title: Interventions for Smoking Cessation in Substance Use Treatment Services in the UK: A Mixed Methods Study and Behavioural Change Synthesis
Creators: name: Swithenbank, Z
Publisher: name: Liverpool John Moores University
Year: 2024

description: Smoking prevalence in people accessing substance use treatment services is high, yet much of the existing evidence on behavioural interventions for smoking cessation is of limited utility in this setting. This is due to the specific needs and challenges that this population present, and a lack of evidence specific to this context. This thesis uses a concurrent, embedded, mixed methods design to examine the existing evidence on this subject and assess its applicability to the context of substance use treatment. It is underpinned by a pragmatic paradigm, and uses a recoverist perspective, which supports a person-centred, holistic approach to substance use treatment, reframing addiction through a cultural lens and focusing on the people affected. Three studies each explore a different type of evidence: Study 1 explore reporting guidelines for smoking cessation trials, using both deductive framework analysis and a generic thematic approach to examine meeting transcripts from an expert consensus meeting and the associated reporting guidelines for behavioural trials for smoking cessation. This study concluded that established forms of evidence such as systematic reviews, randomised control trials (RCTs) and Delphi studies are not appropriate methods for defining the evidence base for this population. In addition, 5 Behavioural Change Techniques (BCTs) were identified as being recommended for inclusion in a potential intervention (1.1, 2.5, 8.2, 10.2, 11.1). Other key intervention aspects for consideration include: fidelity, mode of delivery, outcome types and measures, and concepts of agency and autonomy. Study 2 presents quantitative secondary data analysis on the components of smoking cessation interventions, comparing the behaviour change techniques and other aspects of smoking cessation interventions received by people who use drugs or alcohol, when compared with the general population. This was done using a large dataset made of up variables extracted from RCTs. This study found that there were significant differences in many aspects of interventions delivered to people who use drugs and / or alcohol (PWUD/A) and those who did not; specifically, PWUD/A were more likely to receive pharmacotherapy, more likely to receive an intervention delivered by a counsellor of health educator, and less likely to receive group-based interventions. In addition, 12 BCTS demonstrated a significant difference between the likelihood of being delivered to PWUD/A when compared with people who did not. Overall, this study shows that there are significant differences in the content and delivery of interventions received by PWUD/A and people who do not. The third Study presents the findings of a qualitative, reflexive thematic analysis of semi structured interviews conducted with staff (N=9) and people accessing substance use treatment services (N=18). Key themes were identified: the importance of choice, autonomy and acceptability; risk perception and prioritisation; organisation and policy; and recovery. Barriers and facilitators to implementing smoking cessation in this setting, across different levels (individual, organisational, system wide) are identified as well as ways to address these. This study also emphasised the importance of the acceptability of interventions to all stakeholders. The findings from these three studies were synthesised using a behavioural change approach, following the framework of the Behaviour Change Wheel. This examines both the ethos and specific components of behavioural interventions for smoking cessation in this context to present recommendations for intervention development which are both acceptable and effective, as well as tailored for this population and setting. APEASE criteria, with a specific emphasis on acceptability to PWUD/A is used to evaluate the BCTs and intervention components. Twenty-six BCTs meet the acceptability criteria, and recommendations include a group based mode of delivery; the appropriateness of substance use treatment as a setting for smoking cessation; delivery by staff within the treatment service, supported by a peer; enhanced training and education for staff; outcomes used to include harm reduction approaches and outcome measures to be self-reported. The findings were also integrated to explore broader concepts of acceptability of smoking cessation, and the relevance and applicability of existing evidence to the context of substance use treatment services within a UK setting. Ten recommendations are laid out which make suggestions for design and implementation of a smoking cessation intervention. These are all underpinned by key concepts of choice and recovery. The recoverist lens is used to offer a person centred perspective which embodies the values of recovery, and puts PWUD/A at the heart of research and healthcare, and challenges the hierarchy within research which excludes or marginalises lived experience and the perspectives of PWUD/A. In conclusion, more contextualised research is needed for PWUD/A to address their specific needs and wants. This research offers an alternative approach which challenges many of the preexisting assumptions about this population and how smoking cessation should be delivered, whilst making recommendations for ways in which a recoverist informed approach can be used to design and implement smoking cessation interventions which are contextualised and tailored for this group. This approach aims to reduce stigma and the health inequalities faced by PWUD/A, by increasing the availability and suitability of smoking cessation programmes, as well as empowering people to have greater agency and autonomy and promoting the values of a recoverist approach.