Evaluating the effectiveness of e-cigarettes compared with usual care for smoking cessation when offered to smokers at homeless centres: protocol for a multi-centre cluster-randomized controlled trial in Great Britain.

BACKGROUND AND AIMS: Smoking is extremely common among adults experiencing homelessness, but there is lack of evidence for treatment efficacy. E-cigarettes are an effective quitting aid, but they have not been widely tested in smokers with complex health and social needs. Here we build upon our cluster feasibility trial and evaluate the offer of an e-cigarette or usual care to smokers accessing a homeless centre. DESIGN, SETTING AND PARTICIPANTS: Multi-centre two-arm cluster-randomized controlled trial with mixed-method embedded process and economic evaluation in homeless centres in England, Scotland and Wales. Adult smokers (18+ years; n = 480) accessing homeless centres and who are known to centre staff and willing to consent. INTERVENTION AND COMPARATOR: Clusters (n = 32) will be randomized to either an e-cigarette starter pack with weekly allocations of nicotine containing e-liquid for 4 weeks [choice of flavours (menthol, fruit and tobacco) and strengths 12 mg/ml and 18 mg/ml] or the usual care intervention, which comprises very brief advice and a leaflet signposting to the local stop smoking service. MEASUREMENTS: The primary outcome is 24-week sustained carbon monoxide-validated smoking cessation (Russell Standard defined, intention-to-treat analysis). SECONDARY OUTCOMES: (i) 50% smoking reduction (cigarettes per day) from baseline to 24 weeks; (ii) 7-day point prevalence quit rates at 4-, 12- and 24-week follow-up; (iii) changes in risky smoking practices (e.g. sharing cigarettes, smoking discarded cigarettes) from baseline to 4, 12 and 24 weeks; (iv) cost-effectiveness of the intervention; and (v) fidelity of intervention implementation; mechanisms of change; contextual influences and sustainability. CONCLUSIONS: This is the first study, to our knowledge, to randomly assign smokers experiencing homelessness to an e-cigarette and usual care intervention to measure smoking abstinence with embedded process and economic evaluations. If effective, its results will be used to inform the larger-scale implementation of offering e-cigarettes throughout homeless centres to aid smoking cessation.

A cluster feasibility trial to explore the uptake and use of e-cigarettes versus usual care offered to smokers attending homeless centres in Great Britain.

Smoking rates in the UK are at an all-time low but this masks considerable inequalities; prevalence amongst adults who are homeless remains four times higher than the national average. The objective of this trial was to assess the feasibility of supplying free e-cigarette starter kits to smokers accessing homeless centres and to estimate parameters to inform a possible future larger trial. In this feasibility cluster trial, four homeless centres in Great Britain were non-randomly allocated to either a Usual Care (UC) or E-Cigarette (EC) arm. Smokers attending the centres were recruited by staff. UC arm participants (N = 32) received advice to quit and signposting to the local Stop Smoking Service. EC arm participants (N = 48) received an EC starter kit and 4-weeks supply of e-liquid. Outcome measures were recruitment and retention rates, use of ECs, smoking cessation/reduction and completion of measures required for economic evaluation. Eighty (mean age 43 years; 65% male) of the 153 eligible participants who were invited to participate, were successfully recruited (52%) within a five-month period, and 47 (59%) of these were retained at 24 weeks. The EC intervention was well received with minimal negative effects and very few unintended consequences (e.g. lost, theft, adding illicit substances). In both study arm, depression and anxiety scores declined over the duration of the study. Substance dependence scores remained constant. Assuming those with missing follow up data were smoking, CO validated sustained abstinence at 24 weeks was 3/48 (6.25%) and 0/32 (0%) respectively for the EC and UC arms. Almost all participants present at follow-up visits completed data collection for healthcare service and health-related quality of life measures. Providing an e-cigarette starter kit to smokers experiencing homelessness was associated with reasonable recruitment and retention rates and promising evidence of effectiveness and cost-effectiveness.

Understanding women's feelings about safety and hazards of street drinking in London through interpretative phenomenological analysis.

AIMS: Drinking alcohol in outdoor public places (e.g. streets and parks) and outside of formally organised events is perceived and reported as antisocial behaviour and may be indicative of a problematic relationship with alcohol, and other clinical needs. This paper aims to address a lack of qualitative research on street drinking in the United Kingdom and develop a textured understanding of the lived-experience of how some women engage in street drinking, in the context of one London borough. METHOD: The authors collected semi-structured interviews as part of a larger mixed methods study on street drinking from April to August 2018. A sub-set of interviews (n = 3) with women who were accessing local drug and alcohol services and had a history of street drinking behaviour were selected as a case series for triangulating analysis with a smaller, homogenous sample. These data were analysed using Interpretative Phenomenological Analysis with a reflexive, feminist, social constructionist approach. RESULTS: The authors developed and named a superordinate theme, Constellations of Safety and Hazards for Women Drinking in Public and Private. Within this, four themes were defined and illustrated from the data: Drinking outdoors to be away from hazards at home; Women's awareness of geo-temporal factors to moderate risk; Women identifying risks of accepting drinks from strangers; and Threats of untreated trauma within histories of heavy drinking. Definitions and illustrations from participants aid explanations of how the texts add detail or disruption to dominant discourses. CONCLUSION: The case studies illustrating how these women have experienced alcohol misuse and behaviour change provide reflexive accounts of exercising agency in managing embodied and affective states of vulnerability. This was demonstrated by asserting choice around environmental spaces and friendships, even when still in positions deemed as 'risky'. These three women's decisions around drinking in public, outdoor spaces were shaped by complex interactions of interpersonal, intrapersonal, socio-economic, and cultural structures. Understanding behaviours is improved with data that situates people in contexts where they experience and make sense of their lives.

A cross sectional survey of smoking characteristics and quitting behaviour from a sample of homeless adults in Great Britain.

BACKGROUND: Smoking is a key contributor to health and social inequalities and homeless smoking prevalence rates are 4 times higher than the general population. Research on homelessness and smoking to date has been concentrated predominantly in the US and Australia. This study aimed to describe smoking and quitting behaviour in homeless adult smokers in Great Britain. Data on perceptions of, and willingness to try, e-cigarettes were also gathered. METHODS: Cross sectional survey of 283 adult smokers accessing homeless support services in Kent, the Midlands, London and Edinburgh. Participants answered a four-part survey: i) demographics; ii) current smoking behaviour and dependence (including the Fagerström Test of Cigarette Dependence [FTCD]); iii) previous quit attempts; and iv) e-cigarettes perceptions. RESULTS: High levels of cigarette dependence were observed (FTCD: M = 7.78, sd ±â€¯0.98). Although desire to quit was high, most had made fewer than 5 quit attempts and 90% of these lasted less than 24 h. 91.5% reported that others around them also smoked. Previous quit methods used included cold turkey (29.7%), NRT (24.7%), varenicline (22.3%) and bupropion (14.5%). 34% were willing or able to spend £20 or more for an e-cigarette and 82% had tried one in the past although 54% reported that they preferred smoking. CONCLUSION: We observed high nicotine dependence, few long-term quit attempts, strong desire to quit and amenability to both traditional cessation methods and e-cigarettes. Community embedded and non-routine approaches to cessation may be promising avenues promoting engagement with the homeless community. Likely barriers to uptake include low affordability, preference for cigarettes and high numbers of smoking acquaintances.

LGBT people and suicidality in youth: A qualitative study of perceptions of risk and protective circumstances.

Evidence suggests that lesbian, gay, bisexual and trans (LGBT) people are more likely to attempt to take their own lives in their youth when compared to heterosexual and/or cisgender people. This study draws on in-depth interviews with 17 LGBT individuals living in England, and explores the narratives used by participants to better understand their perceptions of risk and protective circumstances to explain suicide attempts in youth. Using a Goffman-informed thematic analysis, results identified three key themes that were linked to attempts to end life in youth. The first theme considers the conflicts resulting from first disclosure of sexual orientation and/or gender identity/trans status and being 'out' to others. The second theme explores participants' accounts of their concurrent mental health issues and how diagnoses of the mental health issues helped them make sense of their own experiences of attempted suicide. The final theme explores the experience of grieving over lost relationships and how that grief is received by others, including health professionals. Our results indicate that some LGBT individuals have effectively, although often arduously, navigated suicidal crises by utilising various approaches to coping. We provide a rich and layered picture of LGBT suicide risk in youth and potential resilience scenarios, although these are a reflection of our specific group of participants' experiences and realities. We argue that it is important to understand how LGBT individuals with a history of suicide attempts narrate and make sense of their experiences in early life and we suggest that the early negative experiences continue to have an effect on LGBT adults today.