This thesis explores psychological group treatment provided to people with co-existing substance misuse and serious mental health problems in secure settings. The work presented draws from existing research evidence to design an empirical research study. Chapter one provides an introduction to the research literature relating to co-existing serious mental health problems and substance misuse, theoretical approaches to understanding aetiololgy and the links with offending behaviour. Chapter two presents a systematic literature review examining the effectiveness of substance misuse treatment provided within secure settings. The review aimed to investigate the efficacy of current structured substance misuse intervention treatment in secure settings for offenders with co-existing serious mental health problems. Chapter three provides a critique of the Stage of Change and Treatment Readiness scale, a psychometric tool widely used in the field of substance misuse treatment. The psychometric properties of this measure are critically examined and the scale’s clinical utility considered. Chapter four provides a piece of empirical research exploring the efficacy of a specifically designed substance misuse group intervention developed for those with serious mental health problems within the context of two clinical settings. A mixed methods repeated measures programme evaluation design was used and is reported. Study findings are discussed in relation to methodological limitations, implications for practice and recommendations for future research. In conclusion, Chapter five discusses the full thesis findings in the context of previous literature, exploring the limitations of the current thesis and considering future directions for research and practice.

The aim of this thesis was to examine the relationship between substance misuse and crime. Whilst extensive research exists in this area, there remains a paucity of research utilising qualitative methodology. A narrative review demonstrates the complex nature of the drug/crime relationship and provides an argument for the use of narrative in examining the aetiology of a complex relationship. This relationship is further examined in Chapter 3, where Interpretative Phenomenological Analysis (IPA) was used to analyse the narratives of 6 participants. The use of substances contributed to various types of offences for these participants as well as being apparent in the literature appertaining to sexual offending. Chapter 4 examines an intervention conducted with an alcoholic sex offender in treatment at a community drug and alcohol service. The intervention described enabled the client to identify pertinent risk factors (i.e. alcohol misuse) of recidivism without relinquishing his stance of ‘categorical denial’. A critique of the Substance Abuse Subtle Screening Inventory 3 (SASSI-3) is provided in Chapter 5. Examination of psychometric properties suggests that the SASSI-3’s validity is questionable raising concern regarding its appropriate application. The author concludes that this thesis will enhance current understanding of the relationship between substance misuse and crime.

This submission to the University of Greenwich for a Ph.D. by published works is composed of ten peer-reviewed articles, five book chapters, and one journal editorial. The earliest publication is dated from 1992 while the two most recent articles have been formally accepted for publication and are to be published in the near future. The pieces, to aid coherence, are not arranged in strict chronological order but rather in an order best able to demonstrate coherence and theme. The central theme running through these published works relates to the ways that drugs, drug users, and the activities which surround them are often subject to exaggeration, distortion and untruths and that drug control policy, rather than being rationally based is often the result of fear, prejudice and unreason. The core of the submission, eight papers researching the dangerous adulteration of illicit drugs, reflects these issues strongly. An area almost untouched by social science prior to this research these papers represent an attempt to pull together a range of evidence to inform more fully about drug adulteration practices. A wide range of methods, including a relatively innovative approach to researching hard to reach groups via the Internet and World Wide Web were employed. Almost all of the findings are at odds with what is commonly and professionally (drugs field) assumed to happen as regards the adulteration/dilution of illicit drugs. The other contributions all reflect similar concerns but are focussed on other drug related areas. Each piece is preceded by a short contextualising introduction. The appendices include a complimentary unpublished paper on drug adulteration, the preface to one of two books to which I was sole editor, some shorter contributions to drug field publications which, whilst widely read are less academic in their tone and approach, and two publications which represent the culmination of earlier joint research on drug policy.

This thesis seeks to examine the root causes of over-medication in China. I have applied Donald Light’s theoretical model of “Countervailing Powers” in the context of socio-economic transition in China, focusing on the important causes of over-medication (over-prescription) in the healthcare system and seeking to explore how the interacting powers of government, the pharmaceutical industry and the medical profession relate to the phenomenon of prescription drug over-use. The study has mainly used documentary and interview research methods. The primary methods of data collection are: 1) a review of documents and literatures obtained from governmental (e.g. MOH report and Year Book of Public Health, etc.) and non-governmental sources, and 2) semi-structured and structured interviews that focus on doctors in Shandong Province. The findings of this thesis suggest that a complex of interactive social relationships in China causes its problem of over-medication. These include insufficient government subsidy for hospitals and doctors, loopholes in the drug pricing policy and regulations, close ties between the pharmaceutical industry and doctors, doctors’ prescribing practice, and the financial incentives involved in drug sales. This thesis is the first study to apply the countervailing powers theory in China’s healthcare context. The study of the interaction between different groups of actors in the healthcare domain provides a novel understanding of the phenomenon of over-medication in China. The findings are expected to contribute to the development of strategies and recommendations that could reduce drug over-use and improve the healthcare system by improving policy design, implementation and evaluation, doctors’ prescribing behaviour and the doctor–patient relationship. The analytical results of this research will also shed some critical light on current global issues concerning the role of the state and effective healthcare policy implementation in the healthcare domain.

Background and aims: In the UK, the illegal use of anabolic androgenic steroids (steroids) among recreational gym-users has been increasing alongside a growth in the number of steroid-users accessing harm reduction services. Steroid-misuse has therefore become a public health concern. This study explored first-hand experiences of steroid-users’ attitudes towards and motivations for using steroids. It also explored whether and how societal and individual pressures as well as barriers and facilitators influence steroid-users’ decisions to use steroids. One key aim was to develop a Theory of Planned Behaviour (TPB; Ajzen, 1988; 1991) questionnaire. This study also examined the application of TPB variables (attitudes, subjective norms, perceived-behavioural-control and their respective underlying beliefs) to account for the variations in intention to use steroids. Finally, the study explored the differences between steroid-users and non-steroid-users in terms of the TPB variables (i.e., differences in explanation of actual past or current behaviour, and predictions of future intentions within a steroid-user group), as well as their underlying beliefs towards steroids. Methodology: This study used a cross-sectional mixed methodology (exploratory sequential design). The study utilised the TPB theoretical framework and consisted of two phases: (I) A qualitative exploration of steroid-use, leading to the development of a TPB questionnaire and (II) The use of the developed TPB questionnaire to investigate participants’ future intentions concerning steroid-use or non-use.188 adult male recreational gym-users (113 steroid-users and 75 non-steroid-users) participated in this study. Participants were recruited from various online social media (e.g., Facebook, bodybuilding forums) and from Addaction within Lincolnshire, where paper copies of the questionnaire were available. Results: Findings from phase one led to the development of the TPB questionnaire as well as providing novel insights to explain reasons for steroid-use (e.g., reduced natural testosterone levels, self-protection) accounted for outside the TPB framework. During phase two, hierarchical multiple regression revealed that a positive attitude towards steroid-use among users is the most 3 important contributing factor for explaining future intentions to use the drug. Findings from the two individual logistic regressions and between group comparisons highlighted that steroid-users’ attitudes towards steroid-use and perceived-behavioural-control (i.e., a higher level of positive control and factors that enabled steroid-use) were higher than non-users. Non-users’ normative beliefs (i.e., a perceived increase in negative social pressure and disapproval from significant others) were higher than users. Conversely, users perceived a positive outcome of steroid-use whereas non-steroid-users perceived an increased negative outcome of steroid-use for behavioural beliefs. Finally, independent t-tests identified particular beliefs and factors that the groups differed on (e.g., non-users mostly reported unfavourable consequences of steroid-use). Conclusions: This study provides evidence that the application of the TPB can be useful in understanding an individual’s future intentions concerning steroid-use or non-use. The TPB could be used in future research as a template for the development of harm reduction, awareness and education programmes. Furthermore, it may be applied within clinical practice by supporting healthcare professionals to develop specific interventions to target the TPB variables in order to help reduce the use of the drug.

Background: Smoking in pregnancy is a major cause of morbidity and mortality, with a significant cost burden to the NHS. An estimated 26% of women still report smoking at the beginning of, or just before, pregnancy, with 12% reporting smoking throughout. While economic evaluations of cessation interventions in the non-pregnant population are well developed, similar evaluations of within-pregnancy interventions are not. Because of the special circumstances associated with pregnancy, general smoking evaluations cannot be applied in these settings. This thesis outlines the development of an improved economic model designed to capture the healthcare costs and benefits associated with smoking and cessation within pregnancy. Methods: A series of scoping reviews of the electronic resource Medline were conducted to identify either within-pregnancy or childhood morbidities which had potentially causal associations with smoking during or after pregnancy, as well as the incidences of morbidities and health related quality of life (HRQoL) scores attributable to those identified. A systematic review appraised the previous economic literature on cessation during pregnancy, to determine where improvements were needed. To ensure that relapse to smoking could be accounted for, a second systematic review generated pooled estimates of abstinence from smoking in the postpartum period. This information was used to develop and construct the improved economic model. Results: 11 conditions were identified as having a causal association with smoking during pregnancy. The systematic review of previous evaluations identified 17 studies; however, only three were considered high quality, suggesting the need for an improved model. The pooled estimates of abstinence suggested that by two years postpartum, most women had restarted smoking, with most relapsing after three, but before 12, months postpartum. The Economic impacts of Smoking In Pregnancy (ESIP) model consists of two linked decision trees which capture the within-pregnancy aspects, while two linked Markov chains capture the post-pregnancy smoking behaviour for both the mother and her child. ESIP was also extended to control for uncertainty. Conclusion: ESIP improves on the previous literature since it directly captures the impact of the mother’s smoking behaviour on the health of her offspring, both within-pregnancy and childhood, using the most accurate data currently available. Future extensions to ESIP include an adult component for the infant to capture their smoking behaviour.

Prevalence rates for mental health problems amongst drug and alcohol service users in the UK were 74.5% and 85.5% respectively (Weaver et al 2003). 44% of people with psychiatric problems also had a substance misuse problem (Weaver 2003). Aims and objectives: This study aims to identify what service users with dual diagnosis and practitioners who work in this area perceive to be the factors that foster and inhibit their recovery (a meaningful quality of life). This is a narrative study using unstructured interviews to develop a framework for understanding the experiences of people who have a dual diagnosis and to guide those that help them. Methodology: Ten service users and ten practitioners were interviewed using a narrative approach. These were then transcribed and analysed using Langdridge’s (2012) Critical Narrative Analysis framework (CNA). Goffman’s, Link and Phelan’s and Sayce’s theories on stigma and Frank’s discussion of the role of narrative storytelling in illness were used as hermeneutics of suspicion to study meaning within the narratives. Findings: The study explores how four key themes Stigma, Motivation, Recovery and Tension narratives provide an explanatory framework of recovery and identity for both service users and practitioners. It uncovers the interrelationships between the spoiled identities (double jeopardy) of service users and the influence this stigma has on practitioners. The study develops a perspective of how narrative storytelling can help articulate and reframe identities to aid recovery amongst people with a Dual Diagnosis. Relevance: There have been very few studies that explore the lived experience of people with a Dual Diagnosis or the practitioners who work with them. Meta analyses of randomised controlled trials in Dual Diagnosis have found little conclusive evidence of interventions that are effective. The study suggests that in pursuing empiricist research standards, previous studies have missed the holism provided by seeing individual experience as an important factor in affecting the course and effect on people who experience Dual Diagnosis and those around them who try to help.

Those who use heroin and other Class A drugs have been labelled by successive governments since the 1980s as the `enemy within'. Problem drug users, it is claimed, threaten the social cohesion of local communities and put the lives of honest citizens at risk. Anti-drug campaigns have rallied the nation to wage a `war' against drugs, but some commentators have argued that this is actually a war against drug users. British drug policy, it is argued, acts to legitimise and reinforce discrimination, stigmatisation, marginalisation and the social exclusion of Class A drug users, particularly female drug users. This research sought to investigate the social exclusion of heroin users within a high crime area of North East Lancashire. To achieve this aim a survey was undertaken in the area, which in addition to asking the non drug-using residents how they dealt with living in a high crime area, sought to understand their opinions of and behaviour towards those residents believed to be using heroin. The findings of the survey indicated many residents felt their quality of life had seriously been affected by the high amount of crime committed within the area and the majority of these residents claimed the drug-using residents were responsible for this crime. Responses given during the completion of the survey strongly suggested that most non drug-using residents had strong feelings of animosity towards those residents believed to be using Class A drugs and this was confirmed by the negative responses the non drug-using residents gave when discussing the drug-using residents. An understanding of the social existence of those using illicit substances was also sought and this was gained through an ethnographic study of male and female heroin users resident within the area. The findings of the ethnographic research were that drug use was a gendered activity and while both male and female heroin users suffered from discrimination, marginalisation and social exclusion, female heroin users were more `demonised' than male heroin users. This study concludes by making recommendations for changes in policy which, in addition to addressing the deprivation experienced in high crime areas, could also address the discrimination and stigmatisation drug users, especially female drug users, experience. These may also afford drug users the opportunity to overcome social exclusion and return from the margins of society.

Smoking is a deep-rooted and complex psychological, behavioural, social and physiological practice. Smoking is reinforced by positive reinforcement outcomes and negative withdrawals symptoms experienced during abstinence (Marks et al., 2006). Furthermore smoking is a primary contributing factor in health inequality (Raw, McNeill, & West, 1998). Current data suggests that smoking rates in England have fallen to their lowest rate in over eighty years (Brown & West, 2014). Despite the downwards trend in smoking prevalence, smoking remains the UK’s biggest preventable cause of premature mortality (Twigg, Moon, & Walker, 2004). It has been acknowledged that the specialist Stop Smoking support programmes provided by the NHS have helped reduce smoking prevalence (Bauld, Bell, McCullough, Richardson, & Greaves, 2010). Whilst there has been a vast amount of research investigating the most effective behavioural and pharmacological support models (Lancaster, Stead, Silagy, & Sowden, 2000) there has been little research on the impact of smoking cessation advisor smoking status and clinical effectiveness (Lindson-Hawley, Begh, McDermott, McEwen, & Lycett, 2013). This study aimed to identify factors that contribute to NHS Stop Smoking advisor performance. Factors analysed included: advisor smoking status (historic and present); attitudes and beliefs towards smoking; level of training; proportion of time spent supporting patients; and number of patients supported. This study implemented a quantitative cross-sectional design. An online survey was used which consisted of three standardised questionnaires. The sample consisted of Stop Smoking advisors (n=159) from 24 London boroughs. The results were analysed using an ordinal logistic regression. The regression model showed no significant impact on the majority of the variables investigated. The non-contributing variables included: level of training; years practiced; level of advisor education; and number of patients supported in a given year. The model did however show that proportion of time spent delivering smoking cessation support significantly influenced quit rate. The results reinforce previous literature by Lindson-Hawley et al. (2013) which suggests smoking status does not significantly influence smoking practitioners’ outcomes or attitudes towards smoking. Proportion of time spent providing support was found to be a significant factor in predicting quit rate. These results suggest that these factors should be considered when recruiting, commissioning and training new smoking cessation advisors or provider organisations.

The World Anti-Doping Agency (WADA) is the primary global organization responsible for implementing rules against doping in sport. A central element of its mission is the requirement that elite athletes submit their whereabouts information for every day of the year to their relevant Anti-Doping Organization (ADO), in order to facilitate no advance notice out-of-competition doping testing. These requirements have attracted considerable criticism, including the claim that they invade elite athlete privacy in a legally or ethically unacceptable manner. The validity of these claims is threatened by the contestedness of the concept of privacy, which arises from the many different uses to which the concept is put, including in legal and philosophical contexts. Resolving this conceptual confusion requires taking an explicit position on various questions of philosophical methodology, themselves subject to contention. As an alternative to such abstraction, and particularly given the need for a philosophically defensible yet pragmatic policy application, I argue that privacy is best conceived of as the absence of certain contextually relevant harms to the person, which arise in relation to such underlying normative values as fairness between competing athletes. In the specific context of elite athlete whereabouts requirements, I maintain that privacy concerns arise principally in relation to surveillance, intrusion, and breaches of confidence. Of these, the first and second face legal difficulties in the UK, on the basis of European legislation concerning human rights and maximum working time. Ethical problems also arise due to WADAs undifferentiated application of the whereabouts requirements, which ignores the heterogeneity of different types of sports and their respective vulnerabilities to doping. I argue that WADAs whereabouts requirements ought therefore to be revised to (a) ensure that they do not conflict with established law, and (b) respect the very different sets of circumstances entailed by the heteroge­neous world of elite sports.