Development of a co-designed tobacco harm reduction toolkit for use within the homeless sector

Smoking rates are exceptionally high amongst people who are homeless which causes severe health and financial problems. Homeless services have a long history of using harm reduction methods to support service users to make safer choices (e.g. offering clean needles for people who inject drugs). Tobacco harm reduction (THR) refers to a number of approaches designed to reduce the harms of smoking by providing nicotine in a safer (non-smoked) way e.g. through e-cigarettes or nicotine replacement therapy (NRT). However, this approach is not well understood or integrated within the homeless sector and staff do not feel confident to support their clients to stop smoking. This study aims to create a 'THR toolkit' - a set of resources e.g. smoking and vaping policy templates, conversation guides and treatment information leaflets, which will be co-designed with people who use and work in homeless services. This will be the first attempt at this type of project in the UK and will generate an opportunity for those from a range of backgrounds, not well connected to each other, to develop this resource together.

We have been working on THR projects with people who experience homelessness for several years. We ran the first survey of smoking behaviour and practices of people who are homeless in Great Britain; we found desire to quit was high but opportunities were scarce. In another study we found that people accessing homeless services who smoked, would accept and use a free e-cigarette to try and quit smoking, but knowledge of THR among homeless centre staff was poor. The need to use person centred, non-stigmatising language was also highlighted. At the moment we are running a survey of smoke free and vaping policies across homeless centres in the UK, funded by Cancer Research UK. An emerging key finding is that homeless charities wish to develop an evidenced based and service user focused approach to THR. To date, no resources exist aimed at this group's unique health needs.

Working with people with lived experience of homelessness and those who work in the homeless sector, we propose to develop a THR toolkit which can be used as a resource guide. The project has several stages: Stage one: We will produce a short film about smoking and THR using video footage we already have from our previous projects. This will be used as a starting point in the focus groups to prompt discussion. Stage two: We will run three discussion groups, each with 6-10 service users (people who have experience of being homeless) and three, each with 6-10 staff from homeless centres. At the start of each group, the short film will be shown and participants will be asked to discuss their responses, paying particular attention to 'touchpoints' i.e. emotionally charged or key moments in their smoking histories/provision of THR support. We will also ask for views around several themes we are interested in: 1) understanding and experience of THR; 2) what good THR would look and feel like; 3) what an effective and compassionate homeless service THR policy would look and feel like; 4) what person-centred terms and language are preferred. Stage 3: We will ask some service users (~4) and staff (~4) who participated in the discussion groups to join a co-design group along with representatives from PHE, Action on Smoking and Health (ASH) (~2) and the research team. The team will meet on 2-3 occasions to design the THR toolkit together. An artist scribe will visually capture each group event. Materials for the THR toolkit will be developed by consensus methods (e.g., voting) and the agreed resources will be produced by a design company. Stage 4: The draft THR toolkit will be tested in one homeless service and interviews will be carried out with 5 service users and 5 staff, one month after its introduction. The THR toolkit and feedback will be used to shape a future study to explore how well it works to support people to reduce harm from tobacco.

Smoking rates are high amongst people who are homeless yet those working with this population do not feel competent offering tobacco harm reduction (THR) support. This study aims to address this by co-designing, with people who use or work in homeless services, a THR toolkit (to include policy templates, conversation guides, treatment information resources) for the homeless sector. We will utilise elements of experience-based co-design (EBCD) methodology: Stage one: In keeping with an accelerated EBCD approach, we will produce a short film about smoking using existing footage from our previous projects. Stage two: We will facilitate 6 focus groups (each with 6-10 participants); 3 with service users with past or current lived experience of homelessness and 3 with homeless centre staff. Participants will be encouraged to discuss their responses to the film, paying attention to 'touchpoints' - emotionally charged or key moments in their smoking histories/provision of THR support. We will also elicit and thematically analyse views around several pre-defined themes: 1) understanding and experience of THR; 2) what good THR support would look and feel like; 3) what an effective and compassionate homeless service THR policy would look and feel like; 4) preferred person-centred terms and language. Stage 3: Four service users and four staff who participated in the focus groups will be recruited to join a co-design group with representatives from PHE, Action on Smoking and Health and the research team. The group will meet on 2-3 occasions and an artist scribe will visually capture each event. Materials will be developed via consensus and a design company will produce agreed resources. Stage 4: The THR toolkit will be implemented in one homeless centre. Interviews will be conducted with 5 service users and 5 staff one month after introduction. The THR toolkit and implementation feedback will shape a future main study to evaluate its efficacy.