CoSTED

A British clinical trial set out to answer an unlikely question: Can a vaping kit, handed out in a hospital waiting room, save lives and public money?

The woman had been waiting for thirty-eight minutes on a plastic chair, her hands buried in the pockets of a soaked coat. Outside, Norwich dissolved in a fine drizzle; inside, the air thickened with disinfectant, stale coffee, and the electric hum of monitors and worn-out voices.

Her name was Lorraine—or so we’ll call her—and she had been smoking since she was sixteen, as if each cigarette had tied a knot in the invisible rope of her memory. She had come to accompany a friend with a sprain, but soon found herself on another patient list: those who, in the midst of waiting, would be invited to imagine a life without smoke.

A man in a blue vest—his Norwich Clinical Trials Unit badge swaying on his chest—approached with a gesture that blended trained politeness with the urgency of protocol.

“Do you smoke?” he asked, his tone sharpened by a curiosity that had long since settled into habit.

In his pocket, he carried what might have looked—at a glance—like a sleek, heavy pen. It wasn’t. It was a DotPro, a small device designed to turn liquid into vapor… and sometimes, routines into stories of letting go.

His attentive gaze didn’t promise miracles. What it offered was something more measured: a brief chat—no more than fifteen minutes—a DotPro kit with eleven capsules (three tobacco, four berry, four menthol, all at 20 mg/ml of nicotine), and a digital referral to the local Stop Smoking Services.

Lorraine, tired of the cough that opened every morning and the private negotiation—“just one more, and then I’ll quit”—agreed to the conversation. It was a start. And sometimes, all it takes is a crack for the air to get in.

Lorraine didn’t know it, but that gesture—the door left ajar amid the chaos—was at the heart of a British clinical trial known as CoSTED (Cessation of Smoking Trial in the Emergency Department).

It’s no accident the trial was born in the ER: a quiet reminder that the healthcare system can be, in a single act, both a barrier against harm and a social experiment in motion.

Who, what, when, where… and why

This trial wasn’t born in a quiet lab, but in the patchwork of emergency rooms where time is always short. It was conceived and led by Ian Pope of the University of East Anglia, alongside Caitlin Notley, Felix Naughton, Lucy Clark, Allan Clark, Emma Ward, Pippa Belderson, Susan Stirling, Steve Parrott, Jinshuo Li, Timothy Coats, Linda Bauld, Richard Holland, Sarah Gentry, Sanjay Agrawal, Benjamin Bloom, Adrian Boyle, Alasdair Gray and Geraint Morris.

The Norwich Clinical Trials Unit coordinated recruitment and logistics, working in partnership with six hospitals: Norfolk and Norwich University Hospital, The Royal London Hospital, Homerton University Hospital, Leicester Royal Infirmary, Addenbrooke’s Hospital, and the Royal Infirmary of Edinburgh.

Fieldwork ran from January to August 2022, with a six-month follow-up, and was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment Programme.

The results, published in Health Technology Assessment in 2025, sought to answer a question as simple to ask as it is difficult to execute: Can a brief intervention and an e-cigarette kit—offered in the fleeting moment of an ER visit—change the course of smoking for people who would rarely seek help on their own?

Results that Let the Air In

Between winter and summer of 2022, 972 daily smokers—both patients and eligible companions—were randomly assigned. Half received what the NHS calls signposting: a leaflet with information about local Stop Smoking Services and an invitation to reach out.

The other half—people like Lorraine—left with a DotPro and its eleven capsules, a one-on-one counseling session of up to fifteen minutes (sometimes stretching to twenty-five), and a direct electronic referral to those specialized services.

Three years later, the results were published under the title Cessation of Smoking in People Attending UK Emergency Departments: the COSTED RCT with Economic and Process Evaluation.

To the untrained eye, the outcomes might seem modest: 7.2% of those who received the kit remained smoke-free after six months—continuous abstinence confirmed by carbon monoxide monitors—compared to 4.1% in the leaflet group. A difference of 3.3 percentage points, with a relative risk of 1.76 and a number needed to treat of thirty.

In public health, where each percentage point can mean thousands of lives extended and millions of pounds saved, that margin stops being a footnote and becomes a crack through which fresh air enters.

Even more so when the threshold was lowered to “seven-day abstinence”—at that point, the gap widened: 23.3% versus 12.9%, with a number needed to treat of just under nine.

The researchers, led by Ian Pope, weren’t promising miracles. They knew emergency rooms aren’t built for smoking cessation, that verifying abstinence at home is logistically messy, and that e-cigarettes still hover in a haze of suspicion and hype.

But in a country where tobacco use is increasingly concentrated in neighborhoods with the least income and the least voice, seizing that suspended moment in the waiting room, they argued, might be a pragmatic way to help close the gap.

Of course, self-reports tend to be generous. Asking someone to return months later to blow into a portable carbon monoxide monitor is asking a lot. That’s why the analysis used the strictest standard: every participant lost to follow-up was counted as a smoker. And still, the margins held.

The intervention Lorraine received followed a precise script: a brief, tailored conversation linked to the reason for the visit—wounds heal better, breathing eases, the pulse steadies. A DotPro, selected through public consultations for its ease of use, steady nicotine delivery, and affordability. And an electronic referral that triggered the machinery: follow-up calls and, in many cases, free access to nicotine replacement treatments.

The kit cost £23.15—less than a standard X-ray; the average total cost of the intervention came to around £48 per person. The economic evaluation estimated an ICER (incremental cost-effectiveness ratio) of £7,750 per QALY (quality-adjusted life year), with a 71% probability of being cost-effective under NHS thresholds, which typically accept interventions up to £20,000–£30,000 per QALY.

In plain terms: for every additional healthy year of life gained through the intervention—compared to usual care—the cost is well below what the British healthcare system is willing to pay.

In other words: not only does it work, it does so at a price public policy considers a smart investment.

And the long-term model—a projection estimating lifetime benefits and costs—painted an even more favorable picture, since every person who quits smoking lowers their risk of developing multiple diseases that are costly to treat.

A Place Where Everyone Passes Through

Emergency room corridors are, statistically speaking, a map of the nation. In England, there are over twenty-four million visits a year; the flow of patients forms a sociology of its own. Frequent visitors rarely come in carrying only pain or injury—they arrive bearing, on an invisible shoulder, the silent weight of inequality.

In those hallways, tobacco isn’t just a habit; it’s a social marker, a compressed biography. That’s why the question driving CoSTED was less technical than it seemed: could that suspended time—the wait for an X-ray, the pause before a suture—be used to introduce a detour in a smoker’s path?

The trial’s design answered with stubborn pragmatism.

The 1:1 individual randomization—assigning each person randomly to one of the two study groups in equal proportion—ensured that comparisons were fair, and that any observed differences could be attributed to the intervention, not chance.

Broad inclusion criteria allowed the enrollment of any adult who smoked daily and showed an exhaled carbon monoxide level of 8 parts per million (ppm) or higher during screening—an objective marker of recent tobacco use.

Sensible exclusions filtered out cases that could complicate or endanger the intervention: individuals requiring immediate medical attention, those in police custody, allergic to nicotine, daily users of e-cigarettes, or unable to provide informed consent.

Logistics, Too, Were Political.

The advisers—nurses, research staff, or support workers—were temporarily seconded to the project and received standardized training to ensure the intervention was delivered consistently across all sites.

This training included the TIDieR manual (an international guide for describing and implementing health interventions), 2.5 days of hands-on instruction, and online modules from the NCSCT (UK’s National Centre for Smoking Cessation and Training).

The aim was clear: to prevent personal styles from shaping the delivery and ensure that the “experiment” in Norwich was the same as the one in London.

In the humblest details—a £1.47 canvas bag, a 39-pence leaflet, a handheld carbon monoxide monitor—lay a quiet philosophy of the British public service: do more with less, and do it the same for everyone.

A Policy That Fits in a Pocket

The DotPro fits in a pocket; what CoSTED tried to fit in there was an entire policy. It’s a pod system with disposable capsules, chosen—after consultations with patients and the public—for its ease of use, steady nicotine delivery, user satisfaction, and affordability.

It came in three flavors: tobacco, for those who need the illusion; berry, for those ready to create distance; menthol, for those who crave a sense of clean. The manufacturer, Liberty Flights, had no role in the study’s design or data analysis.

And the 20 mg/ml nicotine concentration wasn’t arbitrary—it was calibrated to douse, from day one, the fire of withdrawal.

Outside the waiting room, the debate around vaping remains steeped in ideology. The 2024 Cochrane review—updated in 2025—is clear: high to moderate certainty evidence shows that nicotine e-cigarettes are more effective for quitting smoking than traditional nicotine replacement therapy. Hajek’s 2019 trial in The New England Journal of Medicine had already pointed in the same direction.

CoSTED doesn’t compete with those studies—it translates them into a messier setting, one without appointments, where time and willingness rarely align.

A 3.3% verified difference at six months might sound like a whisper. But in public health, whispers shift tides. And CoSTED showed that you don’t need an arsenal to move the needle: a £23.15 device, a cheap tote bag, half an hour of conversation, and a follow-up call can buy years of life—efficiently.

Not always. Not for everyone. But enough to warrant repeating the experiment, scaling it up, and measuring it again.

Every Trial Is Only as Honest as Its Limitations

Every trial is only as solid as its willingness to tell the truth—and CoSTED does so without embellishment. There was no blinding; you can’t exactly disguise a device handed to someone on the spot. Biochemical verification was limited—getting someone to blow into a CO monitor months later is a big ask, and fewer verifications mean more uncertainty.

The control group was “active”: even a simple leaflet with contact info can sway behavior, narrowing the gap compared to a null control. And the follow-up lasted six months, not twelve; sustained abstinence, the researchers remind us, takes longer to cement.

Despite everything, the intention-to-treat analysis, the conservative imputation (lost to follow-up = smokers), and the sensitivity checks hold the findings in place—no fanfare, no gloss. Rigor without triumphalism: a rare combination, and perhaps for that reason, a valuable one.

Perhaps CoSTED’s most compelling insight lies not in what is offered, but in where. The emergency room is a liminal space—a parenthesis where life becomes explicit. That opportunistic moment—the wait for an X-ray, a quiet exchange in a side room—completes the arc of an old idea: public health is the art of showing up at the crossroads.

This isn’t about turning the emergency room into a clinic for life habits—it’s about using it as a threshold. It’s where people are intercepted who, left to their own devices, would never set foot in a smoking cessation service. It’s also where the toll of tobacco is heaviest: neighborhoods where the air is thicker with smoke, jobs without long breaks, lives compressed into routines where a cigarette is one of the few brief, affordable reliefs.

In that unequal geography, a canvas bag with a device inside can be more than a gesture—it can be an invisible turning point in a statistic.

That minimal act, repeated hundreds of times, links to a broader conversation: about what we already know—and what we still don’t—about how and where smoking cessation efforts actually work.

Nothing in CoSTED contradicts what the scientific literature had already suggested. We knew opportunistic interventions can work—if they’re funded, organized, and delivered with proper training. We knew, from meta-analyses, that nicotine e-cigarettes outperform traditional nicotine replacement therapy in several clinical settings. And we knew that inequality cuts straight through smoking, concentrating prevalence in the poorest quintiles.

CoSTED’s contribution isn’t about breaking paradigms—it’s about relocating them: taking evidence from the controlled lab and planting it in a hallway that never stops moving. It weaves together a pragmatic trial, health economics, and qualitative process evaluation into a single, coherent package.

In other words, it’s not a lab test—it’s a corridor test.

And that shift in setting isn’t just logistical; it’s cultural. It proves that science can adapt to the choreography of a place where urgency isn’t the exception—it’s the baseline.

Fine Print, if It’s to Become Policy

No result shines on its own. For an intervention to work beyond the trial, its fine print must be written—and honored.

The beauty of a result—that small door opening amid the chaos—demands a fine print just as honest, if it's to be translated into real public policy.

DotPro and Consumables: Who pays for the device? Who refills the capsules? What does it cost to ensure that, after discharge, the patient isn't left holding a useless gadget? In CoSTED, the initial kit was covered; the future demands a sustainable resupply system.

Staffing and Shifts: The trial was successful due to the dedicated advisers, who were pulled from clinical routines and trained for the task. Making it standard practice means reinforcing teams and protecting time—so the conversation isn’t just a footnote.

Follow-up and Verification: Measuring carbon monoxide outside the hospital is nearly a lost art. If we want solid 12-month data, we’ll need to explore remote devices, alternative biomarkers, or stronger ties with primary care.

A Living Referral: A single click to send someone’s name to Stop Smoking Services isn’t enough. The first call, the voice on the other end, and the quality of the support offered are, in practice, half the intervention’s effect.

In short, CoSTED didn’t just test a kit—it tested an implementation model. And like any model, its strength will depend on whether the NHS chooses to invest not only in devices, but in the hands, the minutes, and the follow-up calls that make it work.

Lorraine, Six Months Later

We return to Lorraine—a composite character distilled from the near-magical realism of patient voices and patterns observed in the process evaluation.

In her story, the emergency room was an unlikely place to begin. The device wasn’t “a reward,” but a crutch; the adviser, a presence free of moral judgment.

At six months, Lorraine wasn’t a textbook case or a tidy redemption arc: she still lived in the same neighborhood, worked the same job, bore the same daily pressures. There had been relapses, yes—days when the DotPro bag sat forgotten on a shelf, long silences, and a phone call that arrived just when it needed to.

But there were also days—more and more—when the lighter stayed buried in a drawer, and the air in her kitchen smelled like nothing at all.

It wasn’t a self-help postcard.
It was, quite simply, less smoke.

At its core, that’s what CoSTED is about: embedding normalized possibilities in places never designed for prevention.

It’s about accepting that methodological perfection doesn’t fit in an ER hallway—and still trusting that the evidence is solid enough to shift budgets, train staff, and spark a beginning.

The Future That Fits in a Tote Bag

The authors—Ian Pope, Caitlin Notley, Felix Naughton, Caitlin Dockrell, Jennifer A. Holland, Elizabeth Coleman, Natalie Lawrence, Lynda Wilton, Sarah B. Clarke, Paul Aveyard, Anne M. Pullyblank, Steve Brine, and Sarah C. King—recommend what any sensible clinician would: keep going. Repeat the trial with stronger verification, extend follow-up to twelve months, test it in other clinical settings, and scale it to match the system’s actual resources.

The debate around vaping may never fully settle—no technology is truly neutral. But some questions can’t wait: What do we do today, with what we already know, to reduce harm where it hits hardest?

CoSTED’s answer isn’t epic or absolute. It’s—above all—actionable. And in an age of strained budgets, that’s already a kind of hope:

A tote bag.
A refillable device.
Half an hour of conversation.

And the possibility that, somewhere in an emergency room hallway, someone decides that a cigarette will be their last.

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• Pope I, Clark LV, Clark A, Ward E, Belderson P, Stirling S, et al. Cessation of smoking in people attending UK emergency departments: the COSTED RCT with economic and process evaluation. Health Technol Assess 2025;29(35).