Background Smoking is endemic amongst people accessing homeless services, and they are disproportionately affected by smoking-related diseases. This paper reports on the results of a 3-month small scale intervention which explored the efficacy, challenges and opportunities of using electronic nicotine delivery systems (ENDS) to support cessation of tobacco smoking with people accessing an Irish supported temporary accommodation (STA) homeless service. It considers the results of this intervention with reference to the balance of harms between the use of vaping to support smoking cessation and continued smoking. Methods Twenty-three participants were recruited. Demographic data, carbon monoxide (CO) measurements, homelessness status and smoking history were recorded. Participants were given an ENDS device and two 10-ml bottles containing e-liquid available in several flavours and at several strengths. Participants could pick up new bottles on a weekly basis. At weeks 1, 4, 8 and 12, the Fagerström Test and Mood and Physical Symptoms Scale (MPSS) were administered. Results Over 75% of the residents in the participating hostel were recruited (23/30). However, there was a substantial loss to follow-up (n = 14) as a result of data protection issues, the transient nature of the population of interest and non-compliance with the intervention. Self-reported reductions in cigarette consumption were found to be statistically significant (p < 0.001). However, reductions in carbon monoxide measurements were not statistically significant. Decreases in Fagerström Nicotine Dependence Test were statistically significant (p = 0.001), but decreases in MPSS “urge to smoke” and “strength of urges” composite scores were not. Reported side effects included coughing, runny nose, bleeding nose, slight sweating, dizziness, increased phlegm and a burning sensation at the back of the throat. Barriers to engagement were peer norms, vaping restrictions in accommodation and adverse life events. Positive effects reported included increased energy, less coughing, better breathing and financial benefits. An improvement in the domain “poor concentration” was also found to be statistically significant (p = 0.040). Conclusion ENDS-based interventions may be effective with this population. Future research should aim to improve follow-up, consider including behavioural components and monitor health effects in relation to ongoing concerns around risks and the balance of harms. Trial registration Registered retrospectively ISRCTN14767579

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Background: Smoking and smoking-related disease is endemic amongst many marginalised populations such as people experiencing homelessness, people who use drugs, people living with HIV, sex workers and members of the LGBTQ+, Indigenous, Traveller and migrant communities. Alternative Nicotine Delivery Systems (ANDS)-based interventions including those using Nicotine Replacement Therapy (NRT) and Electronic Nicotine Delivery Systems (ENDS) show promise in supporting people to reduce their smoking. However, little is known about ANDS-based smoking reduction interventions with marginalised populations. This systematic review provides a best evidence synthesis of ANDS-based smoking reduction interventions to address this gap.Methods:A systematic review protocol was registered on PROSPERO (CRD42020158832) and literature review conducted through MEDLINE/PubMed, CINAHL, EMBASE, OVID SP, ScienceDirect and Google Scholar. The primary outcomes of cigarette smoking, and biochemical validation of abstinence were reported. Secondary outcomes reported included physical health, mental health and other outcomes.Results: Twenty-Nine studies were included in this review. Thirteen of the included studies were randomised controlled trials (RCTs) (n= 2828) and 16 studies were quasi controlled studies (n=1172). The sample size across the studies ranged from 9 to 775 participants. The mean reported age of participants ranged from 32.4 to 56.9 years old with an overall mean age of 39.55. A minority of study participants identified as female (33.43%; with two studies not reporting gender). A range of ANDS-interventions were found to be effective in reducing smoking amongst a range of marginalised groups. However, the overall quality of both the controlled and quasi experimental studies, as evaluated using the JBI Appraisal Tool, was found to be low.Conclusions: Studies are often evaluated as homogenous interventions although they are frequently a group of interventions and lack power analysis of the effects of individual components of the intervention effect. Several studies suggest potential mental health benefits consequent of ANDS-based intervention, though this effect is poorly explored. There is a current lack of RCTs related to ANDS-based smoking related interventions with people experiencing homelessness. Similarly, there is a lack of properly controlled RCTs exploring the use of ENDS with marginalised populations. Future studies should aim to address these deficits.

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