#78. The Complexity of Smoking in Mental Health And Addiction Services - Dr. Zoe Swithenbank

Dr. Zoe Swithenbank, a senior research associate at Lancaster University, delves into her work at the intersection of mental health, addiction, and public health. Zoe's research focuses on treatment pathways for individuals with alcohol use and mental health challenges. She highlights the structural barriers in accessing care and the need for long-term support in smoking cessation, which is often not included in core treatment services. Zoe advocates for a more integrated approach to addiction and mental health services, emphasizing the role of lived experience in shaping effective interventions. Her work also explores the social norms around smoking within recovery communities and the importance of empowering individuals to make choices that support their recovery journey.

00:00 Introducing Dr. Zoe Swithenbank
02:18 The Role of Smoking Cessation in Recovery
08:55 Barriers in Addiction and Mental Health Care
11:55 The Intersection of Mental Health and Addiction
25:19 Qualitative Research in Addiction Studies
33:57 Navigating Diverse Perspectives in Qualitative Research
37:00 Balancing Scientific Rigor with Human Experience
40:10 Understanding Service Provider Perspectives
42:52 Challenging Stigma in Addiction and Mental Health
49:40 Rethinking Smoking Cessation Outcomes
50:42 Long-Term Studies in Substance Use Treatment
54:30 Future Directions in Research and Service Delivery

Chapters

• 0:00 Introducing Dr. Zoe Swithenbank
• 2:18 The Role of Smoking Cessation in Recovery
• 8:55 Barriers in Addiction and Mental Health Care
• 11:55 The Intersection of Mental Health and Addiction
• 25:19 Qualitative Research in Addiction Studies
• 32:57 Navigating Diverse Perspectives in Qualitative Research
• 37:00 Balancing Scientific Rigor with Human Experience
• 40:10 Understanding Service Provider Perspectives
• 42:52 Challenging Stigma in Addiction and Mental Health
• 49:42 Rethinking Smoking Cessation Outcomes
• 50:42 Long-Term Studies in Substance Use Treatment
• 54:30 Future Directions in Research and Service Delivery

Transcript

0:03

Hello, hello, hello. And today on the Smooth Brain Society, we're joined by Zoe Swithenbank, a senior research associate in health research at Lancaster University. Zoe works at the intersection of mental health, addiction and public health, looking closely at how people with complex needs navigate care and how services can... support them. Her research spans treatment pathways for people with both alcohol use and mental health challenges. The realities of supporting behaviour change like smoking cessation and the structural barriers that shape access to care. Before academia, she worked directly in mental health addiction and homelessness settings, experiences that deeply informs her research perspective. Beyond the research, Zoe contributes to the Addiction Audio podcast. and volunteers with the National Mental Health Charity, helping bridge conversations between lived experiences, frontline practices and evidence. Today we'll talk about her journey, her approach to qualitative insight and what meaningful change could look like in mental health and addiction care. Welcome Zoe. Thanks for having me. we always start off with is almost what is your origin story? What got you to the place where you are today in the research you do and all the PPI? I ended up in research because I initially ended up in addiction treatment myself and in mental health treatment about 10 years ago, I think just over and got very involved in that world, all those recovery focused stuff so I ended up volunteering in both services and then working in substance use services and I wanted to do more. I felt like I was helping people on the ground. I had lot of questions around the policy side and the organisational aspects. So I found a masters that was close enough to me to commute, which was in public health with an addictions focus. So I did that, uh loved it and that kind of everything went on from there basically. So that was the foundation for my PhD. I built on that. So yeah, that's why for me, lived experience is really important. Now, awesome. So then you said PhD. What was sort of your PhD in? uh Did it link? Does it link quite well to sort of your experiences? Or was it like how some of us do PhDs, which is we decide that, OK, this is the best sort of idea we can find because somebody else is doing it and jumping on board. I was really lucky, so the Society for the Study of Addiction funded my PhD. So it was, yeah, so I wrote it, I wrote the proposal and everything and it was based on my experiences in treatment. So for my masters I I interviewed people in residential treatment about their sort of attitudes and perceptions around smoking and if that was a helpful sort of context to be looking at it in. And got some really interesting stuff, so for the PhD I wanted to kind of build on that. So yeah, it was very much kind of built around... what I knew from being in and working in services and what I'd seen, people I'd spoken to and then on that research I wanted to do more and figure out not just is this a good idea but what does it look like, how can we do it. Yeah, just a... m So what kind of m services were you looking at uh in relation to the addiction? So I interviewed people from across the North West for people accessing substance use treatment services. So they were for any substance and the kind of general eligibility criteria, if you like. If someone thinks they've got a problem with a substance, then that's good enough for me. Don't rely too heavily on sort of official diagnostics because that misses a lot of people. So, it was anyone that was accessing either community or residential services. to address their substance use. think we should probably ask a slightly basic question, which is what do these sort of services look like or what help can you see for somebody who has sort of no idea about them, no idea about these organizations, what they do? Could you sort of paint a picture for us? Yes, starting with community. if it was so if one of us decided that we thought we could do with some help, you might go to your GP or you might Google and find your local service and you'd either get an appointment or you turn up and speak to somebody and say, you know, I'm concerned about my my alcohol use or my drug use or whatever. you'd meet with the key worker who would do some kind of assessment. So fill in all the paperwork as to kind of how how severe that is, if you like. what's going on for you and sort of all the other issues going on because it's rare that these issues happen kind of in isolation there's normally a whole host of things going on which is why i'm also interested in the mental health aspect. So you do that and then once you've been accepted into treatment then the pathway will vary somewhat depending on your personal situation and the substance but generally you'd go through a series of kind of group work programs where they work through sort of starting from you know motivation to change. learning about recovery and what that looks like. Obviously if someone's physically dependent then there will be sort of that aspect of it too, so whether that's medication or some kind of detox. So there's different options and different sort of pathways depending on the severity and all the other issues going on, but the group work is a big part of it and that's kind of why I was quite keen to do something looking at that because in my experience there was a lot of focus around recovery. which is great and I that's really important, but the services kind of have limited capacity to actually work with that. So again, I'm backtracking, but for me, recovery is not just about not using the substance. It's about, it's a really holistic process about improving your life. So that's why for me, smoking cessation is a really important part of it. So physical and mental health, you it's not just about, I'm not using drugs if I'm okay. It's... what else? How is your life? Are you happy? Are you fulfilled? Does your life have meaning? So it's all that kind of stuff that I think is a much bigger part but due to the way that services are funded there's not always a lot of follow-on support so once you've of hopefully successfully completed the treatment program there might be some kind of recovery support you can access but it's generally a lot less structured, less available because it's not part of the sort core treatment offer. So when you say about groups, is it things like AA or is it different types of groups? We've got one in the north east called Recovery Connections, for example. Is it the fact that you're kind of building a life around that instead of it just as soon as you stop taking whatever substance you're taking, it's like, yeah, there's so much more than that. you're building a life afterwards, I guess, isn't it? definitely. I mean, for me, it's kind of a combination of the statutory services. So they're normally run by, well, occasionally NHS, but your CGL, your Turning Point, your Westminster Drug Project and others. And they'll do the more kind of structured groups, if you like. But then other, so some people use AA, NA, Smart Recovery or other sort of independent groups, either as well as, or instead of depending on people's treatment. em So yeah, it can be quite varied, but... So the group thing is quite common across the whole spectrum of treatment for various reasons. But yes, for me it's a lot about that building kind of community and social capital, recovery capital, and that's a big part of it. And so with your work within smoking cessation, are you trying to add in like, well as like, okay, you've stopped your substance. So I don't know if smoking classes as eh substance you saw, I'm not quite sure. I guess it's a middle ground, that one maybe. em it, cause I guess like smoking of course, you know, doesn't help you. So I guess it's trying to the next level of after you've maybe stopped maybe the, whatever substance you've been taking, is it the fact then you're stopping the smoking cause that is just not gonna have. the long-term good health benefits for example. Yeah, I mean, think that's a really important point because one of the things that keeps coming up when I talk to people is it's about the timing. So some people want to do everything at once. They want to stop using drugs, alcohol, quit smoking, join the gym, do all these other things. And for some people, that's great. em For some people, they want to do it one thing at a time. So the key point for me is about giving people that choice. Do it when they feel ready to do it. And I say that is an issue that the really long term support isn't there. certainly in the statutory services. So it can be a bit like, great, I'm ready to quit smoking, but now there's no support. I mean, it's actually nice to come on to the next question I was going to ask, because you've kind of briefly touched on it, but what do you think are some of the barriers or gaps you're seeing m in the way care is currently structured for people with these co-occurring problems, like working, for example? think one of the issues is about the funding and the commissioning of services. So generally speaking, drug and alcohol treatment is funded to deliver substance use support and that usually doesn't include smoking. So it's kind of a nice add on and there are people that are kind of trying to build that in, but it's not really a core funded part of the service. So that in itself is a bit of a challenge. I've spoken to a lot of people who work in services and... There's mixed views generally, some people think it's really important and definitely something we should be addressing and they would like to do that. But generally capacity is so limited, particularly kind of post COVID, people just, lot of people were really enthusiastic but said, but please don't make me do it. I don't have time, I can't fit it in, you already overworked. So that's a big one. But then some of the staff didn't think it was that important or it wasn't their job. So for me, that's kind of, we need to look at why that's happening and encouraging staff to feel able to offer that kind of support. unwilling to do so. Do you think it's also like smoking itself has sort of a different or has a wider acceptance in terms of like normal society that it's not considered as much of a problem? Is that one of the reasons why there's not as much push to it as well? I think that the legal aspect is a huge issue, which is interesting when you look at alcohol, but it's generally seen as a lot more socially acceptable and particularly within people who use drugs and alcohol. I think the current UK prevalence is around 10%, whereas the data released this week reckons that it was, I think, 44 % of people accessing treatment. And I'd argue that's probably an underestimate. So there's this massive gap between what's happening between the kind of wider population. But I think part of it is it's so... kind of socially acceptable and culturally ingrained within people who use drugs and alcohol. So if you go to something like an AA meeting or a smart meeting or whatever, a lot of them will have a lot of people who smoke. Smoking breaks will be kind of built into some of the program, like the convenient break points instead of coffee. It can be a really useful tool as well for building that therapeutic alliance. That was one of the things that I found when I was working in services. We were almost encouraged to kind of... bond with people, you you go outside after a difficult group and you have a chat and that would be usually over a cigarette. So yeah, there's a whole kind of host of issues that make it particularly challenging, I think, to address and one of that is kind of the socially acceptable aspect of it. Yeah, I guess if it was the choice between going back to the substance, like the addiction, is it better for that or to have the smoking addiction is probably what I'm kind of getting is the feeling of what you're saying. There's a lot of that, yeah, and there's a lot of concern, I think, that people are focusing on the thing that's gonna immediately kill or harm me, so the smoking can... I can worry about that later. But, I mean, there is evidence that if people can address both at the same time, the outcomes for both are improved. So that's not generally kind of acknowledged, I don't think. It's very much a, one thing at a time. You you can't do everything at once, so don't kind of stress yourself. And it is a really stressful situation when I spoke to people in rehab, people are away from home, they're dealing with a lot of stuff. And for someone to then say, while you're in that really vulnerable place, great, now you can quit smoking. Not always the best way to do it. I mean, spoke to people that started smoking in rehab or in treatment or went back to smoking because there's a whole host of reasons, but what do you do? People are anxious, people are bored, and it just becomes part of their life again. So within this, what were the key insights about how service support people who want to change health behaviours? there any key findings within the research that you were doing? I was looking specifically at behavioural interventions. mean, we know that there's plenty of pharmacological stuff that works. So that did come up a little bit, but I was looking more at things like, well, mainly at the acceptability to people accessing services. That was kind of what I think makes my research quite unusual in that it wasn't looking as much at effectiveness because we know what works. There's decades of evidence on smoking cessation, but it's what works in this context and how can we get that? how do we get people to actually access it? If people access the stuff then it is effective, but there's so many barriers in place that that can be really difficult. yeah, for me it was going through every recommendation, every suggestion of what would work and kind of applying that. If you're familiar with the behavior change wheel then I use the APs framework, uh but with a bit of a twist. So one of the is acceptability. So I made that kind of my, if you don't meet this you're not in kind of thing, but it was acceptability to people who would be accessing the service. So obviously it needs to be acceptable to everyone, you know, we need the organisations and management and staff to be on board, but if people accessing it aren't gonna like it, aren't gonna think it's worth doing, then I don't think it's worth doing. So that was kind of how I sort of filtered and focused my recommendations about what what we should be doing. In terms of what the recommendations are, there's a whole host of them, but there was kind of broken into three sections, if you like. So the first one was the underpinning ethos, which for me is really important, and that's kind of should be underpinning everything and influencing how these things happen. So there's issues around... excuse me one second... choice. I think I've mentioned that that was really important and how that relates to recovery, it's empowering people to make those choices and to do what works for them, when it works for them. Linked to that, there's the concept of agency and autonomy, because a lot of people feel like that's kind of taken away. You get what treatment you get, you don't always get a huge amount of choice in how that happens and people can feel like they don't have a lot of control. So giving people that back is really important. and then around the availability and accessibility of whatever service that may be. So we need to be looking at things like where it's offered, who it's offered by, what time, you know, because a lot of the services unfortunately are Monday to Friday, nine to five, and that doesn't work for people for a whole host of reasons. So we need to make things not just acceptable, but accessible. Yeah, I mean, I can tell you what the specific recommendations are for what a smoking cessation intervention should look like, but they're the kind of broad things that I think apply to any sort of behaviour change in this context. I'm just interested a little bit in how these recommendations sort of came about. So who all did you speak to? um Did you see sort of buy-in from both service users as well as service providers? Like, yeah, sort of a little bit about the background to how we got here. So did, for the PhD it was three studies all looking at a different source of evidence. It was really interesting this idea of what are we using as evidence, what are we calling kind of high standard evidence. So I did, looked at an existing systematic review that I'd worked on previously and looked at what behavior change techniques people were receiving as part of a smoking cessation intervention and compared that between kind of the general population and people specifically. targeted intervention to people who use drugs or alcohol. So wanted to see are they getting the same thing? Are they getting effective things? How does that work? So that was kind of one. And then on a similar, not the same project, but another aspect of it that I'd worked on was a consensus meeting. So part of a modified Delphi study where we got a load of experts in smoking cessation research together and kind of had a very long in-depth discussion about what they thought. reporting guidelines should look like, but that kind of in itself defines what the intervention looks like. em So that was kind of all the sort of background stuff. And then the really kind of key bit for me was then the interviews with staff and people accessing services to get both of those perspectives. Because I think I said, you need both. If one side isn't on board, there's no point doing it. em So there were definitely differences of opinion amongst them and between the different groups. One that for me was really interesting is that nearly every person accessing services that I spoke to said that they thought the staff working in substance use service would be ideally placed to offer this. said they already know about addiction, they already know about these things, we've got a great relationship, yeah, they would be brilliant. Whereas nearly all of the staff said, I couldn't do it, I don't know enough, or I don't have capacity, I have the skills. So there was definite sort of difference in perspective about who was... qualified to offer that really, which I thought was really interesting that the service users had much more sort of confidence in the staff than they had in themselves. It sounds like empowering the staff would be a really good step out from what you're saying. Yeah, definitely that was one of my kind of key recommendations for future workers, need that. Because it is difficult, particularly when you're about things like e-cigarettes, which come up quite a lot. You know, I've spoken to health professionals and a whole range of people who just aren't entirely sure what they're supposed to be saying about e-cigarettes because it is so fast-paced, know, evidence is constantly changing and recommendations are changing from nice and people. So it was very, it is really difficult for people to feel like they have... definitive idea about what they're supposed to say and what they're supposed to recommend. yeah, think for that aspect for me is something that definitely needs some further work. think it makes sense. Is there an area or a group which you've done interviews of that you feel have actually quite, have already set up quite a good kind of almost like protocol or kind of setting that kind of is something that you'd like to mimic elsewhere or is there nowhere that you think is doing a particularly great job? uh happening. think CGL are doing it down in Croydon. So this is not part of my PhD. This is just some work that I know of. check the details with them basically. But because they're looking at not just smoking cessation, but kind of a harm reduction and a sort of motivational aspect to the pathway. it's not just a lot of smoking cessation interventions for any population are based on you set a quick date and you do, whether there's behavioural support or... nicotine patches or an e-cigarette and then you quit smoking and there's not a lot of wiggle room in that. It doesn't always work for a lot of people. I think the idea is that you've had one cigarette therefore you failed. That for me was a massive problem because we're just setting people up to fail and then all the things that go along with that feeling like you've let yourself down or the people down can lead to a bigger relapse if you like. So I think that's really important looking at those different approaches and how can we reduce harm. and encourage people to kind of want to make those changes and feel ready to. So yeah, I'm very interested in the work that they're doing because they're using those kind of different pathways to sort of encourage people rather than just a straightforward, you you must quit smoking now. I guess so, from what I know, please tell me if I'm wrong here, with, you know, with substance use and addiction, when people go to rehab, a lot of the time what they do is they give everyone the tools. if they, for example, heard people say is they like, it's, you know, that's not a failure. It's you being able to, have the tools to be able to be like, right, this is not the end of the world. can, you know, I can re, you know, re, you know, become sober, you know, quit this addiction. Or I guess, so would you say like smoking, you would do something similar where it's like, even if you have one, it's like, that's not a failure. That's, I've got the tools to kind of help me carry, you know, stop smoking again, you know, you know, less. I think that's a really important point for smoking and for all substance use, that we kind get into this mindset that you've had one drink or one cigarette or whatever and then you failed and that can kind of spiral into a self-blame and all the rest of it. So it's kind of switching that onto, okay, this happened, what can I learn from it? And it doesn't undo all the work you've done before that. If you've been sober or quit smoking or whatever for so long, having one does not take you back to square one or even further back. it takes you to, well, I'm at this point, what do I know about it? What can I learn from the, it's that whole thing about a lapse versus a relapse. A lapse is not, yeah, you start from scratch again, it happened, but I have the tools, I have this information and I have now this experience to add to that, so what can I learn from it and how can I move forward? And yeah, think that's a really positive thing that we should be encouraging. The other thing I guess which is hard, like you mentioned, is a lot of programs like SMART sort of have smoking breaks almost. You didn't say the word encouraging, but it is in a way like saying that it's OK to do this. uh OK to smoke. Does that mean that we need to sort of change our approach and systems to account for smoking now? And then how would you replace what people have accounted for as like, yeah, smoking is OK to change that. Am I making sense of what I'm asking? I think so. If my answer's completely off target, then we'll revisit it. But it's very much a social norms kind of issue that needs to be shifted. And a lot of that is around people's attitudes with the whole, you know, one thing at a time. You can't do that. And a lot of people you talk to will say, oh, I've given up everything else, I can't give up this, it's my only vice, it's all I've got left kind of thing. So it's sort of about shifting those, the social norms to making that. okay. So not work in the sort of general population we've changed so much in how we view smoking over the past couple of decades. You know it used to be you could smoke everywhere, you could smoke at university, you could smoke on a plane and now that seems ridiculous you wouldn't think to walk into work and light up would you know. But so it's it's kind of shifting that in a way that doesn't feel like it's being, what's the word, you want people to feel encouraged, not punished. I think that's one of the issues that people feel like the, it's a lot around identity, particularly if you're in recovery or accessing treatment. And people can kind of struggle with that and figuring out your identity as now a nonsmoker can be quite difficult, particularly if... your identity has now become part of this group of people in recovery or trying to be in recovery and they all smoke so it can kind of be quite challenging on an individual level so I think by trying to challenge some of those social norms and saying we know smoking happens but we're not going to make it easy if you like so yes you can smoke but you have to go you know off the premises or whatever we're making it just that little bit more of a choice I suppose to do it rather than just the default I think that's kind of the big issue for me. And I've forgotten the rest of your question, I'm sorry. I mean, no, that answers it quite well instead of like, yeah, encouraging it, sort of making it like it is a bit more of a choice for you to actively do it. um No. Yeah. Thanks. I'm still thinking of like in the 60s, how smoking was allowed on planes. Blows my mind. Like, surely that's not a smart idea in any way. You wouldn't think so, but... No. So I know we've spoken a little bit about smoking cessation and the addiction, but we also want to chat a little bit about the mental health and addiction as well, because I appreciate you volunteer for a mental health charity. So what do you think in what ways health systems maybe, do they separate mental health and addiction too much? Do they kind of go hand in hand with each other? Does it truly reflect this lived experience? I think there's a bit of a mismatch in there basically in how they kind of like the co-morbidities shall we say. I think there's very much a mismatch with what people are living and what services are acknowledging. So like I said, substance use services are commissioned and run by non-NHS services, whereas mental health is usually NHS. So you've got a whole host of issues there that separate services, separate organisations, IT systems, separate staff, separate everything. So getting those two to communicate can be quite tricky. if you even get into one. But there's also this issue of access, that if you turn up to a mental health service and you have a problem with alcohol or drugs, quite often they'll send you away. You need to deal with that first. We can't talk to you while you're intoxicated and all that sort of stuff. Which can be really difficult because the two go hand in hand. For a lot of people, substance use is how they cope with their mental health, it's how they manage, it's self-medicating. not for everyone obviously, but for a lot of people. So being told that you have to stop so we can deal with your mental health can be really damaging because if you stop, often without support, you're left to sort of sit with the reasons you were drinking or taking drugs in the first place. So it's not a very, I don't think it's a very person-centered approach. And it feels like a bit of a ping pong effect where you can kind of bounce between the services depending on your eligibility and who you speak to and... Yeah, I mean, we've done some work at Lancaster looking at the treatment pathways for people with co-occurring substance use and mental health conditions. And we've got an amazing lived experience group that we've worked with over the last couple of years. And some of their stories will totally reflect that the pathways are not easy, they're not straightforward, they can be really complicated and kind of leave people really feeling quite frustrated and that they don't have basically unempowered whatever the word for that is. how it's good. So, wait, did you say that the NHS doesn't necessarily cover addictions as much as it does like sort of mental Yeah, the addiction services are usually tended out to different organisations. They come through the public health grant rather than through the NHS. So it's a whole different funding system. And also with things like m the substance use services, they normally go up for tender every few years. So you've got that additional fact that you might have a great relationship with your key worker or whoever, and then the service gets recommissioned and someone else puts a better offer in. So you suddenly have to go back and start from scratch with some... Not always the staff will stay on depending on the situation, but it can add an extra sort of layer of disruption to that. And yeah, it's because they're not part of the NHS, so they obviously work really closely with them. So it can just add a whole load of extra issues in communication. Then you're sort of losing that consistency, right? If something changes, then suppose like a session happens on a Wednesday, it doesn't happen anymore. And if you're not given the right information. yeah, that's a massive issue. And when I was working in services, was, I think was volunteering when we had a sort of shift from one organisation, one provider to another. And that was very difficult for people, well, for the staff, obviously, because they don't know what's happening with their jobs. But when people who are accessing services have had a routine for the past many years that this is what they do. And then suddenly you come and the door is shut that day. That for a lot of people can be really, really damaging. you've got your routine, you know that keeps you safe, that keeps you well, this is what you do and then you feel like your kind of support network, your lifeline's been taken away. And yeah, having spoken to some people who kind of lived through that, for some people it was really, really damaging. It's so sad to hear that when people, even if they are going through addiction, going like, need some help with my mental health, like, can't do anything. That sounds like a huge, huge problem, or even being like, we can give you this level of support and we can put something in place when you stop drinking, almost like a, you know, when this happens, you will go straight through. We can, you know, support as much as possible. I guess what, how do you think they would be, how do you think you could integrate the two? yeah, as you said, addiction and mental health go hand in hand. How do you think in an ideal world, would you integrate them m to be dealing with both alcohol and mental health issues? think in an ideal world it would be one service that can deal with everything. you've got, I'm not saying everyone has to be an expert in everything, but having staff who are an expert in mental health, who are an expert in substance use and having that kind of very holistic approach and not, so that would get rid of, in an ideal world obviously, some of the barriers between people having to physically move between services, but also of kind of how that information moves between services. Because if you go and you're trying to get support, generally have to kind of, you're spilling your guts on, this is my life and this is where I'm at and it's really difficult. And then you have to go and do the same thing again in a different service. So that kind of not having to constantly repeat, know, kind of go through that trauma again in itself is really powerful. And then having other people sort of around instead of just relying on that one service that doesn't always have the skills, the expertise. able to deal with multiple issues because they are so intertwined. I think for a lot of people it is really difficult to deal with one issue at a time because there's just so much, yeah they're so interconnected it's really difficult. Yeah, so integrating, yeah, that makes complete sense. So from like hearing you, you mainly use, assume qualitative research methods. So that's not, know, for people who may be a new to qualitative quantitative, quantitative is like, it's numbers and you know, like, the word and things that you can kind of put in boxes. Qualitative is like conversations. um As an example, I'm sure there's a whole host, you can tell about quantitative research rather than a qualitative here. So can you explain m why those may be especially useful for understanding addiction and mental health experiences? I think for me the qualitative, that's kind why I got into this because I wanted to kind of showcase those experiences. True case isn't quite the word, but give people a voice because all the treatment and research to some extent can be, I'm going to use disempowering again, unempowering. It's really difficult to kind of feel like you have control, in that setting. And I think as researchers we can sometimes unintentionally reinforce that. So think actually listening to people, giving them a voice, asking them what their experiences are and what they think is important, it's not just good for them, but it's good for the research. If we don't know what's going on, we can come up with abstract ideas about what we want to know that can have very little relevance to what's happening on the ground. So I think for me, it's really important to talk to people. This is why I'm a big fan of PPI and lived experience involvement as well as qualitative research, because you get that kind of additional layer, if you like, of that input. But yeah, think, I mean, I'm technically a mixed methods researcher, mainly because I think there is often a disconnect between the quals and the quants people. So for me, some of that is trying to kind of use both of them to kind of make a stronger argument. Because if you're not convincing people by, know, that it's a good thing to do because it's ethically a good idea, you can often convince them that it's financially a good idea. So I think the more kind of tools you have to do that, better. a good example would be like em with maybe while qualitative is better than quantitative is like, how are you feeling today? Two boxes, good, bad. And it's like, I'm sad, I'm angry, I'm frustrated. There's so many different levels of bad and so many different levels of good. then there's, yeah, so yeah, absolutely, absolutely makes sense. yeah, go on and it. as a qualitative researcher, how hard is it to sort of synthesize different opinions? um I guarantee you, or I can assume that um the number of people you spoke to even among service users would all have had different opinions about what to do and how to do things. So how hard is that? I think for me that's one of the challenges because you want to make sure that everyone's voice is heard because they're all equally important. Which is why in some of my findings I've got sort of what might seem like slightly random, obviously not technically random, I'm not a Quons research, em suggestions. So someone was really keen on acupuncture, for example, and that was, you one person brought it up so I feel like it's valid, but I can't say that there's a consensus because no one else mentioned it. em So it's difficult to kind of... make sure everyone's voice is being heard without it getting lost in that kind of trying to generalise too much. But then you sort of need to to make recommendations. You can't say one person wants this, therefore that's what we're doing. It needs to be a bit stronger than that. So it is really difficult and there's so many different perspectives. And if you start doing something like a focus group or something, then you're going to get all those different people sort of and arguing potentially and all the rest of it, which is what makes it really interesting. you want those different perspectives if we're not understanding not just the what but the why and the how then how are we going to address it so yeah it's kind of a challenge but also definite strength if we can do it well. Yeah, that makes sense. guess it's very difficult to balance the scientific rigor of being an academic or researcher with the messiness of a real human experience and putting it into qualitative data. So let's say, as you say, maybe acupuncture, example, how would you see if you've kind of got with qualitative someone's, you know, somebody might have said five comments that nobody else has said, how do you then incorporate that into when your analysis or you're crafting your recommendations for what for what they should do. I think with using the acupuncture example, it was trying to figure out why they thought that was uh important. So a lot of that came down to that kind of the main theme around choice. So it's the people wanted different options. didn't just want, this is what you get. They wanted a choice. They wanted to be able to choose what worked for them. So it was kind of unpicking that the why rather than just the what. So yeah, so people came up with all sorts of different ideas, some of which were, you know, completely impossible but lovely ideas and some of which were just a bit out there. So I wanted to kind of include all of those and you don't want to dismiss people's ideas because they've come from somewhere. But it's trying to figure out why they think that's good idea and what that might look like in a slightly more generalised recommendation but then without losing the individual voice. Tricky. Yeah, that makes sense. why I applaud anyone who works close to data because it can be really quite something, but really incredibly important. mean, we were only talking about the service user side. It would be on the other side as well, right, of sort of the service providers. They'd all have opinions about what they can and want to do. Yeah, there was definitely a divide between some of the staff who didn't think it was important, didn't think it was, you know, they very against the idea. And I suppose I was quite lucky that they even spoke to me because a lot of people when you say, want to talk to you about smoking, people are like, it's not important, they don't care. So I was, was actually, those interviews were really important to understand why they didn't think it was important and kind of how, how that shapes what's happening. interesting when you're going, is my life's work and this is what I think, and they're going, no, no, we don't like that. So it's certainly challenging on a personal level, particularly because some of the interviewees were people that I worked with. So, which I hope was a positive because they obviously felt comfortable telling me these things. But yeah, that's a slightly different issue. But there were definitely that sort of divide between the people that didn't think it was a good idea, usually because they didn't think it was in the best interest of people accessing services, not because they didn't care. because they thought we are here to stop somebody from, you know, injecting heroin or whatever that may be and that's our priority and that's what we do and that's what we do well. So the other stuff they felt that perhaps was diluting some of that. So yeah, they're kind of, they were all very well intentioned. I don't think people work in this field, you know, it's not because it's brilliantly paid or whatever, it's because people care about it. So that was sort of, yeah, again, unpicking that kind of why and what. if it was relevant what you could do to kind of challenge some of those ideas. I mean, you also mentioned earlier that people are competing for limited funding. So I don't think anybody's making a lot of money in this field generally. um But that's an interesting point. So by thinking that they were diluting the service, it because they would think that more people would come to the service if they were offering something or they wouldn't have the capacity or they have too many service users come? Or is it just like focus wise that you're diluting what you can do? Yeah, I think it was more focus wise because a lot of people were dealing with, I mean, not a crisis service, but they're dealing with people who are in immediate harm and danger from what they're doing. I spoke to one participant who was like, I've got people coming in, know, injecting heroin in the groin, this is going on. I'm not talking about smoking. You know, I'm going to get into the day, hopefully. So it's that kind of immediate priority. So yes, was very much, I don't have capacity to do that as a member of staff because I'm trying to keep people alive. I'm trying to deal with this thing that might, yes, smoking might kill them, but it's not going to kill them today. So that's kind of how it was prioritised. It sense, it doesn't it? Yeah, I mean, I do not envy people working in services that trying to deal with that kind of level of firefighting and then trying to support people to have a long and meaningful life as well. It's a really difficult situation. Yeah, absolutely. My sister works in the recovery services and she loves her job, but she does it because she loves it. it's, yeah, it does sound quite something. So I think quite a lot of this, what lot of you're saying, like obviously the quality of research, but a lot of it is having these interviews and this kind of like public engagement as well from both the service users and the people who are providing the services. So you contribute both to addiction audio and you volunteer with mental health charities. How do you feel these roles feed back into your academic work and why are they so important, do you think? I think it's, I mean, it can be a challenge, but also a huge benefit. So for me, it's, I think my lived experience and having that kind of connection with other people with lived experience is a really important influencing factor in my research. That's why I do what I do. And that's why I do it the way that I do it. But it can be, it can be really challenging of trying to remember which hat I have on. So particularly with the uh mental health and alcohol project that we working on. You know, I had a group of people with lived experience and I had not the same lived experience but you know the same type if you like. So remembering I'm there as a researcher not as an expert by experience or know PPI member or whatever terminology you want to use. So that I think for me can be slightly difficult to separate the two because you know I'm not two different people. I have all these different, as we all do, all these different aspects. So trying to kind of balance that and remember which job I'm doing because I do PPI work as an expert by experience or whatever, sort of with other groups and yeah I recently joined the Board of Trustees for Rethinkmental Illness. I've volunteered with them for some years now and I really wanted to get more involved in kind of the organizational aspect of it and figure out how that can be shaped by lived experience and as an organization they are amazing at the lived experience involvement co-production. They've been doing it for quite some time. can't say it's always been easy. I've been involved in, know, arguing and challenging some things over the years, but they keep doing it and they do it well. So that is quite inspiring for me to think, well, I can get it right. You know, other people can too. So I feel like, you know, it's kind of a duty, if you like, to sort of push that agenda that it is really important and there's no reason people can't be engaging more with lived experience involvement. Yeah, absolutely makes sense. And I guess from that, what was something that you'd wish that, the public practitioners, policymakers understood more clearly about people with maybe even just substance use or co-occurring kind of substance use and mental health issues? So, we tried to drive home. oh so much... I mean things have changed a lot but stigma is still alive and well, unfortunately. There's a lot of perhaps outdated ideas about what someone with a mental health condition or someone with a substance use disorder looks like and in some cases how less deserving of treatment. Particularly with addiction, think people are more inclined to blame someone for that. It's a choice, they picked up the drug or whatever. Whereas mental health has shifted a bit more. But we still have some quite outdated ideas. Like I've been in situations as a person with lived experience and the way I get treated in some circumstances can be quite frustrating, shall we say. Some of the things that you hear about, the assumptions made, is really challenging. And then I go, well, actually, I'm here as the researcher. I've got a PhD and the kind of perceptions are like, eh and that challenges things. But yeah, I think generally speaking, We've got a long way to go in terms of challenging stigma. Yeah, I still keep coming back to the thing which you said that addiction services aren't treated the same way as mental health services are when, yeah, well with, with people, like we said, the comorbidity of the two is so high. I do not know the exact stats, but I remember reading somewhere that it's usually around 50 % of someone has a substance use disorder, some sort of they have 50 % likely or slightly higher to have some sort of mental health condition along with it with them to some extent. Um, with With that, know NHS is trying to pilot these things called mental health hubs. um Have you heard about them? Do you know if they're viable? Have you spoken about them in any way? It's something I'm aware of. think still figuring out what that's going to look like is going to be interesting because there's definitely the scope to do something quite meaningful. But with a lot of these things, there's perhaps a reluctance or a concern that it might be short lived. Certainly from the mental health sphere, we've seen a lot of changes over the last 10 years. And each idea is met with enthusiasm. And this is going to be the answer. And some of us, you know, we get a bit jaded. We've been through this before. So I'm kind of cautiously optimistic, I think. I think there's definitely scope to be introducing substance use into that. think they should be, you know, personally, I think they should be holistic and looking at the whole person, the mental and the physical health. Whether that happens or not is down to the people implementing them. I'd say optimistic, but cautiously so. So it's just sad about saying about the stigma with addiction has just really got me thinking it's, of course we get older, we're gonna have friends or your friends are friends who go on to become, need have substance use issues and they're so embarrassed, cagey, even if they're on the recovery, it's almost like it's like, I think I've chatted with. about this and they said like it feels like I'm the kind of like the kind of the black dot in the family you know like I'm I am you know the the the ink the ink kind of like spilling out and it was just it's sad and you know I think we should be celebrating people who are you know have got through that one of the toughest things yeah so sad but hopefully we can one of the things as long as along with them empowering some of the the service users and service people themselves and getting rid of that stigma Yeah, I think that is so important. And I mean, there's just so many different levels of stigma that some of them are really well intentioned, but people can perhaps be sort of overprotective or shielding people from things because they're not sure you have capacity to deal with it. so, yeah, people generally hopefully mean well. But yeah, it's challenging. And I think even like in this conversation, the language we use is really difficult. particularly because it changes so often, trying to keep it kind of appropriate and meaningful and authentic without over-medicalising it, because a lot of the more traditional language around this sort of stuff can be quite stigmatising, so I don't use the term alcoholic or addict, because if someone wants to use that about themself, that is entirely their call, but it's not something that I will put on people. Same with the, is it addiction, is it dependence, is it a substance use disorder, is it... There's so many nuances to it that it can be really tricky to even have an open conversation about it. I don't know if you realise I'm like stopping and pausing quite a bit to be like, I know that this is okay. And it is, it's, you, you don't want to, you don't want to label any, anybody in something way that's going to upset, offend them. And, you know, it's like, I guess, but I guess it's a constant kind of like, you're always bettering and finding out what you should and shouldn't, shouldn't, shouldn't be said. I mean for me that's the most important bit. Language changes, people's use changes. As long as you're kind of not trying to offend anyone and you're willing to kind of adapt and try and learn from that then I change what I say about myself quite regularly because it's evolving and so yeah think as long as we're open to that then... Yeah, language is a massive thing. think Zoe, we've seen in some of the PPI groups we've hosted together, that sort of the terminology comes up quite a bit of like what's being said or how you say it makes a big difference. um that being willing to change, especially in sort of when we're talking about minority communities and that work we've been doing there, um sort of the language being used there, the statements being made, the understanding of these things, very... can differ widely and therefore you need to adjust and show that flexibility. Yeah, definitely. It's really difficult because obviously everyone's got their own preferences. say one of, you know, the term alcoholic can be really contentious because some people kind of feel that that's empowering to own it. Things like AA, that's what they do. I'm an alcoholic and I'm dealing with it and that's something to be kind of celebrated. Whereas for other people it's quite a stigmatizing term. So there's no right answer. I think it's just whatever someone wants to use about themselves. giving people that empowerment that they can say they can make themselves whatever they want, whatever they want to be. This might be a good time to ask you about one common assumption or misconception about addiction or mental health that you think m deserves rethinking. Big question. em There's so many. mean, in terms of smoking, if I'm going to be quite specific, one thing that I get a lot when I teach about this, it's people think that nicotine is the problem, that that's what's going to kill them. And it's not. That's what makes it addictive. That's what makes you keep going back for more. But it's not what's going to be. That's why we use NRT. That's why we use patches, nicotine replacement therapy. patches and gums and all the rest of it because you can have the nicotine without the really bad parts of the cigarette. There's many debates around the ECB cigarettes but nicotine for me shouldn't be the focus of that. If someone needs the nicotine then it is what it is, it's not likely to kill them. um I think there's another question which we ask everybody, m I feel like we should, Beth usually ask it, but I'll ask it this time. um this is looking towards the future. So suppose you were given a grant of let's say 2 billion pounds um or at whatever number, more money that you know what to do with. And I guess in theory, the ethics boards are away. What would be your sort of dream research project? uh Which you would want to do. Okay, assuming that there's also no time limit on the project, what I would love to do is a really long-term study on people accessing treatment for substance use. Because a lot of the studies we have, we're looking at six month outcomes, is great and all, but it's like, what about five years? What about 10? This is a lifetime thing for lot of people. So I would love to do something that embeds smoking cessation, not just into treatment, but into the recovery sector and fund something like that, and then measure those outcomes over the whole course of somebody's life and not just. did you quit smoking? It's like have your attitude changed, has your substance use changed, has your quality of life changed, has your mental health changed and all of that stuff. So really in depth and it would never get funded because the outcomes would be far too vague and it would take years to get anywhere but ideally I'd love to do something like that. The closest to that, which I've seen is, you know, like in the UK Biobank or any sort of longitudinal studies, sometimes they don't really measure the mental health outcomes to that extent, but they sort of see like, are they still smoking or are they not? And you can pull that data out. I don't know if there's any other cohort studies which do it a bit better, but that's the closest which I can think of. which is really good. But I think for me, one of the key issues, which I probably should have mentioned earlier, is the outcomes that we're measuring. So I don't think a binary, yes, no, have you quit smoking, really captures that. Because someone could have reduced from 40 a day to one, let's say, and they'd still be counted as a failure. uh As a smoker, you have failed at quitting. And that is why I think it's so damaging. you know, we're kind of just undermining all that work that's gone into it. So I think we need to look at much broader outcomes and how those interact with other things and also over long term because you know might not quit in the first six weeks, six months, but the idea is that you plant the seed then that someone might quit over a year, over two years. So I do think we need to look much more broadly at how smoking outcomes are measured. Also, if you have unlimited funds, can fund sort of the follow-ups being better so that there's consistency and sort of check-ins and... and accessibility as well, guess. Yes, I'd want to, you got to meet people where they're at. if that means, you know, going to them, then great. rating an app. So it's on their phone to some people. You can do it in a multitude of ways. so many ways of giving people that choice again. But having the conversations, we have, what do you think is important? You know, this is your recovery journey for one of the slightly cheesy phrase. What does that mean to you? And what outcomes are going to capture that? Because, you know, a simple, you quit smoking? Have you used alcohol? Whatever it is, it just reduces it down to something so small and it should be so much bigger. And there are so many different facets of recovery that are really positive. and all kind of build up hopefully to a really positive recovery. But if we're not looking at all of that, then we're not seeing the whole picture. So where do you see this field heading in the next maybe decade, both in research and in practical service delivery? I'm again cautiously optimistic with some of the work that's going on that there is interest in expanding smoking cessation to include people in substance use treatment. mean, ideally we want to be expanding not just for people in treatment, but people who for whatever reason aren't in treatment because there's a massive population that could probably benefit from treatment but aren't accessing it for whatever reason or aren't able to. So yeah, I think that's a really kind of key population that we're missing. So I'm hopeful that we will. start shifting those norms around smoking because you know for the general population we've done really well, smoking rates have reduced dramatically over the past couple of years, decades, whereas we're not seeing that the same in some of these subpopulations so I think we need to look at that, all the different factors, so we know what works for smoking cessation but how do we get it to these people that need it, how do we make it appropriate? So yeah that's what I would like to see and what I hope we will see. both in research and in practice. We can get you back in five to 10 years time to like get the verdict whether it's been what you expected it to be or not. Hopefully, hopefully it will have gone wonderfully but we'll see. I'm sure there'll be some new challenge we haven't thought of by then. And what about yourself personally? you've, so you, you spoke about your, your PhD and then your current sort of work. What are you planning on doing in the next five to 10 years? What's your next research? em We'll be I've got a lot of ideas about what I'd like to do. I think in terms of methodology, then anything PPI related is really important. And that's probably to some extent more important than the actual content. For me, it's really shifting those ideas and hierarchies within research and within practice. So it's not just, you know, we don't just have a sort of token personal lived experience. We actually embed that, you know, so that should be across the entire life cycle of a project. how we come up with the idea in the first place, how we see if it's worth doing. So that's the work I'd really like to be doing, preferably in the kind of substance use, mental health and recovery kind of field and say smoking being part of that. But yeah, that's the really important bit to me is getting that lived experience firmly embedded, which we've changed a lot over the past few years with that. It's great to see it being recognised a lot more and so many funders expect it now that We kind of have to include it to some extent, but making sure that it's really meaningful and not just to kind of, the funders want it so we'll tick a box. But how to really use that to its full benefit, you know, for the research and for the people taking part and for the researchers and then hopefully the impact of that. So yeah, I mean could bang on about this all day, but it's a win-win if it's done well. Everyone benefits. Yeah, that sounds really important. Is there anything, any kind of research that you particularly want to share or anything, any questions that you feel you want to talk about? we haven't covered. think we've covered quite a lot of the stuff that I had on my notes of things to mention. I say that, yeah, I can recap, but yeah, the lived experience bit, always going to be important. I'm really interested in those outcome measures and how we can improve them. That's kind of, think, an under-researched area. I mean, this is what someone tells me they've already done it, but looking at how we can... get a consensus from people in treatment, whatever that treatment may be, and kind of working with then the people who process all that data and, from the government and all the rest of it to balance that so that an outcome isn't just a yes, no, did they clear in six weeks? It's, you know, how do we make that something that's meaningful and useful across the board? And yeah, that's, most of my PhD, although it was obviously on smoking, was sort of about challenging the research hierarchy and how these things these things happen because they've always happened and sort of challenging some of that. Maybe an RCT isn't the best way to do this, which some people will probably think is hugely controversial, but it's about kind challenging the whole mechanisms of research and making sure that that's fit for purpose and really empowers people and produces useful and meaningful research. And one final thing Zoe, what is your hot take? So think that a reduction in cigarette smoke should be included in every smoking cessation intervention as an outcome. And that might not sound particularly out there, but there's a lot of controversy around this in smoking cessation research, and I think it's really important. What's the controversy? There's sort limited evidence that reducing the number of cigarettes you smoke actually have health improvement outcomes. So there's kind of the, what's the point if you're still smoking then you're still gonna get cardiovascular disease or whatever. But for me it's not just about cutting down and that being the outcome, it's about a bigger picture. So encouraging someone to cut down and supporting that and celebrating that is more likely to lead to them quitting. or making other positive changes, it's encouraging people and making them feel valued and that their choices are worth doing. So for me, it's about that kind of bigger picture, which is not necessarily going to be as useful for definitively measuring smoking cessation. But I think if we're talking bigger picture and longer term, then that kind of harm reduction approach, whatever that may be, should really be included as a valid outcome. And it's not in a lot of studies. Awesome. Oh, thank you. That was awesome. All right. So thank you so much, Zoe, for coming on. great. Thanks for having me, it's been a pleasure. And thank you everybody for listening and until next time, take care. Bye.