented herring, etc., so believes that he will be able to discover entirely new flavours for the chefs of tomorrow.Even more interestingly, he finds that the chemical tuning of a couple of parts of the Ms. Repor‐Tastory: Golly: that is absolutely fascinating. Well, viewers: on that culinary note, we end this edition of ‘Discoveries that Change our Lives'. We will be back next week with a follow‐up edition to reveal some more of the amazing findings of GLOPS and its experimental follow‐up.++++++++