This PhD research examined how: smoking varied among a homogenous population from Ghana living in different locations; among different ethnic groups living in Amsterdam and; across the sub-Saharan African region. Ghanaians comprised one of the largest African migrant groups living in Europe. This provided an opportunity to study how smoking differed between migrant and non-migrant Ghanaians and to other ethnic groups. The factors associated with smoking were determined to inform strategies to prevent smoking among immigrant ethnic-minority groups living in developed countries. Three study methods were used: a systematic review of smoking in sub-Saharan Africa; a crosssectional study of Ghanaian populations living in 3 European cities and Ghana (RODAM); and a cross-sectional study of ethnic groups living in Amsterdam (HELIUS). The main findings that emerged showed that gender seems to be the strongest determinant of smoking among adults in sub-Saharan Africa. Smoking among the Ghanaian migrant population is multi-factorial in nature, with exposure to a high smoking environment having a strong influence, though the prevalences are still far lower than the European population. Factors including one’s immediate social networks operating through family, religion, social communities, culture and higher education are associated with a lower uptake of smoking. Compared to the Dutch and other ethnic groups in the Netherlands, Ghanaians smoked significantly less. However, the higher levels of smoking prevalence and higher levels of smoking cessation among some ethnic minority groups compared to the Dutch are largely, but not completely explained by SES. Smoking among migrant populations is related to cultural attitudes that exist towards smoking in both the country of origin and the host country. It implies that if smoking is made culturally abnormal, as in Ghana, a significant reduction in the prevalence and onset can occur in developing countries where the smoking epidemic is increasing. Anti-smoking policies designed to target smoking within the lower SES groups of ethnic minority groups may substantially reduce ethnic inequalities in smoking. Role in data collection Throughout the PhD, I was a part of the data collection team for the RODAM project at the London location. Data collection was conducted during 2012 and 2015. The team was responsible for recruiting Ghanaian residents living in London into the study and collecting data according to the study protocol. To accomplish this, the team visited several locations across the London boroughs where Ghanaian communities often congregated for church services or meetings. This usually occurred on Sundays or Saturdays, depending on the occasion. At these meetings, the project was advertised to the Ghanaian community and invitations to participate were sent out. After an informed consent to participate was received, participants visited the data collection venue to participate in the study. I was often assigned the responsibility of taking physical anthropometric measurements from participants including weight and height, waist and hip ratios, bio-electrical impedance monitor, sitting blood pressure and lying blood pressure measurements. Due to my inability to speak the local Ghanaian language, I was unable to interview participants who often preferred to speak their local Asante Twi language. During September 2013, for two weeks, I visited the study location in Ghana, to participate in the fieldwork activities at the Kumasi and Obuasi locations.

Traditional anti-doping assays target known banned drugs and endogenous molecules. A discovery platform such as metabolomics can be employed to find small molecule biomarkers that are related to the function of drugs of misuse. Biomarkers can be endogenous surrogate metabolites which have the potential to facilitate the discovery of new doping agents with biological activities similar to related named prohibited substances, as well as improving the sensitivity and prolonging the detection time window. Working towards this end, the focus of this thesis was to apply metabolomics to the anti-doping field in order to enhance detection of drug misuse in sport, in particular focusing in methodology that would help discover endogenous biomarkers, namely: sample information, quality, storage, transport, and multivariate/univariate statistics to mine significant biomarkers from metabolic data. The first part of the thesis explored analytical method-development in metabolomics, overall assessing the amount and quality of the metabolic information acquired in small sample volumes using paper spots. Methods for high resolution and high mass accuracy instrument were also studied to aid with the identification of molecules. After this, paper spots were also assessed for storage stability and compared with the conventional sampling method. From these analyses it was concluded that paper spots are a good option when limited sample is available, due to reproducibility, storage and transport advantages, however there is a loss of metabolic information when compared to liquid samples. The high mass accuracy did help with identification although the method was not tested in fragmentation mode. Then the application of multivariate statistics to mine biomarkers from “doping fingerprints” was studied in detail. Firstly, a small clinical trial with longitudinal samples containing one (endogenous and exogenous) metabolite in urine, GHB, was “fingerprinted”. The aim was to find biomarkers that could be identified for a longer detection window than GHB in urine. A battery of multivariate tools was used to mine the data. Several metabolic features, albeit partly unidentified, showed interesting results, however it was concluded that a new study design with diet control and a placebo group, was needed to validate these features. Lastly, samples from athletes were analysed and were grouped as salbutamol detectable and non-detectable specimens. Since this study was based upon the shortcomings of the previous GHB study, a strategy to diminish false positive biomarker discovery was included by adding a salbutamol spiked group in the experimental design. Results revealed a potential endogenous biomarker of salbutamol, hypoxanthine, with a ROC of 79 % prediction. These promising results need further validation with a subsequent clinical trial. Overall these preliminary studies show the potential of metabolic fingerprinting in anti-doping. The findings have shown that metabolomics is a valuable tool in the discovery of surrogate biomarkers in doping.

A hallmark feature of addiction, including nicotine dependence, is persistent drug use despite the adverse consequences of such behaviour. This implies that there may be deficient processing of punishment in dependent individuals. However, despite growing bodies of research investigating both altered reward sensitivity and error monitoring deficits there is a paucity of empirical work investigating sensitivity to punishment in nicotine dependence. The main aim of this thesis was therefore to investigate the effects of satiation level (abstinent/satiated) and smoking history (current/former/never) on behavioural measures of punishment sensitivity. Furthermore, the related phenomenon of loss aversion (the tendency for individuals to be more sensitive to losses compared to gains) was investigated in former smokers alongside a range of self-control indices.

Background: Dual diagnosis (substance misuse and mental illness) is recognised as a significant clinical problem. However there is little evidence contributing to the understanding of what motivates people with psychotic illnesses to use drugs and alcohol, and in what social context. There is still less evidence concerning the correlates of dual diagnosis in in-patient settings including the relationship between mental health service settings and the initiation and maintenance of substance misuse. This study reports the prevalence, social context of, and motivations for substance use in a sample of in-patients with psychotic illnesses.;Methods and measures: Staff on 9 acute mental health wards and 2 psychiatric intensive care units in North London used a Clinician Drug and Alcohol Use Rating Scale to assess whether working age in-patients with psychotic illness also met the criteria for harmful alcohol or drug use, or dependence during the preceding six months. Those meeting the criteria for harmful use or dependence were then approached to participate in the study. Participants were interviewed and asked to report on the nature, extent, social context and attributions of their substance use, and whether they had continued to use whilst an in-patient. Measures used included an Inventory of Alcohol and Drug Use Situations, a Self-Medication Questionnaire, a demographic schedule and a structured set of questions concerning substance use history and it's relationship to mental health service settings.;Results: All working age adult in-patients (264) were screened for a current or recent substance use disorder. One hundred and twenty nine individuals met the study criteria (48.9%), whilst a further 39 (15%) had a substance use history, but no associated impairment of these, 102 agreed to take part in the study (response rate 79%). Those with dual diagnosis were younger on average and more likely to be male, than those with psychosis alone. The majority (76%) suffered from schizophrenia and were detained under the Mental Health Act (1983), with 19% being street homeless. A wide range of substances including opiates, stimulant substances and khat were used by participants, but alcohol, cannabis and cocaine (respectively) were the most frequently used substances. Eighty one percent of the participants reported using on the ward during their current admission, with almost half of the participants buying substances from other in-patients. Methods of using reflected the wide range of substance use reported, and included intravenous injection, chasing, and smoking. A third of participants reported feeling pressurised to buy, or use substances with other in-patients. For the majority substance use was clearly a social activity with three quarters of the participants reporting that they typically used or drank with others. Sixteen percent of the participants reported typically using with other mental health service users. Two principal components analyses of use situations and self medication data each revealed three factors, explaining 68% and 66% of the variance respectively. All factors had high mean scores, and elicited motivations for substance use. They were (use related to): negative personal and social states (48% variance), pleasant social conditions (13% variance), reward (7% variance), social interaction and boredom (41%) social acceptance (14% variance), and medication side effects (9% variance). An exploratory cluster analysis aimed at identifying sub-groups with distinctive patterns of motivations for use. Scores within clusters varied, with the membership of one cluster scoring highly on all factor items while other cluster members scored low on several items, clearly influencing their motivations for use. This exploratory analysis gives some indication that there are a number of distinctive patterns of use, including people who use in a wide range of situations with a variety of motivations, those who primarily use for relief of unpleasant feelings and social anxiety, and those whose use is predominantly social.;Conclusions: Substance misuse is a common problem in users of adult mental health services, and innovative solutions to understand and address these problems are needed. Although it was uncommon for individuals to directly medicate the symptoms of their illness with substances, their motivations for use reflected a range of social difficulties, isolation and other affective problems. Further investigation of demographic variables and substance use motivations in a larger sample may be an effective way of delineating sub groups with distinct motivations and of developing treatment strategies which take these motivations into account.

In the following paper I aim to provide a review of the literature relevant to this research topic. I begin with a summary of prescription opioids and their use in treatment for pain. I follow with a discussion about opioid misuse and abuse and recent epidemiological research. I review current knowledge about addiction and drug dependency, including recent psychological theories and models of addiction. I also provide an examination of studies which have investigated cognitive impairments associated with drug use, with particular emphasis on deficits in decision-making. Following this, I consider differences in abuse potential between drugs, particularly in light of recent concerns about increases in oxycodone abuse. I highlight gaps in the literature regarding the acute rewarding properties of opioids in non-drug abusing humans. I conclude the review with a rationale for the present study investigating the acute effects and abuse-liability of oxycodone compared to morphine in non-drug abusing healthy volunteers.

This thesis is concerned with heroin. Its use, addiction to it, and the policy measures that have come to surround both in what is now commonly known as 'austerity Britain'. It provides a set of interlinked arguments around these topics through the presentation of four journal articles and related theoretical engagement with data gleaned from an ethnographic exploration of heroin use in a deprived area of North-West England. Whilst the arguments here are diverse, they share one common thread; the need to rethink what we know about heroin at this particular point in time. To this end the thesis makes original contributions to criminological knowledge surrounding the ways in which drug addiction is researched; the socio- economic role(s) of heroin in marginalised communities; heroin assisted treatment techniques; and the ways in which drug policy problems, and some potential solutions to them, have been culturally (re)presented. Following this, the thesis then teases out some of the links between the above and in so doing, offers a unique and progressive theory of heroin addiction in the UK today alongside some tentative suggestions around the future directions of national drug policy. The potentials and limitations of the above, along with the areas revealed to be in need of future research, are discussed to close.

Background: People with substance use disorders (SUDs) often have co-existing physical and/or mental health conditions and are prescribed a large number of medications which may or may not be justified. Among this population, psychiatric medications and opioids are often involved in adverse events. There is, however, a lack of research on the quality of prescribing of these medications. In this thesis, the appropriateness of these medications is explored, as well as the response of prescribers in a specialist addiction service (SAS) to their inappropriate prescribing. Methods: A mixed methods design was utilised. A descriptive quantitative study using routinely available data was conducted to describe the scale of prescribing for service users. A second quantitative component involving questionnaires was carried out to assess the appropriateness of psychiatric medications and opioids in a sample of service users by SAS prescribers. Qualitative interviews were conducted with service users to explore their perspectives on the appropriateness of these medications while prescriber interviews explored how they responded to inappropriate prescribing. Results: The descriptive study showed that 27% of service users were prescribed four or more medications with almost half of them receiving antidepressants. The second study showed that nearly half of service users had at least one inappropriate psychiatric medication or opioid. Interviews with service users revealed that most of them benefited from these medications but that their use often involved making a compromise between risks and benefits. Benefits/risks of medications, prescriber expertise, nature of addiction and communication with service users and prescribers were considered by SAS prescribers before responding to inappropriate prescribing. It appears the need to maintain service users’ stability and well-being may lead to a greater focus on these issues when assessing the appropriateness of prescribing decisions. Conclusion: The quality of prescribing of opioids and psychiatric medications to service users referred to this SAS appeared to present room for improvement. Further research is required with the availability of a more mixed economy of service providers in the alcohol and drug treatment sector to establish if these findings are applicable.

Background: Evidence-based behaviour change interventions are increasingly implemented in wider clinical practice, such as smoking cessation behavioural support interventions (BSIs) delivered via the English NHS Stop Smoking Services (SSSs). However, the process of translating evidence into practice is complex, slow and often unpredictable. Aims: This thesis investigated factors related to the translation of evidence into practice for smoking cessation BSIs, including: specification and reporting of intervention components, fidelity and quality of delivery, and associations between implementation and outcome. Methods: Six mixed-methods studies were conducted using BSIs delivered by the NHS SSSs as a case study for examining implementation. In Study 1, a taxonomy of smoking cessation behaviour change techniques (BCTs) was applied to specify components comprising effective BSIs for pregnant smokers. Study 2 applied the taxonomy to assess the current standard of published reporting of the content of BSIs. Study 3 assessed the reliability of the taxonomy as a framework for specifying BCTs in transcripts of audio-recorded behavioural support sessions. Studies 4 and 5 applied the taxonomy to assess the extent to which manual-specified BCTs are delivered in practice (i.e. fidelity). Study 6 developed a 10-point scale for rating quality of delivery of a key BCT ‘goal-setting,’ and examined whether quality was associated with smokers’ enactment of planned quit attempts (i.e. outcome). Results: The taxonomy demonstrated consistently high reliability for coding into component BCTs the content of BCIs as described in published reports, trial protocols, service treatment manuals and session transcripts, (Studies 1-5). Using this method, 11 evidence-based BCTs for smoking cessation in pregnancy were specified (Study 1). Published reports of BSIs were inadequate, omitting on average 50% of intervention content originally specified in trial protocols (Study 2). Fidelity was found to be consistently low, with typically less than 50% of manual-specified content being delivered (Studies 4 and 5). It was possible to reliably assess quality of ‘goal-setting,’ which on average was low; however, higher quality of goal-setting significantly increased the likelihood of smokers enacting planned quit attempts (Study 6). Conclusions: Translation of evidence into practice for smoking cessation BSIs is not uniform, with information loss occurring as interventions are disseminated and delivered in practice. The taxonomy provides a reliable methodological approach for examining factors related to implementation. Observed translational issues may inform future training and interventions to improve implementation of BSIs in clinical practice.

Substance use among adolescents is a major cause of concern as it can compromise adolescents‘ health, defined in 1948 by the World Health Organization (WHO) as ―a state of complete physical, mental, and social well-being‖ and may hinder adolescents from achieving the developmental transitions they are supposed to accomplish. Further, when individuals initiate substance use as adolescents, addiction is established more easily and quickly (Crews, He, & Hodge,2007; Prokhorov et al., 2006) and individuals remain at greater risk for negative outcomes in the future even if they successfully stop using (Georgiades & Boyle, 2007; Meier et al., 2012; von Sydow, Lieb, Pfister, Höfler, &Wittchen, 2002). With substance use being a preventable behaviour, prevention interventions have been implemented worldwide, mostly focused on demand reduction (Kulis, Nieri, Yabiku, Stromwall, & Marsiglia, 2007) and aimed at achieving some form of abstinence (Midford, 2009). Over recent years, efforts to determine whether prevention interventions are effective have increased due to the growing demand for accountability of interventions in public health (Hillebrand & Burkhart, 2009). Programme evaluation, besides considering the positive and desirable effects from prevention interventions, should also taken into consideration its negative and undesirable effects (i.e. iatrogenic effects) (European Monitoring Centre for Drugs and Drug Addiction (EMCDDA, 2012a)). Programme evaluation is the mechanism through which this judgment on efficacy can be made (Midford, 2000), and isan essential tool to enable policy makers and practitioners to decide which projects to fund and whether a particular intervention is worth continuing, adapting, or discarding (EMCDDA, 2012a). However, in Europe, despite prevention interventions now being systematically monitored by the majority of Member States (EMCDDA, 2009a), prevention effectiveness remains poorly researched (EMCDDA, 2010) and very few prevention interventions have actually been evaluated (EMCDDA, 2012b). Thus, evaluation of prevention interventions is urgently required to increase knowledge about how to enhance their intended effects and decrease the unintended, which in turn will contribute to future prevention interventions‘ success in reducing the prevalence of substance use among adolescents.

Attachment theory has been proposed as a potential framework from which to understand the variable effect of family of origin experiences on the problematic use of drugs in young people. The present study measured family experiences, attachment styles, hopelessness and drug use, drawing participants from both a drug treatment service and the general population of young people. The findings indicated that the young people with drug use problems differed from the control group in that they emphasised the positive consequences of drug use and were more likely to leave school early. Furthermore, aspects of the family experience, close relationships, and attachment anxiety were associated with higher levels of drug use. However, there was an absence of a direct relationship between family of origin experiences and attachment style. The number of close relationships the young person had experienced was directly related to higher levels of drug use, greater attachment anxiety and particular family experiences. It was concluded that, although attachment theory appears to be a promising framework from which to approach the influence of the family on subsequent drug use, the current research failed to identify a direct link between family experiences and measured attachment style. However, the role of romantic relationships appeared to be crucial for young people as they endeavour to create a secure close relationship. Lack of success in this domain of life may be viewed as either, a cause or a side effect of increased use of drugs. It is proposed that, irrespective of the causal instigator, poorer relationships and high levels of drug use will have an interacting effect. Therefore, close relationships are regarded as a legitimate target for therapeutic intervention when addressing the treatment needs of young people with drug use problems.