'The London Drug Culture, c. 1926-1966' is the first historical study of metropolitan drug-use in mid-twentieth-century Britain. This thesis challenges orthodox historical understandings of the development of metropolitan drug-use during the twentieth-century which - focusing upon the events of the 1960s - characterise the phenomenon in terms of rupture, detailing the gradual coalescence of a complex and multifaceted drug culture within central London over the course of these decades. This drug culture, I demonstrate, was both profoundly urban and transnational in its structure and organisation: the coteries of drug-users which crystallised within the capital during the mid-twentieth-century were simultaneously situated within specific spaces of the city, and" within discrete transnational networks of the drug culture. Additionally, this study analyses the narratives of the London drug culture which emerged during this period, seeking to locate and identify the historical roots of these representations, to deconstruct them, and to analyse how they shifted in form during the course of the mid- twentieth-century. Narratives of the metropolitan drug culture, I contend, constituted a site in British culture in which both gendered and racial 'Others' were constructed in opposition to notions of Britain and Britishness. Finally, this thesis charts the construction of an apparatus of drug control from the 1920s, analysing the manner in which this regulatory system was operationalised at ground-level in the capital by its various interlocutors - principally the Metropolitan Police - and detailing how these practices became bound up within the institutional politics of law enforcement. The regulation of the London drug culture, I argue, was productive: both of official knowledge regarding the phenomenon, and of new identities and ways of being. In this study, then, the London drug culture is conceived of as a prism through which the historian might trace the formation of British modernities in this period.

Background - The Gateway Hypothesis argues that there is a sequence in the use of various drugs and that the use of one substance serves as a gateway for the use of another substance. The aim of this thesis was to examine various aspects of the Gateway Hypothesis using data from the Avon Longitudinal Study of Parents and Children (ALSPAC) (unless stated otherwise). Individual summaries of the multiple methodologies applied are described below. Systematic Review and Meta-Analysis - Aim: To conduct a systematic review of current Gateway Hypothesis literature. Methods: Longitudinal studies examining empirical data were selected and study characteristics extracted. Results were combined using metaanalysis. Results: Nineteen articles from 14 studies were included reporting 17 drug exposure and outcome combinations. Meta-analysis provided evidence for association of tobacco use (OR=2.60, 95% CI 1.39-4.85, p=0.003) and alcohol use (OR=1.56, 95% CI 1.16-2.10, p=0.003) with cannabis use, and between cannabis use and other illicit drug use (OR=2.79, 95% CI 2.01-3.87, p<O.OOl). Conclusion: There is consistent evidence for association at some stages of the Gateway hypothesis. An influence of confounding, reverse causation and/or bias cannot be ruled out. Recanting and Hair Drug Testing - Aim: To examine the extent of recanting and the potential of hair drug testing as a biological measure of illicit drug use for use in studies of the Gateway Hypothesis. Methods: Hair and self-report measures of cannabis and other illicit drug use were available at age 18 years. Recanting was defined as reporting use at any of the earlier time points and denying ever use at age 18. Recanting and self-reported responses in hair positive individuals were compared on a range of predictors. Previously reported sensitivity and specificity values were used to compare expected numbers of false positives and false negatives. Results: Cannabis and other illicit drug use was recanted by 176 (14.4%) and 99 (25.2%), respectively. Recanting cannabis use decreased with the reporting of other substances and anti-social behaviour. For the hair testing of cannabis use, we would expect to see 0 (95% CI: 0 to 169) false positives and 394 (95% CI: 323 to 449) false negatives, where 362 potential false positives and 436 potential false negatives were observed. Conclusion: Self-reported use of illicit substances could be affected by recanting. Hair is an unreliable measure of substance use in a general population sample. Mendelian Randomisation (MR) - Aim: To use MR to examine the causal effect of on alcohol consumption. Methods: I used rsl051730 as a proxy for heaviness of smoking and smoking cessation. MR methods were used to assess the relationship between: [1] continued smoking and alcohol consumption during pregnancy; and [2] smoking heaviness weekly alcohol consumption (also using data from The Nord-Trondelag Health Study (HUNT) and the Copenhagen General Population Study (GCPS) to increase statistical power). Results: There was little evidence for an association between rsl051730 and alcohol consumption during pregnancy in ALSPAC (OR = 0.95, 95% CI 0.82 to 1.10, P = 0.473) or between rsl051730 and units of alcohol per week in ALSPAC, HUNT or CGPS (SO increase in units of alcohol per additional copy of the risk allele = -0.01, 95% CI -0.04 to 0.01, P = 0.328, 12 = 0.0%). Conclusion: Previously reported associations between smoking and alcohol are likely to have been over-estimated and the result of confounding and/or reverse causation. Baseline models - Aims: To examine associations between tobacco phenotypes in adolescence and alcohol and cannabis use in early adulthood, accounting for evidence of pre-existing problems. Methods: I examined associations between exposures (smoking status, smoking heaviness and tobacco dependence) and outcomes (hazardous drinking, ever use of cannabis and cannabis abuse) taking account of baseline problems. Multiple imputation was utilised to take account of missing data. Results: After taking account of pre-existing problems, there was evidence for association between: smoking status and ever use of cannabis (OR in former smokers = 1.98,95% 1.53 to 2.57; OR in current smokers = 1.66,95% CI 1.13 to 2.44; P≤O.OOl); smoking status and cannabis abuse (OR in former smokers = 1.57, 95% 0.73 to 3.23; OR in current smokers = 2.79,95% CI 1.40 to 5.65; P = 0.009); cigarettes per day and harmful alcohol consumption (OR = 0.91, 95% CI 0.84 to 0.98, P = 0.018); and tobacco dependence and ever use of cannabis (OR = 0.72, 95% CI 0.53 to 0.97, P = 0.030). Conclusion: Previously reported associations between tobacco and alcohol/cannabis might be due, in part, to underlying psychopathology. Latent Class Analysis - Aims: To characterise patterns of cannabis-use across adolescence, and assess their influence on substance in early adulthood. Methods: longitudinal latent class analysis was used to derive trajectories of cannabis use. 1 investigated whether latent class membership predicted subsequent nicotine dependence, harmful alcohol use and other illicit drug use. Results: Cannabis-use patterns were captured as four latent classes: 'non-users' (80.1%); 'late-onset occasional' (14.2%); 'early-onset occasional' (2.3%); and 'regular' users (3.4%). Compared with the non-user class late-onset occasional, early onset occasional and regular cannabis user class had higher odds of nicotine dependence (OR=3.5, 95%CI 0.7-17.9; OR=12.1 95%CI 1.0-150.3; and OR=37.2, 95%CI 9.5- 144.8, respectively); harmful alcohol consumption (OR=2.6 95%CI 1.5-4.3; OR= 5.0 95%CI 2.1-12.1; and OR=2.6 95%CI 1.0- 7.1, respectively); and recent illicit drug use (OR=22.7, 95%CI 11.3-45.7; OR=15.9, 95%CI 3.9- 64.4; and OR=47.9 95%CI 47.9- 337.0, respectively). Conclusion: One-fifth of UK adolescents follow a pattern of occasional or regular cannabis-use. These people are more likely to progress to harmful substance use behaviours in early adulthood. Conclusion - Evidence that smoking does not causally influence alcohol consumption suggests that future interventions targeting both drugs should include a common factor. Strong associations between various other drugs provide further evidence for the Gateway Hypothesis, however, other theories of drug use cannot be ruled out as causality cannot be determined

The aim of the present thesis was to examine the cognitive and attentional processing of smoking-related stimuli in abstinent, active and non-smokers. The initial research reported here is directed at establishing appropriate experimental and questionnaire materials for the main studies. This included the development of a valid list of smoking-related words with frequency-matched controls, and revising the Smoking Motivation Questionnaire based on analyses of structure and reliability. Generalised cognitive biases were assessed through a series of modified Stroop experiments. Although the findings suggested that abstinence alters cognition with respect to smoking-related stimuli an assessment of the results suggested that there were some inconsistencies in the findings. Only when a blocked-format Stroop with vocal responses was used was there evidence of a cognitive bias for smoking-related words in abstinent smokers. In order to specifically examine attentional bias in abstinent, active and nonsmokers, a final study assessed performance on a Dot Probe task. Results showed no shift in attention towards smoking words in abstinent smokers. However, a subsidiary analysis revealed that smokers who reported an awareness of smoking shifted their attention towards smoking words. These findings may suggest that different formats of attentional tasks provide differing outcomes in terms of smokers processing of smoking-related information, and that awareness is an important aspect of this processing. Finally, analyses of self-report measures revealed that smokers were more state anxious than smokers and that abstinence increased state anxiety and cigarette craving. The results from this thesis have provided some useful indicators of successful smoking cessation and may assist in the development of a cognitive model of smoking. However, the development of the work will be dependent on modifications and extensions needed to address the anomalies in the findings. Specifically the smoking-related words used and the type of attentional task employed.

This thesis is a study of drug policy in England between 1994 and 2004. It focuses on five areas: - how drug policy was developed, why partnership forms were chosen as the mechanisms by which to achieve implementation and the impact of that décision, the relationship between the centre and localities, partnerships as new forms of governance and whether institutional resilience has been observed. The research used a multi-method approach comprised of three components: a literature review; an analysis of documentary sources, including the three key drug policies, and original, empirical research. The latter was undertaken with two separate groups, the first responsible for drug policy development and the second for policy implementation. Tackling Drugs Together (TDT,1995) was developed by a small group of people who successfully exploited the opportunities open to them and who were observed to have used all of the 'factors' identified by Levin (1997) in their capacities, as civil servants, politicians and members of the voluntary and campaigning sectors. They were 'motivated' to achieve change (from their institutional, personal or organisational position) and used the 'opportunities' and 'resources' open to them to do that. They did not however form a 'policy network' (Berridge 2006; Duke 2002; Sabatier 1998; Wong 1998; Hughes 1997). Those developing TDT (1995) chose partnership forms (Drug Action Teams - DATS) as a mechanism for implementation, because they provided an answer in a complex social policy area, allowing a wide variety of organisations to be brought together. In addition, the concept was associated with newness and dynamism. The direction of drug policy, post 1998, is linked to New Labour's wider social policy perspective - incorporating a focus on communlty and social responsibility. On the whole, DATs have supportéd this direction. Their relationship to the centre has in general been positive, whilst responding to a strong performance management framework. DATs have accepted this for the benefits it brings; and highly functional DATs have learned to adapt policies to their own local needs. Their sophistication, functionality and structure indícate that they have become new forms of governance (Newman 2001). This does not mean however that the old institutions have disappeared; they have shown resilience (Klein 1993) and adapted to the changes, working within a partnership, performance management and regional framework. The thesis makes a contribution by focussing on drug policy development and implementation. Through the examination of the impact of the partnership and performance management approaches over a décade, it illuminâtes other social policy areas and New Labour changes, especially within the area of governance, developing our understanding of institutional change and resilience.

Despite over two decades of crack use in the UK, there is little UK-focused research and little understanding of crack careers, the social context of crack use and health-related risks. This is of concern because research in the UK suggests that service provision for crack users is inadequate. Research also suggests that there are high attrition rates of crack users in drug support services. Based on ethnographic data collected in 2004/2005, this thesis examine how crack cocaine users start using crack, what happens over time, and where they end up as a consequence - the crack scene. Many become mistrustful because of the manipulative and violent interactions that take place in these spaces. This is not helped when crack users reflect on past mistakes, which only results in increased crack use. As practical and health issues become too problematic, ways out, too, become more difficult. In addition, many find it difficult to place trust in drug support services because of negative past experiences, and feel ashamed about past failures in treatment. Taken together, the thesis shows how this is not helped by aggressive social policies, law enforcement and the configuration of drug support services.

Background: Exposure to tobacco smoke imposes a heavy morbidity and mortality burden and exacerbates health inequalities. Whilst the health and economic benefits of smoke-free legislation (SFL) are evident in high income countries (HICs), there is a lack of evidence from low- and middle-income countries (LMICs) where implementation and monitoring mechanisms are generally weak. Objectives: To examine whether the health benefits of SFL identified in HICs are likely to accrue in LMICs and whether any benefits are evenly distributed between socioeconomic status (SES) groups. Methods: 1) A systematic review was undertaken to examine the impact of SFL on socioeconomic inequalities in tobacco-related health outcomes in adults 2) Secondary analyses of the Global Adult Tobacco Survey (GATS) data from 15 LMICs was undertaken to examine inequalities in second hand smoke (SHS) exposure at work and at home 3) Quasi-experimental difference-in-differences study design was used to examine whether the National Tobacco Control Programme (NTCP) in India was associated with reductions in active smoking. Results: 1) Evidence from LMICs examining the health impacts of SFL was sparse. Comprehensive SFL was associated with pro-equity impacts in smoking associated health outcomes in HICs 2) In LMICs, exposure to SHS at workplaces and at homes was higher among the low SES groups. Being employed in a smoke-free workplace in LMICs was associated with reduced exposure to SHS in the home 3) There was no compelling evidence that NTCP reduced bidi and cigarette consumption over and above the general reduction that occurred in all districts in India. Policy implications: Poor implementation of SFL in LMICs is associated with substantial forgone health benefits, especially in the low SES groups. Strengthening tobacco control is key to improve health outcomes and reduce inequalities in LMICs and attainment of the Sustainable Development Goals for Health.

Street-seized crack cocaine samples are cut with diverse impurities which may be very harmful to health. Harm reduction experts say that interventions are urgently needed to reduce the harmful behaviours associated with drug abuse. In this multidisciplinary approach, a successful intervention, Promoting Inhaled Pleasure Easily and Safely (PIPES), has been designed and tested in pilot studies. PIPES informs crack smokers about the crack sample content, efficiency of crack delivery, and the harms associated with different home-made smoking tools and cutting agents. Crack samples were profiled by spectroscopic and chromatographic methods. In an attempt to track crack sources, PCA of the 1H NMR spectroscopic data clustered samples of similar contents together. A laboratory crack smoking model was optimised to measure the emitted and recovered doses of cocaine and cutting agents from common crack smoking devices. Seized samples contained 24% cocaine base and 32% phenacetin. A medical inhaler delivered the highest dose of cocaine and phenacetin into the apparatus, then a glass pipe (shooter), and then tin cans. The analytical results and the harms associated with each smoking device and toxic phenacetin were used to design PIPES, an educational intervention that was delivered by harm reduction workers to crack smokers. Users showed: a lack of knowledge of cutting agents and the harms associated with different pipes and cutting agents, their reasons for sharing pipes, and their attitudes to share knowledge and receive more information about cutting agents and pipes. The results of this applied research should be more widely known and used.

Background: Heroin addiction is an extremely prevalent problem worldwide, and in Britain is commonly treated with methadone maintenance therapy. Previous literature has examined the neuropsychological impact of opioids such as heroin and methadone and points to a detrimental effect on neuropsychological functioning. However no attempt has been made to examine and compare the impact of these opioids on the same group of individuals. This study aims to measure the neuropsychological functioning of a group of opiate dependent males while actively using heroin and again once maintained on prescribed methadone. As previous research has been complicated by the effects of head injury and/or concurrent substance/alcohol dependence, the presence of these factors is used as exclusion criteria. Method: Neuropsychological functioning was assessed in a cohort of 14 opiate dependent males while actively using heroin, using the Repeatable Battery for the Assessment of Neuropsychological Status. The same measure was repeated with the ten members of the original cohort who successfully progressed to methadone maintenance. In order to identify any neuropsychological impairment, participants' level of functioning while using heroin and while using methadone was compared to an estimate of their premorbid intellectual functioning. Quantitative statistical analyses were used to determine whether results were statistically significant. Results: Participants performed significantly below the level predicted by their estimate of premorbid intellectual functioning both while using heroin and while using prescribed methadone. There was no significant difference in the participants' neuropsychological performance while using heroin and while maintained on a daily prescription of methadone. Discussion: The results of the present study support previous research which has demonstrated a link between heroin and methadone use and neuropsychological impairment. Previous literature has not directly compared the neuropsychological performance of heroin users with opioid addicts maintained on a daily methadone dose. The present study found no significant differences between the performances of the group while using heroin and once maintained on methadone. These findings have important implications for clinical practice in the field of addictions. There are a number of challenges associated with recruiting and retaining participants in the context of opioid addiction research, which are discussed in detail. The limitations of this study are explored, and future directions for research in this area are considered.

'Social inclusion from on High: The policy responses of Canada and Scotland to illicit drug use' considers policy orientations to the social inclusion of the illicit drug user. It does so through analyses of national policy responses of Canada and Scotland produced between the years 2000 and 2005. The aim is to understand better the positioning of social inclusion within these policy responses and to understand how the responses of Scotland and Canada share similarities yet reflect differences. The first part of the thesis makes the case that the discourse of social inclusion should be understood as an aspect of governance. It makes the case that all advanced capitalist societies can be characterised as inclusion societies, exerting power and extending social control through terms and architectures of inclusion. This case is derived from literatures describing the historical emergence of contemporary forms of governance, including the ascendance of "psy experts" and the development of "risk society", as well as the current focus on social inclusion. The second part of the thesis analyses selected policy documents as comparative examples of how policies towards drug users are framed within the inclusion society. The policy documents concern the extent to which and how two specific governments, Canada and Scotland, frame and seek to govern illicit drug users through discourses of inclusion and exclusion. Two innovative techniques of analysis are used. First, multidimensional scaling is used to analyse the frequency of key concepts. This reveals that Canada did not use a language of social inclusion in their policy documents and use of this language was modest in Scotland. In both countries 'harm reduction' was not the most frequently used key concept. Second, the storylines of the documents are analysed drawing on six key concepts derived from the work of Nikolas Rose - problematisations, explanations, technologies, authorities, subjectivities, strategies. This reveals similarities and differences in governmental approaches to managing illicit drug use in Scotland and Canada. The former adopting the more punitive and, ironically, also therefore probably the more excluding approach to illicit drug users. The thesis makes the argument that the inclusion society complements psy and risk society frameworks by functioning as a form of social architecture for the integration and betterment of the non drug-using self. The work concludes with reflection on how together, the theoretical, methodological and comparative approaches effectively illuminate architectures of inclusion that act to frame subjectivities, facilitate control, revision stratification and reinforce expert ability to govern the social inclusion of the illicit.

Substance use disorders are one of the most highly stigmatised conditions in the western world. Current figures indicate that illicit drug related deaths are the highest they have ever been in the UK. Stigmatising attitudes have been found to act as a barrier to treatment uptake and engagement. This thesis aimed to explore healthcare professionals’ attitudes towards illicit drug users. Part one of this portfolio presents a systematic literature review of healthcare professionals attitudes towards illicit drug use and the treatment of drug users. The findings of the review suggested that healthcare professionals do display stigmatising attitudes towards drug users but that these attitudes may be moderated by factors such as increased contact and the type of drug used. Part two presents an empirical paper that firstly investigated clients and healthcare professionals’ understandings of positive and negative treatment interactions. Secondly, the paper investigated clients’ perceptions of healthcare professionals’ attitudes compared to professionals’ own reports, and the impact of attributions of controllability on attitudes towards a fictional heroin user. The findings highlighted clear discrepancies between clients and healthcare professionals’ understandings of what constitutes a positive and negative treatment interaction. Clients were also found to perceive healthcare professionals as more stigmatising than the healthcare professionals reported being. Attributions of controllability had a variable impact upon attitudes towards the fictional heroin user. Part 3 provides a summary of my clinical experience throughout training. Part 4 presents the assessments that I have completed during training.