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Background and Aims: Pathways of transitioning from tobacco smoking to vaping after receiving an e‐cigarette‐based smoking cessation intervention have been minimally explored. Study aims: 1) identify pathways between intervention delivery and final follow‐up; 2) describe baseline and post‐intervention statistical data in relation to smoking/vaping behaviour of the different pathway groups; 3) explore qualitative participant perspectives contextualising pathway groups. Design: Embedded mixed‐methods analysis of data collected for the Cessation of Smoking Trial in the Emergency Department (COSTED) randomised controlled trial. Setting: Recruitment from 6 Emergency Departments (5 in England and 1 in Scotland) between January and August 2022. Participants: 366 adult smokers who were randomised to receive the COSTED intervention and provided data at 6‐month follow‐up. Qualitative subsample of 24 participants interviewed after follow‐up. Interventions: Brief smoking cessation advice, provision of an e‐cigarette starter kit and referral to the local Stop Smoking Service. Measurements: Descriptive statistical reporting of identified pathways and smoking/vaping behaviour at baseline and 6‐month follow‐up. Semi‐structured phone/video interviews analysed thematically. Findings 13.4% (n = 49) of participants quit smoking within 1 month of receiving the intervention, 19.1% (n = 70) quit between 1 and 6 months, 24.9% (n = 91) reduced cigarettes per day (CPD) by at least 50%, and 42.6% did not experience a significant smoking reduction. Approximately a third of participants who quit reported not vaping at follow‐up. Reporting dual use was associated with a reduction in CPD. Appoximately a third reported experimenting with a different device to the one provided as part of the intervention. Quitters reported themes of satisfaction with vaping, changes in environment facilitating quitting and motivation to quit. Conclusions: Dual use of cigarettes and e‐cigarettes can result in a reduction of smoking and may prelude quitting smoking. Sustained e‐cigarette use is not always necessary for quitting success. Success depends on personal context as well satisfaction with vaping. [ABSTRACT FROM AUTHOR]

Introduction: E-cigarettes have been shown to be effective for tobacco smoking cessation. Predicting those who are most likely to achieve smoking abstinence after receiving an e-cigarette based smoking cessation intervention could help to target interventions more efficiently. Methods: A secondary analysis of baseline characteristics of 505 people who received an emergency department based smoking cessation intervention incorporating brief advice, provision of an e-cigarette starter kit and referral to stop smoking services. Gender, ethnicity, age, employment status, deprivation, partner smoking status, cigarettes per day, motivation to quit, cigarette dependence and previous e-cigarette use were assessed as predictors of abstinence. Self-reported smoking status was collected 6 months after intervention delivery. Results: At 6 months 169/505 (33%) of those who received the intervention self-reported abstinence. The groups that were more likely to report having quit were females (37.4% of females vs 31.0% of males), older people (41.1% of over 50s vs 33.3% of under 35s), lighter smokers (36.4% of those who smoked less than 10 cigarettes per day vs 30.7% for those who smoked over 20) and more motivated quitters (35.6% for those with high motivation vs 29.2% for those with low motivation). However, in multiple logistic regression, when adjusting for the other factors, no factors significantly predicted smoking abstinence. Degree of nicotine dependence was very similar between those who quit and those who did not. Conclusion: The study found no baseline factors that could predict successful smoking cessation with e-cigarettes. Consequently, this study does not support the use of a targeted e-cigarette-based smoking cessation intervention, suggesting the adoption of a more universal approach. [ABSTRACT FROM AUTHOR]

Background: This paper reports on recruiting strategies in a study which aimed to examine the mechanism of intranasal oxytocin on cue-induced opiate craving and attentional bias in males using heroin in addition to substitute opiates from four UK community drug treatment services. Methods: Recruitment took place during and post-COVID-19 periods of social distancing and lockdowns. Caseworkers obtained consent to contact from interested service users before an initial telephone screen. People were then scheduled for in-person screens, typically within seven days of the initial telephone call. Subsequent visits took place within 30 days of the previous visit. Each visit lasted one hour and participants received one £20 voucher per completed visit. Results: Thirty participants were randomized from 113 referrals. We were unable to contact 36% (n = 41) of people. Of those eligible to start the study (n = 44), 68% (n = 30) agreed to start the study, retaining 82% (n = 24) to completion. Factors which positively influenced recruitment were having a research presence on site, the cultivation of relationships and demonstrating respect and gratitude toward the participants. Conclusions: These results support the feasibility of recruiting males currently using heroin in addition to substitute opiates utilizing a person-first approach with service users and staff. [ABSTRACT FROM AUTHOR]

Background and aims: The use of e‐cigarettes may influence later smoking uptake in young people. Evidence and gap maps (EGMs) are interactive on‐line tools that display the evidence and gaps in a specific area of policy or research. The aim of this study was to map clusters and gaps in evidence exploring the relationship between e‐cigarette use or availability and subsequent combustible tobacco use in people aged < 30 years. Methods: We conducted an EGM of primary studies and systematic reviews. A framework and an interactive EGM was developed in consultation with an expert advisory group. A systematic search of five databases retrieved 9057 records, from which 134 studies were included. Systematic reviews were appraised using AMSTAR‐2, and all included studies were coded into the EGM framework resulting in the interactive web‐based EGM. A descriptive analysis of key characteristics of the identified evidence clusters and gaps resulted in this report. Results: Studies were completed between 2015 and 2023, with the first systematic reviews being published in 2017. Most studies were conducted in western high‐income countries, predominantly the United States. Cohort studies were the most frequently used study design. The evidence is clustered on e‐cigarette use as an exposure, with an absolute gap identified for evidence looking into the availability of e‐cigarettes and subsequent cessation of cigarette smoking. We also found little evidence analysing equity factors, and little exploring characteristics of e‐cigarette devices. Conclusions: This evidence and gap map (EGM) offers a tool to explore the available evidence regarding the e‐cigarette use/availability and later cigarette smoking in people under the age of 30 years at the time of the search. The majority of the 134 reports is from high‐income countries, with an uneven geographic distribution. Most of the systematic reviews are of lower quality, suggesting the need for higher‐quality reviews. The evidence is clustered around e‐cigarette use as an exposure and subsequent frequency/intensity of current combustible tobacco use. Gaps in evidence focusing on e‐cigarette availability, as well as on the influence of equity factors may warrant further research. This EGM can support funders and researchers in identifying future research priorities, while guiding practitioners and policymakers to the current evidence base. [ABSTRACT FROM AUTHOR]

Background: Heroin is a substance with a unique social profile in that it is commonly used by individuals alone but there is a paucity of qualitative research exploring how social influences impact the continuation of heroin use, particularly when people are trying to stop using heroin. This study explored social determinants which influence the continuation of heroin use in males in UK community treatment who use illicit heroin alongside opioid replacement therapy. Design: Participants were self-selecting from an initial purposively recruited sample. Using Janis (1972) 8 symptoms of Groupthink as an a priori framework for analysis, the study method utilised qualitative interviews with fourteen males. The discussions were digitally-recorded, transcribed verbatim, and analysed thematically. Findings: Contrasting with the evidence base, the sample included people who transitioned from recreational drug use to dependent heroin use without experiencing trauma of any kind. Far from becoming socially isolated when actively using heroin, interviews identified a shift in social networks from networks built on shared moments to networks underpinned by transactional exchange. Components of Groupthink were identified when participants described belonging to heroin using networks and continued to use heroin whilst trying to abstain though individual accountability was central to the decision to continue to use heroin. Conclusions: The conflict between the individual goal of abstinence and the group goal of continuation suggests that social network interventions could be more successful if delivered to cohorts of people who buy heroin together. [ABSTRACT FROM AUTHOR]

Background and aims Methods Results Conclusions Youth use of disposable vapes has increased markedly in the United Kingdom in recent years, yet little is known about the motivations, experiences and perceptions of young people themselves. This study aimed to explore young people’s experiences and use of disposable vapes.This was a qualitative study recruiting young people reporting regularly vaping disposables, collecting data via dyad guided, individual and group interviews. Data analysis was theoretically informed by the Social Ecological Model. Inductive and deductive coding approaches were used, with resolution of coded interpretations by consensus.Twenty‐nine young people aged 16–20 years participated in qualitative interviews. At the individual level, participants discussed how characteristics of disposable vapes were important to them—particularly price, accessibility and the attractive designs, colours, names and flavours. Young people frequently engaged in both vaping and tobacco smoking, seeing the behaviours as interchangeable dependent on context, and having inaccurate relative harm perceptions of vaping compared with smoking. Experimentation was widespread and many used vapes as a way of managing stress and anxiety. Vaping was positioned as a social behaviour, common among peers. Parental influence on vaping behaviour was minimal, although vaping initiation could be influenced by family vaping norms. Culturally, vaping was a widespread normalized behaviour. Young people were aware of media reports and potential harms, but were less aware of smoking related harms as a consequence.Disposable vapes appear to be attractive and accessible to young people in the United Kingdom. Vaping is normalized in this population, despite being seen as potentially damaging to health, and vaping and smoking are engaged in interchangeably. Underage sales of vapes are reportedly widespread. Strict regulation, such as banning products or increasing prices, may prompt UK youth to switch from vaping to smoking. [ABSTRACT FROM AUTHOR]

Background: During a quit attempt, cues from a smoker's environment are a major cause of brief smoking lapses, which increase the risk of relapse. Quit Sense is a theory-guided Just-In-Time Adaptive Intervention smartphone app, providing smokers with the means to learn about their environmental smoking cues and provides 'in the moment' support to help them manage these during a quit attempt. Objective: To undertake a feasibility randomised controlled trial to estimate key parameters to inform a definitive randomised controlled trial of Quit Sense. Design: A parallel, two-arm randomised controlled trial with a qualitative process evaluation and a 'Study Within A Trial' evaluating incentives on attrition. The research team were blind to allocation except for the study statistician, database developers and lead researcher. Participants were not blind to allocation. Setting: Online with recruitment, enrolment, randomisation and data collection (excluding manual telephone follow-up) automated through the study website. Participants: Smokers (323 screened, 297 eligible, 209 enrolled) recruited via online adverts on Google search, Facebook and Instagram. Interventions: Participants were allocated to 'usual care' arm (n = 105; text message referral to the National Health Service SmokeFree website) or 'usual care' plus Quit Sense (n = 104), via a text message invitation to install the Quit Sense app. Main outcome measures: Follow-up at 6 weeks and 6 months post enrolment was undertaken by automated text messages with an online questionnaire link and, for non-responders, by telephone. Definitive trial progression criteria were met if a priori thresholds were included in or lower than the 95% confidence interval of the estimate. Measures included health economic and outcome data completion rates (progression criterion #1 threshold: ≥ 70%), including biochemical validation rates (progression criterion #2 threshold: ≥ 70%), recruitment costs, app installation (progression criterion #3 threshold: ≥ 70%) and engagement rates (progression criterion #4 threshold: ≥ 60%), biochemically verified 6-month abstinence and hypothesised mechanisms of action and participant views of the app (qualitative). Results: Self-reported smoking outcome completion rates were 77% (95% confidence interval 71% to 82%) and health economic data (resource use and quality of life) 70% (95% CI 64% to 77%) at 6 months. Return rate of viable saliva samples for abstinence verification was 39% (95% CI 24% to 54%). The per-participant recruitment cost was £19.20, which included advert (£5.82) and running costs (£13.38). In the Quit Sense arm, 75% (95% CI 67% to 83%; 78/104) installed the app and, of these, 100% set a quit date within the app and 51% engaged with it for more than 1 week. The rate of 6-month biochemically verified sustained abstinence, which we anticipated would be used as a primary outcome in a future study, was 11.5% (12/104) in the Quit Sense arm and 2.9% (3/105) in the usual care arm (estimated effect size: adjusted odds ratio = 4.57, 95% CIs 1.23 to 16.94). There was no evidence of between-arm differences in hypothesised mechanisms of action. Three out of four progression criteria were met. The Study Within A Trial analysis found a £20 versus £10 incentive did not significantly increase follow-up rates though reduced the need for manual follow-up and increased response speed. The process evaluation identified several potential pathways to abstinence for Quit Sense, factors which led to disengagement with the app, and app improvement suggestions. Limitations: Biochemical validation rates were lower than anticipated and imbalanced between arms. COVID-19-related restrictions likely limited opportunities for Quit Sense to provide location tailored support. Conclusions: The trial design and procedures demonstrated feasibility and evidence was generated supporting the efficacy potential of Quit Sense. Future work: Progression to a definitive trial is warranted providing improved biochemical validation rates. Trial registration: This trial is registered as ISRCTN12326962. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme (NIHR award ref: 17/92/31) and is published in full in Public Health Research; Vol. 12, No. 4. See the NIHR Funding and Awards website for further award information. Plain language summary: Smokers often fail to quit because of urges to smoke triggered by their surroundings (e.g. being around smokers). We developed a smartphone app ('Quit Sense') which learns about an individual's surroundings and locations where they smoke. During a quit attempt, Quit Sense uses in-built sensors to identify when smokers are in those locations and sends 'in the moment' advice to help prevent them from smoking. We ran a feasibility study to help plan for a future large study to see if Quit Sense helps smokers to quit. This feasibility study was designed to tell us how many participants complete study measures; recruitment costs; how many participants install and use Quit Sense; and estimate whether Quit Sense may help smokers to stop and how it might do this. We recruited 209 smokers using online adverts on Google search, Facebook and Instagram, costing £19 per participant. Participants then had an equal chance of receiving a web link to the National Health Service SmokeFree website ('usual care group') or receive that same web link plus a link to the Quit Sense app ('Quit Sense group'). Three-quarters of the Quit Sense group installed the app on their phone and half of these used the app for more than 1 week. We followed up 77% of participants at 6 months to collect study data, though only 39% of quitters returned a saliva sample for abstinence verification. At 6 months, more people in the Quit Sense group had stopped smoking (12%) than the usual care group (3%). It was not clear how the app helped smokers to quit based on study measures, though interviews found that the process of training the app helped people quit through learning about what triggered their smoking behaviour. The findings support undertaking a large study to tell us whether Quit Sense really does help smokers to quit. Scientific summary: Background: Three million UK smokers attempt to stop smoking each year, but over 80% relapse. A lapse (any smoking) early on in a quit attempt is strongly associated with subsequent relapse back to smoking. Approximately half of all lapses are due to environmental smoking cues which can elicit cravings to smoke, such as the presence of cigarettes or being in a location which a smoker associates with smoking. Few interventions are effective at targeting cue-induced cravings. Smokers are more likely to prevent lapses if they better understand their smoking cues and use lapse prevention strategies, such as controlled deep breathing or avoiding other smokers, to combat these. This would likely help them avoid or cope with cue-induced cravings, but smokers typically lack skills in applying these effectively. If smokers trying to quit used effective lapse prevention strategies, this would very likely increase their chances of success. With patient and public involvement, we developed, refined and piloted a theory-guided Just-In-Time Adaptive Intervention smartphone app called Quit Sense that provides support to help smokers manage environmental cues to smoke as they arise. Pilot studies have shown that Quit Sense can provide 'in the moment' support to smokers, including lapse prevention strategies, and that users will engage with the app and find it acceptable. As Quit Sense is such a novel intervention, before a 'definitive' randomised controlled trial (RCT) can be conducted to test effectiveness, it is important to first undertake a RCT to establish whether such a study might be feasible. Objectives: The main objective was to conduct a feasibility RCT of Quit Sense to inform a definitive effectiveness trial, by estimating: completion rates for the anticipated primary outcome for a full trial (6-month self-reported abstinence with biochemical validation, based on the Russell standard); usual care arm cessation rate; cost of recruitment using online advertising; rates of app installation, use and acceptability; completion of smoking cessation-related resource use and quality-of-life data; intervention effect on anticipated primary outcome; intervention effect on hypothesised mechanisms of action of app at 6 weeks post enrolment; participant views of the app, as part of a qualitative process evaluation. Design: A parallel, two-arm RCT with an embedded qualitative interview process evaluation was undertaken. The evaluation included a preliminary cost-effectiveness analysis and a nested randomised study [Study Within A Trial (SWAT)] assessing the effects of different financial incentives on 6-month follow-up rates. Setting: The study setting was online and trial procedures were primarily automated. Participants: Participants were recruited via online adverts on Google search, Facebook and Instagram, screened for eligibility on the study website and enrolled if they were regular smokers, aged 16 years and above, were willing to make a quit attempt and owned an Android smartphone. Interventions: After completing the baseline questionnaire participants were then randomly allocated to a 'usual care' arm (text message referral to NHS SmokeFree website) or a 'usual care' plus Quit Sense arm, via a text message invitation to install the Quit Sense app. The Quit Sense app required users to set a quit date and then, leading up to their quit date, alongside other support features, invited them to report their smoking in real time and indicate the presence of key environmental smoking cues using a smoking behaviour logging tool. Once their quit date arrived, the app used location sensing and what it had learnt about the individual's smoking behaviour to tailor the timing and content of support messages when they spent time in self-identified high-risk locations. The support and advice aimed to help smokers learn about their smoking behaviour, prepare for their quit attempt and promoted the use of effective lapse prevention strategies during their quit attempt. Main outcomes measures: All participants were contacted at 6-week and 6-month follow-up. This was done initially by text message with an embedded link to the follow-up questionnaires or, if no response, manually by telephone. As part of a SWAT , participants underwent secondary randomisation to receive either a £10 or £20 incentive for completion of the 6-month questionnaire. Four progression criteria and corresponding thresholds for seeking to undertake a definitive trial were set a priori. Criteria were met if each threshold was included in or lower than the 95% confidence interval (CI) of the estimate. Trial measures included health economic and outcome data completion rates (progression criterion #1 threshold: ≥ 70%), including biochemical validation rates (progression criterion #2 threshold: ≥ 70%), recruitment costs, app installation (progression criterion #3 threshold: ≥ 70%) and engagement rates (progression criterion #4 threshold: ≥ 60%), the app's effect on biochemically verified abstinence at 6 months (anticipated primary outcome of definitive trial) and hypothesised mechanisms of action. The qualitative process evaluation sought to identify participants' views of the trial and the Quit Sense app. The protocol and statistical and health economics analysis plan were pre-specified and published (open access). Results: Of the people screened (N = 323), 299 (93%) were eligible and 209 (65% of screened) were consented and randomised either to the usual care arm (n = 105) or to the Quit Sense arm (n = 104). Completion of self-reported smoking questions was 71% (149/209; 95% CI 65% to 77%) and 77% (160/209; 95% CI 71% to 82%) at 6 weeks and 6 months, respectively, and at 6 months 70% provided both cessation support resource use data and EuroQol-5 Dimensions five level (EQ-5D-5L) data. Among those self-reporting abstinence at 6 months follow-up, 39% (95% CI 24% to 54%) returned a viable sample for biochemical verification, although return rates were higher in the Quit Sense than the usual care arm (52% vs. 19%). Online recruitment was completed successfully within the planned 6-week period, split into two campaigns, with a per-participant cost of £19.20, split into advert (£5.82) and running costs (£13.38). In the Quit Sense arm, 75% (95% CI 67% to 83%) of participants installed the app and, of these, 100% set a quit date within the app and 51% (95% CI 39% to 63%) engaged with it for more than 1 week. At final follow-up, the rate of 6-month biochemically verified sustained abstinence, which we anticipated would be used as a primary outcome in a future study, was 11.5% (12/104) in the Quit Sense arm and 2.9% (3/105) in the usual care arm (estimated effect size: adjusted odds ratio = 4.57, 95% CI 1.23 to 16.94). Similar effects were observed for biochemically verified secondary abstinence outcomes at 6-month follow-up and sensitivity analyses. Effect sizes were smaller and non-significant for self-report only abstinence and there was no evidence of a between-arm difference in abstinence at 6-week follow-up. Participants in the Quit Sense arm had higher rates of lapse avoidance in the first 2 weeks of their quit attempt or post enrolment compared to usual care though this was not statistically significant (29.6% vs. 19.2%; p = 0.14). There was no evidence of between-arm differences in hypothesised mechanisms of action of the app, including the mean frequency of lapse prevention strategy use [mean difference (MD) −0.07; p = 0.46], smoking cessation self-efficacy (MD 0.18; p = 0.39), strength (p = 0.23) and frequency (p = 0.83) of urges to smoke or the Wisconsin Inventory of Smoking Dependence Motives subscales of automaticity (p = 0.51) and associative processes (p = 0.58). The qualitative process evaluation identified several potential pathways to abstinence among Quit Sense arm participants. Interviewed participants reported finding the insights gained from engaging with the smoking behaviour learning tool before their quit attempt started particularly valuable. They reported that this reinforced their commitment to quit, helped them better understand the drivers of their smoking behaviour and challenged the need for them to smoke. Some also reported finding regular and location-specific support messages encouraging and motivational and that this reinforced the goal of quitting and made them feel equipped when they spent time in locations that they used to smoke in. Participants highlighted several factors which led to disengagement with the app, including relapse, no longer feeling they needed support, not finding the app met their needs and technical issues. Participants also provided suggestions for app improvement relating to logging smoking, adding gamification elements and improved support triggering. Interviewed participants from both arms highlighted how COVID-19 measures had affected their smoking behaviour and restricted the time they spent outside of their home, which would have had implications for location-based cessation support. In terms of the main cost-drivers, e-cigarettes/vaporisers and nicotine replacement therapy accounted for more than 70% of the total non-intervention costs. The total intervention cost (recruitment advertising and maintaining the Quit Sense app) was estimated to be £28.51 per participant. In both groups, the mean EQ-5D-5L score at both 6-week and 6-month follow-up was lower than that at baseline. A preliminary cost-effectiveness analysis using EQ-5D-5L score as the outcome estimated that the intervention was both more costly and less effective, compared to standard care, though there was no significant difference in cost or effect between the two groups. The SWAT analysis indicated that increasing the incentive for completing follow-up from £10 to £20 did not increase response rates at 6 months (74% vs. 79%; p = 0.36) but did reduce the proportion of participants requiring manual follow-up (62% vs. 46%; p = 0.018) and the median response time to responding (15 days vs. 7 days; p = 0.016). Conclusions: The Quit Sense RCT design and procedures demonstrated feasibility and generated preliminary efficacy evidence of the app on abstinence at 6-month follow-up, although how the app may achieve this is not clear. Three out of the four pre-specified feasibility progression criteria for moving to a definitive trial – completion rate of self-reported abstinence at final follow-up and the rate of Quit Sense installation and engagement – were met. The return of saliva samples among quitters was lower than anticipated, though this can likely be increased in a future trial through increased incentivisation and enhanced procedures. Progression to a definitive trial is warranted. Trial registration: This trial is registered as ISRCTN12326962. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme (NIHR award ref: 17/92/31) and is published in full in Public Health Research; Vol. 12, No. 4. See the NIHR Funding and Awards website for further award information. [ABSTRACT FROM AUTHOR]

Introduction: This article reports on a Department of Health UK funded project to implement consensus substance misuse teaching in undergraduate curricula in medical schools in England. The aim was to better equip practising doctors of the future to deal with substance misuse issues. Method: A project coordinator worked with local curriculum coordinators and academic champions in 19 participating medical schools. Substance misuse teaching was mapped using a toolkit outlining national learning outcomes as specified in Tomorrow's Doctors. This enabled a detailed overview of current substance misuse teaching, and identified gaps. Results: Common areas for all schools requiring further development included iatrogenic addiction, professionalism, fitness to practice, attitudes and issues relating to stigma, child-related issues, and social consequences of substance misuse. Students reported lacking confidence in performing key skills, including substance use history taking, discussing options for patients wishing to reduce or stop use, and recommending appropriate help organisations. This led to medical schools developing new or enhanced learning outcomes and teaching materials. Discussion: The project has, through national guidance and changes, enhanced the training and education of student doctors, and established a basis for substance misuse teaching that has already influenced the learning of our future doctors.

Summary: Background: Alcohol use is the most important factor in determining the prognosis of patients with alcohol‐related cirrhosis and alcohol‐associated hepatitis. Aim: To conduct a systematic review of interventions for alcohol use disorder specific to patients with cirrhosis or alcohol‐associated hepatitis. Methods: We searched five databases between inception and November 2022. The primary outcomes were abstinence, hepatic decompensation and mortality. We included randomised and non‐randomised studies. Risk of bias was assessed using validated tools. Where possible, meta‐analysis was performed. Results: Twenty‐three studies met the inclusion criteria including six randomised trials and 17 non‐randomised studies of interventions. These included 104,298 patients with a mean/median age range from 44 to 65, of whom 75% were male. Interventions included psychological therapy, pharmacological therapies, specialist clinics, patient education and low alcohol drinks. Baclofen was the only intervention to demonstrate a statistically significant impact on the primary outcomes in a randomised trial (abstinence OR: 6.3, 95% CI: 2.4–16.1). Three non‐randomised studies reported reductions in episodes of hepatic decompensation that were significant in multivariate models. This was in response to psychological therapy, use of any pharmacotherapy, and use of any treatment. A meta‐analysis of non‐randomised studies that examined the impact of psychological therapies revealed statistically non‐significant improvements in abstinence (4 studies, OR: 1.87, 95% CI: 0.38–9.23) and mortality (4 studies, OR: 0.47, 95% CI: 0.12–1.77). Conclusions: Baclofen is the only intervention with randomised trial evidence for significant benefit in patients with cirrhosis. Non‐randomised studies also point to non‐pharmaceutical interventions possibly improving clinical outcomes. [ABSTRACT FROM AUTHOR]

Introduction Pod Vaping Devices (PVD) such as JUUL have become extremely popular in the United States although their uptake and use in the United Kingdom remain lower. A key difference between the United States and the United Kingdom is the nicotine strength legally permitted, typically 59 mg/mL in the United States but capped at 20 mg/mL in the United Kingdom and European Union. This may limit the ability of EU vaping devices to deliver satisfactory nicotine levels. The primary aim was to compare the EU- (18 mg/mL nicotine strength) with the U.S.-JUUL (59 mg/mL) on daily smokers' subjective experiences, craving relief, and blood nicotine levels. Aims and Methods Double-blind, counterbalanced within-participants design with two conditions: 18 mg/mL versus 59 mg/mL. On two separate occasions, UK smokers (N =19, 10 males, 9 females) vaped ad libitum for 60 mins and provided blood samples at baseline 5, 15, 30, and 60 min. Subjective effects (incl. satisfaction) were measured at 10 and 60 min and, craving and withdrawal symptoms (WS) at baseline, 10 and 60 min. Results Satisfaction did not differ between conditions. There was a significant interaction between Time and Nicotine concentration for Nicotine Hit (p =.045). Mean self-report of Nicotine Hit increased under the use of the 59 mg/mL from 10 to 60 min and decreased under the 18 mg/mL. Participants reported higher Throat Hits following use of the 59 mg/mL (p =.017). There were no differences in other subjective effects including craving, WS relief (p s >.05). Liquid consumption was doubled under the 18 versus the 59 mg/mL (p =.001) and nicotine boost was significantly higher in the 59 mg/mL at all time-points (p ≤.001). Conclusions The results did not support our hypotheses that satisfaction, craving, and withdrawal reduction would be higher with the 59 mg/mL JUUL. This could be because of the doubling of liquid consumption in the 18 mg/mL. Whether satisfaction and craving relief persist over the longer-term outside of the lab remains to be determined. Implications In a 60-min ad-lib vaping session, the EU-JUUL was found to produce comparable satisfaction, craving- and withdrawal relief as the U.S.-JUUL in this sample of UK smokers. These findings could suggest that the higher nicotine concentrations available in PVDs in the United States are not necessary for providing satisfaction and improving craving and WS. However, this was at the expense of a considerable increase in liquid consumption indicative of compensatory puffing. [ABSTRACT FROM AUTHOR]

Aims: To estimate associations between e‐cigarette flavour and smoking cessation and study product use at 6 months or longer. Methods: Secondary analysis of data from a living systematic review, with meta‐analyses and narrative synthesis, incorporating data up to January 2022. Included studies provided people who smoked combustible cigarettes with nicotine e‐cigarettes for the purpose of smoking cessation compared with no treatment or other stop smoking interventions. Measurements included smoking cessation and study product use at 6 months or longer reported as risk ratios (RR) with 95% confidence intervals (CI); and flavour use at any time‐points. Results: We included 16 studies (n = 10 336); 14 contributed to subgroup analyses and 10 provided participants with a choice of e‐cigarette flavour. We judged nine, five and two studies at high, low and unclear risk of bias, respectively. Subgroup analyses showed no clear associations between flavour and cessation or product use. In all but one analysis, tests for subgroup differences resulted in I2 values between 0 and 35%. In the comparison between nicotine e‐cigarettes and nicotine replacement therapy (NRT) (I2 = 65.2% for subgroup differences), studies offering tobacco flavour e‐cigarettes showed evidence of a greater proportion of participants still using at 6 months or longer (RR = 3.81; 95% CI = 1.45–10.05; n = 1181; I2 = 84%), whereas there was little evidence for greater 6‐month use when studies offered a choice of flavours (RR = 1.44; 95% CI = 0.80–2.56; n = 454; I2 = 82%). However, substantial statistical heterogeneity within subgroups makes interpretation of this result unclear. In the 10 studies where participants had a choice of flavours, and this was tracked over time, some switching between flavours occurred, but there were no clear patterns in flavour preferences. Conclusions: There does not appear to be a clear association between e‐cigarette flavours and smoking cessation or longer‐term e‐cigarette use, possibly due to a paucity of data. There is evidence that people using e‐cigarettes to quit smoking switch between e‐cigarette flavours. [ABSTRACT FROM AUTHOR]

Introduction E-Cigarette voucher schemes have been piloted across the UK to support populations to quit smoking. This short report evaluates a scheme that targets vulnerable and disadvantaged smokers who had failed to quit smoking by other means. Methods Descriptive summary evaluation of service data on smoking outcomes and qualitative data from selected participants, as "key-informants" (n = 4) and key stakeholders (stop smoking staff, vape shop staff, and general practitioners [GPs]). Results In total, 668 participants were referred to the scheme, and 340 participants redeemed a voucher. By intention to treat analysis (ITT) 143/668 (21%) were recorded as quit smoking at 4 weeks. At 12 weeks, 7.5% of participants had quit, by ITT. Overall, the pilot project was well received by clients as it offered an affordable route into vaping for smoking cessation. GPs supported the scheme and appreciated being able to offer an alternative to entrenched smokers. Conclusions The scheme shows promise in supporting entrenched smokers to quit smoking. The offer of similar voucher schemes across the UK suggests the potential to reduce overall smoking prevalence and associated morbidity and mortality. Implications Working with GPs in a deprived area, it was possible to set-up a vape shop voucher scheme for smoking cessation. Patients with comorbidities who had tried and failed to quit smoking previously were referred to receive a vape shop voucher to be redeemed for an initial starter kit, alongside support from the stop smoking service. This innovative scheme enabled 42% of entrenched smokers who redeemed a voucher to successfully quit smoking within 4 weeks. [ABSTRACT FROM AUTHOR]

Background: Many individuals with first-episode psychosis experience severe and persistent social disability despite receiving specialist early intervention. The SUPEREDEN3 trial assessed whether augmenting early intervention in psychosis services with Social Recovery Therapy (SRT) would lead to better social recovery. Aims: A qualitative process evaluation was conducted to explore implementation and mechanisms of SRT impact from the perspective of SUPEREDEN3 participants. Method: A subsample of SUPEREDEN3 trial participants (n = 19) took part in semi-structured interviews, which were transcribed verbatim and analysed thematically. Trial participants were early intervention service users aged 16–35 years with severe and persistent social disability. Both SRT plus early intervention and early intervention alone arm participants were interviewed to facilitate better understanding of the context in which SRT was delivered and to aid identification of mechanisms specific to SRT. Results: The six themes identified were used to generate an explanatory model of SRT's enhancement of social recovery. Participant experiences highlight the importance of the therapist cultivating increased self-understanding and assertively encouraging clients to face feared situations in a way that is perceived as supportive, while managing ongoing symptoms. The sense of achievement generated by reaching targets linked to personally meaningful goals promotes increased self-agency, and generates hope and optimism. Conclusions: The findings suggest potentially important processes through which social recovery was enhanced in this trial, which will be valuable in ensuring the benefits observed can be replicated. Participant accounts provide hope that, with the right support, even clients who have persistent symptoms and the most severe disability can make a good social recovery. [ABSTRACT FROM AUTHOR]

Background and aims: We aimed to create a basic set of definitions and relationships for identity‐related constructs, as part of the Addiction Ontology and E‐Cigarette Ontology projects, that could be used by researchers with diverse theoretical positions and so facilitate evidence synthesis and interoperability. Methods: We reviewed the use of identity‐related constructs in psychological and social sciences and how these have been applied to addiction with a focus on nicotine and tobacco research. We, then, used an iterative process of adaptation and review to arrive at a basic set of identity‐related classes with labels, definitions and relationships that could provide a common framework for research. Results: We propose that 'identity' be used to refer to 'a cognitive representation by a person or group of themselves', with 'self‐identity' referring to an individual's identity and 'group identity' referring to an identity held by a social group. Identities can then be classified at any level of granularity based on the content of the representations (e.g. 'tobacco smoker identity', 'cigarette smoker identity' and 'vaper identity'). We propose distinguishing identity from 'self‐appraisal' to capture the distinction between the representation of oneself (e.g. as an 'ex‐smoker') and (i) the importance and (ii) the positive or negative evaluation that we attach to what is represented. We label an identity that is appraised as enduring as a 'core identity', related to 'strong identity' because of the appraisal as important. Identities that are appraised positively or negatively involve 'positive self‐appraisal' and 'negative self‐appraisal' respectively. This allows us to create 'logically defined classes' of identity by combining them (e.g. 'positive core cigarette smoker identity' to refer to a cigarette smoker self‐identity that is both positive and important). We refer to the totality of self‐identities of a person as a 'composite self‐identity'. Conclusions: An ontology of identity constructs may assist in improving clarity when discussing theories and evidence relating to this construct in addiction research. [ABSTRACT FROM AUTHOR]

INTRODUCTION: Biochemical verification of smoking status prior to recruitment into smoking cessation trials is widely used to confirm smoking status, most commonly using exhaled carbon monoxide (CO). There is variation in the level of CO used as a biochemical inclusion criterion, and thus the possibility for people reporting to be current smokers to be incorrectly excluded from trials. METHODS: As part of the Cessation of Smoking Trial in the Emergency Department, people attending the Emergency Department (ED) who reported being current daily smokers underwent CO testing to confirm eligibility. Elective semi-structured interviews were undertaken with the researchers who recruited participants. As part of the interviews, researchers were asked their views and experiences with CO testing. RESULTS: Of the 1320 participants who reported being current daily smokers and underwent CO testing, 300 (22.7%) blew a CO reading of 7 ppm or less and were excluded from taking part. Possible explanations offered by researchers for participants blowing low CO readings were (1) long wait times in the ED, therefore a long period having elapsed since people had last smoked and (2) patients having reduced smoking for the period before the ED attendance due to ill health. CONCLUSIONS: Biochemical verification has the potential to improve internal validity of smoking cessation for inclusion in trials, but at the cost of reduced generalisability through exclusion of participants who would receive the intervention if it were implemented in practice. We would recommend researchers carefully consider whether it is appropriate and necessary to include biochemical verification as an inclusion criterion. [ABSTRACT FROM AUTHOR]

Background and aims: Ontologies are ways of representing information that improve clarity and the ability to connect different data sources. This paper proposes an initial version of an ontology of tobacco, nicotine and vaping products with the aim of reducing ambiguity and confusion in the field. Methods: Terms related to tobacco, nicotine and vaping products were identified in the research literature and their usage characterised. Basic Formal Ontology was used as a unifying upper‐level ontology to describe the domain, and classes with definitions and labels were developed linking them to this ontology. Labels, definitions and properties were reviewed and revised in an iterative manner until a coherent set of classes was agreed by the authors. Results: Overlapping, but distinct classes were developed: 'tobacco‐containing product', 'nicotine‐containing product' and 'vaping device'. Subclasses of tobacco‐containing products are 'combustible tobacco‐containing product', 'heated tobacco product' and 'smokeless tobacco‐containing product'. Subclasses of combustible tobacco‐containing product include 'cigar', 'cigarillo', 'bidi' and 'cigarette' with further subclasses including 'manufactured cigarette'. Manufactured cigarettes have properties that include 'machine‐smoked nicotine yield' and 'machine‐smoked tar yield'. Subclasses of smokeless tobacco product include 'nasal snuff', 'chewing tobacco product', and 'oral snuff' with its subclass 'snus'. Subclasses of nicotine‐containing product include 'nicotine lozenge' and 'nicotine transdermal patch'. Subclasses of vaping device included 'electronic vaping device' with a further subclass, 'e‐cigarette'. E‐cigarettes have evolved with a complex range of properties including atomiser resistance, battery power, properties of consumables including e‐liquid nicotine concentration and flavourings, and the ontology characterises classes of product accordingly. Conclusions: Use of an ontology of tobacco, nicotine and vaping products should help reduce ambiguity and confusion in tobacco control research and practice. [ABSTRACT FROM AUTHOR]

Purpose: During the COVID‐19 UK first national lockdown (March–July 2020) enactment of healthy behaviours was fundamentally changed due to social restrictions. This study sought to understand perspectives on health behaviour change, as part of a wider study tracking reported health behaviour change over time. Methods: A purposive sample was selected. N = 40 qualitative interviews were conducted remotely (phone/video) from participants across England and Wales, and transcribed verbatim. Descriptive case studies were shared at regular analysis meetings. Inductive reflexive thematic coding was undertaken and coding was discussed using a team approach to agreeing analytical codes. A multiple lens theoretical perspective was adopted to illuminate the perceived influences and restrictions on participants' reports of health behaviour change. Results: There was a clear progressive narrative for all participants, through initial responses and reactions to the pandemic, framed as 'disruption', then, as lockdown was acclimatized to, evidence of 'adaptation'. Adaptation was seen in terms of modification, substitution, adoption, discontinuation/cessation, stultification, maintenance and recalibration of health behaviours. An illustrative case study exemplifies the narrative encompassing these features and demonstrating the complex non‐linear interactions between context and enacted health behaviours. Conclusions: Individuals responded to pandemic‐related social restrictions in complex ways. Those in contexts with existing social assets, community links and established patterns of healthy behaviours were able to respond positively, adapting by modifying behaviour and using technology to engage in healthy behaviours in new and innovative ways. For those in more vulnerable contexts, enacting (negative) health behaviour change was an expression of frustration at the limitations imposed by social restrictions. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]