up a fag . Whether they ’ re in a hostel or they ’ ve been put in the Travelodge it causes trouble , so in a very pragmatic way it was a case of , “ Why don ’ t we try some of these new-fangled vape things ?”’
The Pan-London Homeless Hotel Drug and Alcohol Service ( HDAS ) recognised the importance of harm reduction to address the risks associated with sharing cigarettes during the pandemic – as well as minimising fire risks and reducing the likelihood of evictions – and supplied more than 3,000 vape starter kits , 20,000 refill pods and nicotine replacement products like gum or oral spray . It then produced leaflets signposting people to smoking cessation support and provided education and training for hotel and healthcare staff , and soon found that hotels were regularly requesting further tobacco harm reduction supplies .
‘ If you wanted proof of concept at scale , that was it ,’ says MacKintosh . ‘ Very quickly you could see people at frontline level accepting that this seems to work . There were all sorts of things going on around it – incentivisation , the engagement stuff – but it happened really quickly , and until very recently there was no system of guidance to support a lot of this work , and real issues about who was funding it and where you sourced the kit from .’
Models over the pandemic period ranged from ‘ begging and borrowing from people who ran vape stores through to some areas where the director of public health said , “ Here ’ s the money , go out and do it ”,’ he says . Although the impetus was largely lost afterwards , it did offer commissioners and service providers ‘ valuable reallife examples of what could be achieved for this population over the longer term ,’ says the GSTHR paper . The National Institute for Health and Care Research is now funding work with London Southbank University , UCL and homelessness services that will trial the provision of vape starter kits and provide direct comparisons with smoking cessation care pathways .
ELEPHANT IN THE ROOM Smoking , however , remains something of an elephant in the room for drug and alcohol services as well . According to the latest OHID figures , around half of people in treatment are smokers , but less than 5 per cent have even been offered a smoking cessation referral ( www . drinkanddrugsnews . com / ten-per-cent-increase-in-peopleentering-treatment-for-cocaine ).
‘ There is a massive mismatch ,’ says MacKintosh . ‘ Think about dual diagnosis . We ’ ve been banging on about this for a quarter of a century , but often it ’ s still , “ Sorry , you need to go up the road for that ”. We like dealing with one problem at a time , although that isn ’ t how they tend to manifest in individuals . Helping people around their smoking is actually quite simple , but how many services even know where their local smoking cessation services are ?’
One issue is that many service staff are still smokers themselves .
‘ At one time smoking was a bit of an engagement tool , and that wasn ’ t unique to drug services ,’ he says . ‘ Probation workers , mental health workers , these are jobs where you still see higher than average-population smoking rates . If you ’ re trying to engage with a guy on a cardboard box in a shop doorway then a cigarette isn ’ t a bad way of doing it .’
FUNDING CHALLENGE An obvious challenge is that drug services are inevitably focused on their core business , he says . ‘ I think it ’ s improving , but until relatively recently the idea of smoking hadn ’ t crept into the consciousness much . And who was going to fund it ? It ’ s not coming out of your pot of money for drug and alcohol work .
‘ We ’ re hopefully in a position now where that could change quite rapidly . We know that drug services are an important step in keeping people alive – there ’ s that big protective factor just by someone being engaged – but the reality for most people is the drug that ’ s likely to kill them probably isn ’ t heroin or crack cocaine . Fifty per cent of our heroin users will not die from heroin , but 50 per cent of smokers will die because they smoke . So whether it ’ s smoking cessation or helping people find an alternative , there ’ s a huge potential win there for the individuals and services .’
It ’ s also something that can be done relatively cheaply with a significant impact , he points out . ‘ So I hope we ’ re moving towards a situation where people are thinking more about it . There ’ s going to be central guidance from OHID about how areas can commission and buy the stuff , which is going to be helpful , and the money is being put money out there . So I ’ m hopeful we ’ ll see this going from projects dealing with dozens or hundreds of people to thousands . In a couple of years we could have evidence at scale ,
‘ I ’ m hopeful ... In a couple of years we could have evidence at scale , which could fundamentally change the argument .’
DAVID MACKINTOSH
which could fundamentally change the argument .’ One scheme in Yorkshire includes external monitoring of people ’ s health from the outset , and ‘ we know that some of the improvements in people ’ s lungs are really , really quick ’, he states . ‘ I think it will be a very powerful argument for why people should be doing this .’
A key aspect of harm reduction has always been how pragmatic it is , he says . ‘ It ’ s often a lot cheaper than any other intervention , and you can do it at scale – the moving people on comes later . This really is something services should be looking at in terms of long-term benefits to their clients , and potentially their staff . It ’ s an easy win , and it really shouldn ’ t be controversial . You ’ re helping adults move from something that 50 per cent of them will die from . You put in all this investment to save people from the wicked world of drugs , so why let cigarettes carry them off ?’ DDN
Tobacco harm reduction and people experiencing homelessness – a UK perspective at https :// gsthr . org / resources / briefing-papers / tobaccoharm-reduction-and-people-experiencinghomelessness-a-uk-perspective / gfn . events
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