Smoking Policy Change Within Permanent Supportive Housing

The smoke-free home study: study protocol for a cluster randomized controlled trial of a smoke-free home intervention in permanent supportive housing

Background

Formerly chronically homeless adults who live in permanent supportive housing (PSH) have high prevalence of smoking. It is uncommon to find smoke-free policies in PSH because of the concern that such policies contradict PSH’s harm reduction framework and could increase homelessness should residents lose their housing because of the policy. However, in the absence of such policies, non-smoking PSH residents face the harmful effects of secondhand smoke exposure while residents who smoke see increased risks from high rates of smoking throughout their residence. Our pilot work highlighted the feasibility and acceptability of an intervention designed to promote voluntary adoption of a smoke-free home. Here we report a protocol for a cluster randomized controlled trial of the smoke-free home intervention for formerly chronically homeless residents in PSH.

Methods

The smoke-free home intervention provides face-to-face counseling and instruction to PSH residents on how to adopt a smoke-free home and offers training for PSH staff on how to refer residents to tobacco cessation services. We will randomize 20 PSH sites in the San Francisco Bay Area to either the intervention or wait-list control arms. We will enroll 400 PSH residents who smoke cigarettes in their housing unit and 120 PSH staff who work at the sites. At baseline, three- and six-months follow-up, we will ask residents to report their tobacco use and cessation behaviors and adoption of smoke-free homes. We will ask staff to answer questions on their knowledge, attitudes, practices, and barriers related to supporting residents’ smoking cessation. The primary outcome for PSH residents is adoption of smoke-free homes for 90 days or more at six-months follow-up, and the secondary outcome is point prevalence tobacco abstinence. The primary outcome for PSH staff is change in Smoking Knowledge Attitudes Practices survey score.

Discussion

Voluntary adoption of smoke-free homes is a promising approach for reducing exposure to secondhand smoke and reducing tobacco use among a population facing high rates of tobacco-related disease, and is aligned with PSH’s harm reduction framework. Findings from this study have the potential to inform adoption of tobacco control policies among vulnerable populations most at risk for smoking-related harms.

Trial registration

This study was registered with the U.S. National Institute of Health Clinical Trials register on April 22, 2021: NCT04855357.

Impact of Housing First on Psychiatric Symptoms, Substance Use, and Everyday Life Skills Among People Experiencing Homelessness

The current unblinded, randomized controlled trial analyzed psychiatric symptoms, substance use, and life skills outcomes in participants after 21 months in the Housing First (HF) program. The HF group (intervention) comprised 46 participants and the treatment-as-usual (TAU) group (control) comprised 41 participants. Quantitative outcome measures were collected at baseline and 8 and 21 months. Primary outcomes were mental health and substance use. Secondary outcomes were everyday life skills. Descriptive and comparative analyses and linear regression models are presented. At 21 months, the HF group presented significantly better outcomes regarding alcohol and cannabis use than the TAU group. Moreover, the subgroup of HF participants with severe mental illness had significant improvements in psychotic symptoms, anxiety, depression, social relations, and cannabis use compared to TAU participants. [Journal of Psychosocial Nursing and Mental Health Services, xx(x), xx-xx.].

Public Housing Resident Perspectives on Smoking, Barriers for Smoking Cessation, and Changes in Smoking Mandates

Background

Individuals from low-income groups report disproportionate rates of cigarette use, secondhand smoke (SHS) exposure with increased morbidity and mortality. Smoking bans in public housing have been enacted in attempt to reduce tobacco use and SHS exposure among lower income individuals. This study investigated the support needs of tobacco users living in two public housing complexes in Detroit, Michigan (USA), including their perspectives on smoking, resources and barriers for smoking cessation, and the impact of policy changes.

Methods

This is a mixed-methods study, using a qualitative focus groups approach and a short survey, public housing residents interview data was analyzed to explore themes related to smoking-related issues. Specifically, six themes were assessed across four focus groups: (1) Quitting Smoking, (2) Current Smoking Cessation Resources, (3) Legal Mandates, (4) Education and Perceptions of Smoking, (5) Community Needs and Barriers, and (6) Medical Experiences.

Results

There were 59 participants; the majority (39/42, 93%) of smokers reported at least one quit attempt. During the focus groups, several participants indicated a desire to quit smoking but reported barriers to smoking cessation, such as lack of access to medications, social triggers to continue smoking, and socioeconomic stressors. A number of suggestions were provided to improve smoking cessation resources, including support groups, graphic images of smoking-related diseased tissue, and better communication with health care providers.

Conclusions

These findings demonstrate smoking bans in two public housing complexes can be effective yet are dependent upon a complex set of issues, including numerous barriers to care.

E-Cigarette Use among Current Smokers Experiencing Homelessness

Two-thirds of cigarette smokers experiencing homelessness report using alternative tobacco products, including blunts, cigarillos (little cigars) or roll-your-own tobacco or electronic nicotine delivery systems such as e-cigarettes. We examined attitudes toward e-cigarette use and explored whether e-cigarette use patterns were associated with past-year cigarette quit attempts among current smokers experiencing homelessness. Among the 470 current cigarette smokers recruited from homeless service sites in San Francisco, 22.1% (n = 65) reported the use of e-cigarettes in the past 30 days ('dual users'). Compared to cigarette-only smokers, dual users considered e-cigarettes to be safer than cigarettes. Patterns of e-cigarette use, including the number of times used per day, duration of use during the day, manner of use and nicotine concentration were not associated with past-year cigarette quit attempts. Studies that examine the motivations for use of e-cigarettes, particularly for their use as smoking cessation aids, could inform interventions for tobacco use among people experiencing homelessness.

Smoke-Free Home Intervention in Permanent Supportive Housing: A Multifaceted Intervention Pilot

INTRODUCTION

Smoke-free homes (SFHs), the voluntary adoption of home smoking restrictions, are associated with reduced secondhand smoke exposure. However, SFHs are uncommon in permanent supportive housing (PSH) for formerly homeless adults, who have fivefold higher smoking rates than the general population. We pilot-tested a brief intervention to increase voluntary adoption of SFHs among PSH residents in the San Francisco Bay Area.

AIMS AND METHODS

We pilot-tested a brief intervention to increase voluntary adoption of SFHs among PSH residents in the San Francisco Bay Area. Rest of the methods, PSH residents (n = 100) and staff (n = 62) from 15 PSH sites participated in the intervention between October 2017 and February 2018. Research staff provided counseling to PSH residents on how to adopt an SFH and trained PSH staff on how to counsel residents on smoking cessation. The primary outcome was self-reported voluntary adoption of an SFH for ≥90 days, and the secondary outcome was carbon monoxide-verified PPA at 6-month follow-up. PSH staff completed the Smoking Knowledge, Attitudes, and Practices survey at baseline and 3-month follow-up.

RESULTS

At 6 months, 31.3% of PSH residents had adopted an SFH (vs. 13.0% at baseline) and 16.9% reported carbon monoxide-verified PPA. A positive attitude toward an SFH policy was associated with increased odds of SFH adoption (adjusted odds ratio = 8.68, 95% confidence interval: 2.42, 31.17). Voluntary SFH adoption was associated with increased PPA (adjusted odds ratio = 26.27, 95% confidence interval: 3.43, 201.30). PSH staff reported improved attitudes toward and self-efficacy in delivering cessation care, and decreased barriers to discussing smoking cessation among PSH residents between baseline and 3-month follow-up.

CONCLUSIONS

In this single-arm study, a brief intervention increased SFH adoption and PPA among PSH residents.

IMPLICATIONS

To date, few interventions have addressed SFHs and their association with tobacco use among PSH residents. A "ground-up" approach that relies on buy-in from residents and that promotes voluntary SFHs is an innovative way to increase smoke-free living environments in PSH. This approach could pave a pathway for smoke-free policy implementation in these sites. PSH can play a role in reducing the burden of tobacco use by empowering its residents to adopt voluntary SFHs, which could increase smoking cessation among residents.

Developing Tobacco Control Interventions in Permanent Supportive Housing for Formerly Homeless Adults

Smoke-free policies are effective population-based strategies to reduce tobacco use yet are uncommon in permanent supportive housing (PSH) for formerly homeless individuals who have high rates of smoking. In this study, we partnered with six supportive housing agencies in the San Francisco Bay Area to examine the implementation of smoke-free policies and cessation services. We administered a questionnaire and conducted in-depth, semistructured interviews with agency directors (n = 6), property management staff (n = 23), and services staff (n = 24) from 23 PSH sites on the barriers to implementing tobacco control interventions. All properties restricted smoking in indoor shared areas, but only two had policies restricting smoking in living areas. While there was staff consensus that smoke-free policies were important to reduce tobacco-related harm, participants disagreed on whether smoke-free policies were aligned with PSH's harm reduction framework. Residents' comorbid mental illness and substance use and the lack of appropriate enforcement tools were barriers to implementation. Using these formative findings, we present a framework for a toolkit of strategies to increase implementation of smoke-free policies and cessation interventions in PSH. Successful implementation of indoor smoke-free policies in PSH will require concurrent cessation services to support smoking cessation efforts and address the mental health and substance use needs of residents.

Smoke-Free or Not: Attitudes Toward Indoor Smoke-Free Policies Among Permanent Supportive Housing Residents

Purpose:

Interventions for tobacco dependence are most effective when combined with smoke-free policies, yet such policies are rare in permanent supportive housing (PSH) for formerly homeless adults. We aimed to provide in-depth analysis of attitudes and barriers to and facilitators of implementing smoke-free policies in PSH.

Approach:

Current smokers living in PSH completed a questionnaire and participated in in-depth, semistructured interviews on smoking history, attitudes toward smoke-free policies, and perceived barriers to cessation.

Setting:

We collaborated with 6 San Francisco Bay Area PSH agencies.

Participants:

Thirty-six residents in PSH.

Methods:

Interviews, conducted by trained interviewers, were digitally recorded, transcribed, and analyzed using content analysis methods. Participants were recruited until we reached thematic saturation, or no new themes emerged from the interviews.

Results:

Over half of participants (52.8%, n = 19) reported depression, and 97.2% (n = 35) reported current substance use. Support for indoor smoking bans in living areas was modest (33.1%), although most residents anticipated cutting down (61%) and reported they would not move because of a smoking ban (77.8%). There was interest in quitting smoking, although co-use of tobacco with other substances was a major barrier.

Conclusion:

This study is the first to explore attitudes toward smoke-free policies in PSH. We found that residents in PSH support smoke-free policies and consider them feasible if implementation processes are sound. Our findings underscore the need to address barriers to adopting smoke-free policies and accessing smoking cessation services. In particular, interventions must address the co-use of tobacco with other substances and the impact of smoking on financial and housing stability.