Exploring the uptake and use of electronic cigarettes provided to smokers accessing homeless centres: a four-centre cluster feasibility trial

[Bronchial diseases and heroin use. A systematic review]

INTRODUCTION

Heroin use can cause respiratory complications including asthma, chronic obstructive pulmonary disease (COPD) and bronchiectasis (BD).

OBJECTIVES

A general review of the literature presenting the data on the relationships between heroin consumption and bronchial complications, while underlining the difficulties of diagnosis and management.

DOCUMENTARY SOURCES

Medline, 1980-2022, keywords "asthma" or "bronchospasm" or "COPD" or "bronchiectasis" and "heroin" or "opiate" or "opiates", with limits pertaining to "Title/Abstract". Concerning asthma, 26 studies were included, as were 16 for COPD and 5 for BD.

RESULTS

Asthma and COPD are more prevalent among heroin addicts, who are less compliant than other patients with their treatment. The authors found a positive association between frequency of asthma exacerbations, admission to intensive care and heroin inhalation. Late diagnosis of COPD worsens the course of the disease; emphysema and BD are poor prognostic factors.

CONCLUSION

Bronchial diseases in heroin users can be identified by means of respiratory function exploration and chest CT scans. These tests should be performed frequently in view of optimizing their care, which includes their weaning themselves from addictive substances.

Burden and treatment of chronic obstructive pulmonary disease among people using illicit opioids: matched cohort study in England

Objective

To understand the burden of chronic obstructive pulmonary disease among people who use illicit opioids such as heroin, and evaluate inequalities in treatment.

Design

Cohort study.

Setting

Patients registered at primary care practices in England.

Participants

106 789 patients in the Clinical Practice Research Datalink with illicit opioid use recorded between 2001 and 2018, and a subcohort of 3903 patients with a diagnosis of chronic obstructive pulmonary disease. For both cohorts, the study sampled a comparison group with no history of illicit opioids that was matched by age, sex, and general practice.

Main outcome measures

In the base cohort: diagnosis of chronic obstructive pulmonary disease and death due to the disease. In the subcohort: five treatments (influenza vaccine, pneumococcal vaccine, pulmonary rehabilitation, bronchodilators or corticosteroids, and smoking cessation support) and exacerbations requiring hospital admission.

Results

680 of 106 789 participants died due to chronic obstructive pulmonary disease, representing 5.1% of all cause deaths. Illicit opioid use was associated with 14.59 times (95% confidence interval 12.28 to 17.33) the risk of death related to chronic obstructive pulmonary disease, and 5.89 times (5.62 to 6.18) the risk of a diagnosis of the disease. Among patients with a new diagnosis, comorbid illicit opioid use was associated with current smoking, underweight, worse lung function, and more severe breathlessness. After adjusting for these differences, illicit opioids were associated with 1.96 times (1.82 to 2.12) times the risk of exacerbations requiring hospital admission, but not associated with a substantially different probability of the five treatments.

Conclusions

Death due to chronic obstructive pulmonary disease is about 15 times more common among people who use illicit opioids than the general population. This inequality does not appear to be explained by differences in treatment, but late diagnosis of the disease among people who use illicit opioids might contribute.

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 cross-sectional survey of smoking and cessation support policies in a sample of homeless services in the United Kingdom

BACKGROUND

Smoking is extremely common amongst adults experiencing homelessness. To date, there is no nationally representative data on how tobacco dependence is treated and if and how smoking cessation is supported across the homeless sector. The aim of this study was to document smoking and e-cigarette policies of UK homeless services and identify areas of good practice and where improvements could be made.

METHODS

A cross-sectional survey with homeless centre staff was conducted between June 2020-December 2020 totalling 99 homeless centres. Quotas were stratified based on population and service type across Scotland, Northern Ireland, Wales, and England. Interviews were conducted over the phone or online in a minority of cases. Survey questions were themed to assess, i) onsite smoking and e-cigarette (vaping) policies ii) screening and recording of smoking status, iii) cessation training and resources available to staff, iv) cessation support for service users.

RESULTS

92% accounted for smoking within their policies in some form (stand-alone policy (56%) or embedded within another health and safety policy (36%)). 84% allowed smoking in at least some (indoor and outdoor) areas. In areas where smoking was not allowed, vaping was also disallowed in 96% of cases. Staff smoking rates were 23% and 62% of centres reported staff smoked with service users. Just over half (52%) reported screening and recording smoking status and 58% made referrals to Stop Smoking Services (SSS), although established links with SSS were low (12%) and most centres did not provide staff training on supporting smoking cessation. Areas of good practice included regular offers of smoking cessation support embedded in routine health reviews or visits from SSS and offering tangible harm reduction support. Areas for improvement include staff training, staff smoking with service users and skipping routine screening questions around smoking.

CONCLUSIONS

Smoking is accounted for across different policy types and restricted in some areas within most settings. Smoking cessation support is not routinely offered across the sector and there is little involvement with the SSS.