Smoking policy change at a homeless shelter: attitudes and effects

A systematic review and network meta-analysis of population-level interventions to tackle smoking behaviour

This preregistered systematic review and meta-analysis (PROSPERO: CRD 42022311392) aimed to synthesize the effectiveness of all available population-level tobacco policies on smoking behaviour. Our search across 5 databases and leading organizational websites resulted in 9,925 records, with 476 studies meeting our inclusion criteria. In our narrative summary and both pairwise and network meta-analyses, we identified anti-smoking campaigns, health warnings and tax increases as the most effective tobacco policies for promoting smoking cessation. Flavour bans and free/discounted nicotine replacement therapy also showed statistically significant positive effects on quit rates. The network meta-analysis results further indicated that smoking bans, anti-tobacco campaigns and tax increases effectively reduced smoking prevalence. In addition, flavour bans significantly reduced e-cigarette consumption. Both the narrative summary and the meta-analyses revealed that smoking bans, tax increases and anti-tobacco campaigns were associated with reductions in tobacco consumption and sales. On the basis of the available evidence, anti-tobacco campaigns, smoking bans, health warnings and tax increases are probably the most effective policies for curbing smoking behaviour.

Enablers and Inhibitors to Implementing Tobacco Cessation Interventions within Homeless-Serving Agencies: A Qualitative Analysis of Program Partners' Experiences

Despite the high tobacco use rates (~80%) and tobacco-related cancers being the second leading cause of death among people experiencing homelessness within the United States, these individuals rarely receive tobacco use treatment from homeless-serving agencies (HSAs). This qualitative study explored the enablers and inhibitors of implementing an evidence-based tobacco-free workplace (TFW) program offering TFW policy adoption, specialized provider training to treat tobacco use, and nicotine replacement therapy (NRT) within HSAs. Pre- and post-implementation interviews with providers and managers (n = 13) pursued adapting interventions to specific HSAs and assessed the program success, respectively. The organizational readiness for change theory framed the data content analysis, yielding three categories: change commitment, change efficacy and contextual factors. Pre- to post-implementation, increasing challenges impacted the organizational capacity and providers' attitudes, wherein previously enabling factors were reframed as inhibiting, resulting in limited implementation despite resource provision. These findings indicate that low-resourced HSAs require additional support and guidance to overcome infrastructure challenges and build the capacity needed to implement a TFW program. This study's findings can guide future TFW program interventions, enable identification of agencies that are well-positioned to adopt such programs, and facilitate capacity-building efforts to ensure their successful participation.

The Prevalence and Perceived Utility of Mobile Health Technology Among Recently Incarcerated Homeless Adults

Mobile technologies can deliver physical and mental health services for recently incarcerated homeless adults (RIHAs). The purpose of this study was to examine the prevalence and perceived utility of mobile technology to support health behavior change among RIHAs. Participants (n = 324) from an ongoing clinical trial at a homeless shelter in Texas were included in the current descriptive cross-sectional analyses. Over one fourth (28.4%) of participants had an active cell phone. Nearly 90 percent (88.6%) of participants reported at least weekly use of the internet, 77 percent used email (77.2%), and more than half used Facebook (55.2%). Although most participants (82.8%) believed that smartphone applications (apps) could help change their behavior, only a quarter (25.1%) had used an app for this purpose. These findings highlight the potential for smartphone-based intervention technologies, and future studies should examine whether smartphone apps that address mental health and health behaviors are feasible among RIHAs.

Tobacco use characteristics, treatment preferences, and motivation to quit among adults accessing a day shelter in Oklahoma City

Background

Smoking rates are exceptionally high among adults experiencing homelessness (AEH). Research is needed to inform treatment approaches in this population.

Methods

Participants (n=404) were adults who accessed an urban day shelter and reported current smoking. Participants completed surveys regarding their sociodemographic characteristics, tobacco and substance use, mental health, motivation to quit smoking (MTQS), and smoking cessation treatment preferences. Participant characteristics were described and compared by MTQS.

Results

Participants who reported current smoking (N=404) were primarily male (74.8%); White (41.4%), Black (27.8%), or American Indian/Alaska Native (14.1%) race; and 10.7% Hispanic. Participants reported a mean age of 45.6 (SD=11.2) years, and they smoked an average of 12.6 (SD=9.4) cigarettes per day. Most participants reported moderate or high MTQS (57%) and were interested in receiving free cessation treatment (51%). Participants most frequently selected the following options as among the top 3 treatments that offered the best chance of quitting: Nicotine replacement therapy (25%), money/gift cards for quitting (17%), prescription medications (17%), and switching to e-cigarettes (16%). Craving (55%), stress/mood (40%), habit (39%), and being around other smokers (36%) were frequently identified as the most challenging aspects of quitting. Low MTQS was associated with White race, lack of religious participation, lack of health insurance, lower income, greater cigarettes smoked per day, and higher expired carbon monoxide. Higher MTQS was associated with sleeping unsheltered, cell phone ownership, higher health literacy, more years of smoking, and interest in free treatment.

Discussion

Multi-level, multi-component interventions are needed to address tobacco disparities among AEH.

Mental health correlates of quitting cigarette smoking in youth experiencing homelessness

Smoking prevalence among youth experiencing homelessness (YEH) is three times higher than smoking prevalence among the general population. Many YEH who smoke are interested in quitting smoking, but also report smoking to cope with mental health symptoms. Research on factors that facilitate or impede successful smoking cessation among YEH is limited. This study examined mental health correlates (i.e., anxiety and depression symptoms) of quitting-related factors (i.e., quit attempts, perceived barriers to quitting) and whether smoking to cope moderates these relationships among this vulnerable population. The sample consisted of 77 YEH cigarette smokers between the ages of 18-25 who were interested in quitting. Participants completed a survey assessing various behavioral and cognitive factors related to tobacco use. Analyzing two separate models, hierarchical negative binomial and hierarchical linear regression were used to examine hypothesized correlates of the number of past year quit attempts and perceived barriers to quitting. Smoking to cope moderated the relationships of depression with past year quit attempts and perceived barriers to quitting. Those high in depression and smoking to cope had the fewest number of quit attempts and reported the greatest perceived barriers. Anxiety symptoms were not significantly associated with quit attempts or perceived barriers. Smoking cessation interventions that address using smoking to cope with mental health symptoms may be important for YEH with depression.

A community-based tobacco cessation program for individuals experiencing homelessness

BACKGROUND

Tobacco use is common among persons experiencing homelessness (PEH), and interventions are needed. We conducted a community-based, single-arm uncontrolled trial of a pharmacy-linked intervention for smoking cessation for PEH.

METHODS

The intervention took place between September 2019 and June 2021 in homeless shelters in San Francisco, CA. We trained shelter staff on how to provide brief cessation counseling, then tested a program among PEH in two shelters that included one-time pharmacist-delivered cessation counseling and nicotine replacement therapy (NRT) for 3 months. We examined factors associated with cigarette consumption and quit attempts.

RESULTS

We trained 69 staff from 8 shelters and selected 2 of those shelters as pilot sites for the program. Of the 52 participants, 71% were male and 49% were Black. The majority of participants reported making a quit attempt (70%) and using NRT (84%). Having an encounter with staff in the past week was associated with a 40% reduction in weekly consumption (Incidence rate ratio (IRR) 0.61, 95% CI 0.57-0.67) and using medications in the past week was associated with a 23% reduction in weekly consumption (IRR 0.78, 95% CI 0.75-0.81). Using medications in the past week increased the odds of a quit attempt 2.89 times compared to not using medications (Adjusted odds ratio (AOR), 2.89, 95% CI 1.45-5.77).

CONCLUSIONS

Our findings highlight a role for leveraging community-based pharmacists to expand smoking cessation services in homeless shelters to reduce tobacco use among PEH.

Perceived Disease Risk of Smoking, Barriers to Quitting, and Cessation Intervention Preferences by Sex Amongst Homeless Adult Concurrent Tobacco Product Users and Conventional Cigarette-Only Users

Adults experiencing homelessness smoke conventional cigarettes and engage in concurrent tobacco product use at very high rates; however, little is known about how use patterns, perceived disease risk, barriers to quitting smoking, and smoking cessation intervention preferences differ by sex in this group. Participants comprised a convenience sample of 626 adult conventional cigarette smokers experiencing homelessness. Participants self-reported their sex, smoking history, mental health and substance use diagnosis history, other concurrent tobacco product use (CU), disease risk perceptions, perceived barriers to quitting smoking, and preferences regarding tobacco cessation interventions via a computer-administered survey. CU rates were 58.1% amongst men and 45.3% amongst women smokers. In both sexes, CUs started smoking earlier (p-values < 0.001) and were more likely to have been diagnosed with a non-nicotine substance use disorder (p-values < 0.014) relative to cigarette-only users. Among men only, CUs were younger, smoked more cigarettes per day and were more likely to identify as non-Hispanic White (p-values < 0.003) than cigarette-only users. Additionally, male CUs reported a greater risk of developing ≥1 smoking-related disease if they did not quit for good; were more likely to endorse craving cigarettes, being around other smokers, habit, stress/mood swings, and coping with life stress as barriers for quitting smoking; and were less likely to prefer medications to quit smoking relative to male cigarette-only users (p-values < 0.04). On the other hand, female CUs reported a greater risk of developing ≥1 smoking-related disease even if they quit for good; were more likely to endorse stress/mood swings and coping with life stress as barriers for quitting smoking relative to female cigarette-only users (p-values < 0.05); and did not differentially prefer one cessation medication over another. Overall, findings confirm high rates of CU among both sexes, characterize those who may be more likely to be CUs, and reveal opportunities to educate men and women experiencing homeless on the benefits of evidence-based interventions for smoking cessation.

Guest Support for Outdoor Smoke-Free Policies within a Homeless Shelter

Roughly 70-80% of adults experiencing homelessness smoke cigarettes. Smoke-free living/workplace policies are an empirically-supported tobacco control intervention. However, homeless shelters may be reluctant to implement smoke-free policies due to fears of it discouraging current/potential shelter guests from taking refuge there. The current study was meant to characterize guest support for on-property smoke-free policies within a homeless shelter with an extant indoor tobacco use ban amongst never smokers, former smokers, and current smokers to provide data on this point. Participants comprised a convenience sample of adult guests of a homeless shelter in Texas (N = 394, 28.2% women; 10.2% former; and 75.9% current smokers). Participant sociodemographics, smoking status, behavioral health diagnoses, and support for two versions of an on-property outdoor courtyard smoke-free policy (one partial, one complete) were assessed. Data were collected in two waves in a repeated cross-sectional design. Overall, 64.0% of participants supported a partial, and 32.0% a full smoking ban. Logistic regressions, controlling for wave of data collection, age, sex, and any additional significant predictors from a semi-adjusted model, examined associations between participant characteristics and policy support. Older participants (OR = 1.024, CI_0.95 = 1.005-1.044), non-veterans (OR = 2.523, CI_0.95 = 1.156-5.506), former smokers (OR = 2.730, CI_0.95 = 1.191-6.258), and those without severe mental illness (OR = 1.731, CI_0.95 = 1.061-2.824) had significantly greater odds of supporting a partial smoking ban. Relative to current smokers, never smokers (OR = 3.902, CI_0.95 = 2.133-7.137) and former smokers (OR = 8.257, CI_0.95 = 3.951-17.258) had significantly greater odds of supporting a complete smoking ban. The implementation of smoke-free living/workplace policies in homeless shelters may enjoy more support from guests-specifically, non-smokers-than anticipated by shelter administrators. Aside from reducing ambient smoke exposure for never and former smokers, these policies can help to reduce ubiquitous smoking cues for those who may want to quit, are undergoing a quit attempt, or are trying to maintain abstinence. Interventionists might partner with shelter guests, particularly smokers, to inform the roll-out of such policies for maximal acceptance and adoption.

"I smoked that cigarette, and it calmed me down": A qualitative analysis of intrapersonal, social, and environmental factors influencing decisions to smoke among youth experiencing homelessness

INTRODUCTION

Approximately 70% of youth experiencing homelessness smoke cigarettes; many try to quit and are interested in formal smoking cessation programs. The purpose of this study was to describe the intrapersonal, social, and environmental contexts associated with the most recent smoking experience among youth experiencing homelessness and (2) identify differences in contextual factors by age and willingness to quit.

METHODS

Thirty-six youth experiencing homelessness aged 14-24 years and who reported current smoking were recruited from a drop-in center in a Midwestern city. Semi-structured in-person interviews were analyzed to understand smoking behaviors.

RESULTS

Two-thirds of participants reported stress and nicotine dependence as primary reasons for smoking, and older youth (aged 18-24 years) reported smoking to de-escalate negative emotions associated with stressful events. For 25% of participants, and especially older youth, smoking was described as part of a routine. Over 80% of participants smoked outside at the homeless drop-in center or the places they lived. Social prompts from drop-in center peers regularly preempted smoking. Younger youth (aged 14-17 years) reported smoking socially while older youth were more likely to smoke alone.

CONCLUSIONS

For youth experiencing homelessness, smoking is integrated into daily life and is often used to manage stress associated with homelessness and engage socially with homeless peers. Multicomponent interventions to reduce structural stressors specific to homelessness, change social smoking norms (environmental and social context), and address stress management and nicotine dependence (intrapersonal context) are needed to support smoking cessation among youth experiencing homelessness.

IMPLICATIONS

Youth experiencing homelessness overwhelmingly described how daily stressors associated with homelessness and nicotine dependence preceded recent smoking. Older youth (aged 18-24 years) also reported smoking as "routine", which likely underscores nicotine dependence in this group. Younger youth (aged 14-17 years) described social smoking. Researchers must develop optimized multilevel interventions to support youth experiencing homelessness who want to quit smoking. Interventions directly targeting social determinants of stress (e.g., poverty, housing instability, food insecurity) and linkages to supportive services are needed. Complementary strategies to address stress coping and nicotine dependence (intrapersonal context) and social smoking norms (social and environmental context) are also necessitated.

Examining moment to moment affective determinants of smoking rate following a quit attempt among homeless daily smokers

BACKGROUND

Cigarette smoking disproportionately affects homeless individuals, who have a higher smoking prevalence, fewer resources, and increased stressors compared to domiciled smokers. Little is known about how to facilitate smoking cessation among this population although some findings support focusing efforts on affective variables as well as alternate outcomes in order to optimize interventions for this group.

METHODS

Participants were homeless adults recruited from a Dallas, TX, shelter (N = 57, 61.4% male, M_age = 48.8 ± 9.0) to participate in tobacco cessation classes using an American Cancer Society-based therapy and support group with nicotine replacement therapy. Moment-to-moment changes in affect [e.g., negative affect (NA), positive affect (PA), and stress] were recorded via Ecological Momentary Assessments to assess whether they were associated with concurrent changes in cigarettes smoked per day (CPD) following a specific quit attempt. Separate generalized linear models (GLM) were evaluated for each predictor to examine the associations between affective variables and CPD in covariate-adjusted analyses.

RESULTS

Significant interaction effects of time and affect were found for all variables (NA: p = 0.0011, PA: p = 0.0006, stress: p = 0.0259), whereby the association of affect and CPD were significant in the early part of the week but the effects faded as time progressed. With regard to main effects, only increases in PA during the post-quit week significantly predicted fewer CPD (adjusted incidence rate ratio = 0.924, SE = 0.027, p = 0.0032).

CONCLUSIONS

Homeless smokers may be more likely to decrease their cigarette consumption during periods of greater PA throughout the post-quit week. Relationship between positive affect and reduction in CPD suggest focus on affective variables with homeless smokers may be an effective avenue for change in smoking behaviors, particularly in the days immediately following a quit attempt. Time effects should be further investigated to determine when these interventions might best be implemented.

Interventions to reduce tobacco use in people experiencing homelessness

BACKGROUND

Populations experiencing homelessness have high rates of tobacco use and experience substantial barriers to cessation. Tobacco-caused conditions are among the leading causes of morbidity and mortality among people experiencing homelessness, highlighting an urgent need for interventions to reduce the burden of tobacco use in this population.

OBJECTIVES

To assess whether interventions designed to improve access to tobacco cessation interventions for adults experiencing homelessness lead to increased numbers engaging in or receiving treatment, and whether interventions designed to help adults experiencing homelessness to quit tobacco lead to increased tobacco abstinence. To also assess whether tobacco cessation interventions for adults experiencing homelessness affect substance use and mental health.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialized Register, MEDLINE, Embase and PsycINFO for studies using the terms: un-housed*, homeless*, housing instability, smoking cessation, tobacco use disorder, smokeless tobacco. We also searched trial registries to identify unpublished studies. Date of the most recent search: 06 January 2020.

SELECTION CRITERIA

We included randomized controlled trials that recruited people experiencing homelessness who used tobacco, and investigated interventions focused on the following: 1) improving access to relevant support services; 2) increasing motivation to quit tobacco use; 3) helping people to achieve abstinence, including but not limited to behavioral support, tobacco cessation pharmacotherapies, contingency management, and text- or app-based interventions; or 4) encouraging transitions to long-term nicotine use that did not involve tobacco. Eligible comparators included no intervention, usual care (as defined by the studies), or another form of active intervention.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methods. Tobacco cessation was measured at the longest time point for each study, on an intention-to-treat basis, using the most rigorous definition available. We calculated risk ratios (RRs) and 95% confidence intervals (CIs) for smoking cessation for each study where possible. We grouped eligible studies according to the type of comparison (contingent reinforcement in addition to usual smoking cessation care; more versus less intensive smoking cessation interventions; and multi-issue support versus smoking cessation support only), and carried out meta-analyses where appropriate, using a Mantel-Haenszel random-effects model. We also extracted data on quit attempts, effects on mental and substance-use severity, and meta-analyzed these outcomes where sufficient data were available.

MAIN RESULTS

We identified 10 studies involving 1634 participants who smoked combustible tobacco at enrolment. One of the studies was ongoing. Most of the trials included participants who were recruited from community-based sites such as shelters, and three included participants who were recruited from clinics. We judged three studies to be at high risk of bias in one or more domains. We identified low-certainty evidence, limited by imprecision, that contingent reinforcement (rewards for successful smoking cessation) plus usual smoking cessation care was not more effective than usual care alone in promoting abstinence (RR 0.67, 95% CI 0.16 to 2.77; 1 trial, 70 participants). We identified very low-certainty evidence, limited by risk of bias and imprecision, that more intensive behavioral smoking cessation support was more effective than brief intervention in promoting abstinence at six-month follow-up (RR 1.64, 95% CI 1.01 to 2.69; 3 trials, 657 participants; I2 = 0%). There was low-certainty evidence, limited by bias and imprecision, that multi-issue support (cessation support that also encompassed help to deal with other challenges or addictions) was not superior to targeted smoking cessation support in promoting abstinence (RR 0.95, 95% CI 0.35 to 2.61; 2 trials, 146 participants; I2 = 25%). More data on these types of interventions are likely to change our interpretation of these data. Single studies that examined the effects of text-messaging support, e-cigarettes, or cognitive behavioral therapy for smoking cessation provided inconclusive results. Data on secondary outcomes, including mental health and substance use severity, were too sparse to draw any meaningful conclusions on whether there were clinically-relevant differences. We did not identify any studies that explicitly assessed interventions to increase access to tobacco cessation care; we were therefore unable to assess our secondary outcome 'number of participants receiving treatment'.

AUTHORS' CONCLUSIONS

There is insufficient evidence to assess the effects of any tobacco cessation interventions specifically in people experiencing homelessness. Although there was some evidence to suggest a modest benefit of more intensive behavioral smoking cessation interventions when compared to less intensive interventions, our certainty in this evidence was very low, meaning that further research could either strengthen or weaken this effect. There is insufficient evidence to assess whether the provision of tobacco cessation support and its effects on quit attempts has any effect on the mental health or other substance-use outcomes of people experiencing homelessness. Although there is no reason to believe that standard tobacco cessation treatments work any differently in people experiencing homelessness than in the general population, these findings highlight a need for high-quality studies that address additional ways to engage and support people experiencing homelessness, in the context of the daily challenges they face. These studies should have adequate power and put effort into retaining participants for long-term follow-up of at least six months. Studies should also explore interventions that increase access to cessation services, and address the social and environmental influences of tobacco use among people experiencing homelessness. Finally, studies should explore the impact of tobacco cessation on mental health and substance-use outcomes.

Understanding the Associations between Smoking-Related Risk Perception, Interest in Quitting Smoking, and Interest in Lung Cancer Screening among Homeless Adult Smokers

Individuals experiencing homelessness smoke cigarettes at high rates, suffer a disproportionate incidence of lung cancer, but are unlikely to be screened to enhance early detection. Understanding correlates of lung cancer screening (LCS) interest within this vulnerable group may lend insight into prevention and treatment efforts and reduce their smoking-related morbidity and mortality. This study sought to understand how risk perception and interest in quitting smoking relate to LCS interest among homeless adults. Participants comprised a convenience sample of CO-verified current smokers (N = 310; 72.6% men, M_age = 43 + 11.7) from a homeless shelter in Dallas, TX. Participants self-reported risk perception, interest in quitting smoking, and interest in LCS. The average risk perception was 6.7 + 3.2 (range 0-10), 74.8% (n = 232) agreed or strongly agreed with interest in LCS, and 65.8% (n = 204) were interested in quitting smoking. Greater interest in quitting smoking, but not greater risk perception, was associated with greater interest in LCS (adjusted OR: 1.968, (95% CI: 1.213, 3.191), p = 0.006). Risk perception and interest in quitting smoking did not interact in their association with interest in LCS. Results suggest that homeless smokers with an interest in quitting may be receptive to LCS: a diagnostic tool by which cancers can be caught at earlier stages and prior to metastasis. However, few in the current sample would be eligible for LCS based on current guidelines; results have implications for altered screening practices among chronic smokers experiencing homelessness.

Mental Illness and Youth-Onset Homelessness: A Retrospective Study among Adults Experiencing Homelessness

Financial challenges, social and material instability, familial problems, living conditions, structural issues, and mental health problems have been shown to contribute to youth homelessness. Based on the paucity of literature on mental illness as a reason for youth homelessness, the current study retrospectively evaluated the association between the timing of homelessness onset (youth versus adult) and mental illness as a reason for homelessness among homeless adults living in homeless shelters and/or receiving services from homeless-serving agencies. Homeless participants (N = 919; 67.3% men) were recruited within two independent studies from Dallas and Oklahoma. Covariate-adjusted logistic regressions were used to measure associations between homelessness onset and mental illness as a reason for current homelessness, history of specific mental illnesses, the historical presence of severe mental illness, and severe mental illness comorbidity. Overall, 29.5% of the sample reported youth-onset homelessness and 24.4% reported mental illness as the reason for current homelessness. Results indicated that mental illness as a reason for current homelessness (AOR = 1.62, 95% CI = 1.12–2.34), history of specific mental illnesses (Bipolar disorder–AOR = 1.75, 95% CI = 1.24–2.45, and Schizophrenia/schizoaffective disorder–AOR = 1.83, 95% CI = 1.22–2.74), history of severe mental illness (AOR = 1.48, 95% CI = 1.04–2.10), and severe mental illness comorbidities (AOR = 1.30, 95% CI: 1.11–1.52) were each associated with increased odds of youth-onset homelessness. A better understanding of these relationships could inform needs for early interventions and/or better prepare agencies that serve at-risk youth to address precursors to youth homelessness.

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.

Clinician Training in the Adaptation of a Comprehensive Tobacco-Free Workplace Program in Agencies Serving the Homeless and Vulnerably Housed

Tobacco use is exceedingly high among those who are homeless or at risk of homelessness but not commonly addressed by clinicians. Taking Texas Tobacco Free (TTTF) is a tobacco control program that addresses known clinician barriers to intervention (e.g., low training receipt, limited resources). Here, we examine the process and outcomes of TTTF's adaptation within four agencies that provide housing or other services to individuals who are homeless or vulnerably housed. Pre- and post-implementation data were collected from clinicians (N = 68) to assess changes in training receipt, knowledge, and intervention behaviors, relative to program goals. Results indicated significant gains in clinicians' receipt of training in 9 (of 9) target areas (p's ≤ 0.0042) and a 53% knowledge gain (p < 0.0001). From pre- to post-implementation, there were mean increases in the use of the 5As (ask, advise, assess, assist, and arrange) and other evidence-based interventions for tobacco cessation, with significant gains seen in assisting residents/clients to quit, arranging follow-ups, and providing or referring for non-nicotine medications (p's ≤ 0.0491). All program goals, except gains related to advising smokers to quit and the use of specific interventions (behavioral counseling), were met. Overall, TTTF improved clinicians' capacity to address tobacco use among homeless and vulnerably housed individuals and can serve as a model for tobacco control efforts in similar agencies.

Predictors of Overnight and Emergency Treatment among Homeless Adults

High usage of emergency treatment and hospitalization has been reported among homeless individuals. Hence, this study aimed to identify the sociodemographic predictors associated with overnight and emergency hospital treatment among a sample of homeless adults. Participants were recruited from a shelter in Dallas, Texas (N = 354; Mage = 43.7 ± 11.7) and were predominantly uninsured, low-income men from various racial groups. The outcome variables were: (a) stayed overnight for treatment in a hospital; and (b) treated in a hospital emergency room. In logistic regression models, sex emerged as the only predictor of overnight treatment in a hospital (OR = 2.68, 95% CI = 1.61-4.47), and treatment in an emergency room (OR = 2.21, 95% CI = 1.34-3.65), such that women were more likely than men to be treated overnight and use emergency care. Targeted interventions and policies are needed to address homeless women's primary care needs and reduce costlier treatment.

Smoking cessation methods among homeless youth in a Midwestern city

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More than two-third of homeless youth in this study were willing to quit smoking.

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Evidence-based treatments were being underutilized by homeless youth in this study.

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Nicotine replacement therapy was mostly perceived negatively, likely due to misuse.

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Drop-in centers may be an effective location from which to offer cessation services.

Introduction

Nearly three times as many homeless youth smoke cigarettes in the United States (US) compared to the general population of youth. Few studies have focused on how to help homeless youth quit smoking. As part of a series of studies to develop a smoking cessation intervention for homeless youth, this study aimed to describe methods used in past quit attempts by homeless youth.

Methods

 Recruited from a drop-in center in the Midwestern US, the analytic sample was comprised of 32 unaccompanied homeless youth aged 14–24 who smoked combustible tobacco at some point in the past week. In-person qualitative interviews were conducted to understand prior quit attempt experiences of homeless youth.

Results

Twenty-two youth (69%) were willing to quit smoking in the next 30 days. Most previous quit attempts were unassisted (78%). Participants frequently reported engaging in distracting behaviors (e.g., video games) or thoughts (e.g., remaining positive). Nicotine replacement therapy (NRT) was another popular method (38%), but with mostly negative reactions. While less common, vaping and use of cannabis to substitute cigarettes was reported in a notable faction of youth (28%), primarily 18–24 years of age.

Conclusions

Youth are primarily engaging in non-evidence-based strategies to quit smoking. Existing evidence-based treatments are often underutilized or not used according to instructions, and youth who do use evidence-based treatments do not find them useful. Future research should explore effective cessation treatment among homeless youth that can ideally be provided at shelters and drop-in centers.

Implications

Existing evidence-based treatments are underutilized by homeless youth in this study. Most homeless youth are willing to quit in the next month and are interested in trying behavioral counseling and monitored use of NRT. Drop-in centers may be an effective location from which to develop and offer targeted smoking cessation interventions for homeless youth.

Reducing Drinking Among People Experiencing Homelessness: Protocol for the Development and Testing of a Just-in-Time Adaptive Intervention

Background

Adults who are homeless are more likely to have alcohol use disorders (AUDs) compared with domiciled adults. Although AUD treatments are commonly available, many factors (eg, transportation limitations and inability to schedule appointments) contribute to low treatment completion rates and low success rates of these interventions among adults experiencing homelessness. Most adults who are homeless own mobile phones; however, no interventions have been developed that use mobile devices to deliver and support AUD interventions for this population. Mobile phone–based AUD interventions may reduce barriers that have limited the use and utility of traditional interventions.

Objective

The aim of this study is to (1) identify variables (eg, affect, stress, geolocation, and cravings) that predict drinking among homeless adults (phase I), (2) develop a mobile intervention that utilizes an algorithm to identify moments of risk for drinking and deliver treatment messages that are tailored to the individual’s current needs in real time (phase II), and (3) pilot test the intervention app (phase III).

Methods

In phase I, adults experiencing homelessness with an AUD (N=80) will complete baseline, equipment, 2-week, and 4-week follow-up visits in person. Participants will be prompted to complete five daily ecological momentary assessments on a study-provided smartphone for 28 days. The smartphone app will collect GPS coordinates every 5 min for the entire 28-day study period. Participants will wear a transdermal alcohol sensor that will objectively measure alcohol use. In phase II, we will use phase I data to develop an algorithm that identifies moments of heightened risk for drinking and develop treatment messages that address risk factors for drinking. Phase III will pilot test the intervention in 40 adults experiencing homelessness with AUD.

Results

This project was funded in June 2018. IRB approval was obtained in October 2018, and data collection for phase I began in February 2019. Phase III data collection is expected to conclude in 2020. To date, 80 participants have consented to the study, and data analysis for phase I will begin in early 2020.

Conclusions

This research will highlight intervention targets and develop a novel intervention for understudied and underserved adults experiencing homelessness with AUD.

International Registered Report Identifier (IRRID)

DERR1-10.2196/15610

Smoking amongst adults experiencing homelessness: a systematic review of prevalence rates, interventions and the barriers and facilitators to quitting and staying quit

Background

To date, there has been no review of the research evidence examining smoking cessation among homeless adults. The current review aimed to: (i) estimate smoking prevalence in homeless populations; (ii) explore the efficacy of smoking cessation and smoking reduction interventions for homeless individuals; and (iii) describe the barriers and facilitators to smoking cessation and smoking reduction.

Method

Systematic review of peer-reviewed research. Data sources included electronic academic databases. Search terms: ‘smoking’ AND ‘homeless’ AND ‘tobacco’, including adult (18+ years) smokers accessing homeless support services.

Results

Fifty-three studies met the inclusion criteria (n = 46 USA). Data could not be meta-analysed due to large methodological inconsistencies and the lack of randomised controlled trials. Smoking prevalence ranged from 57% to 82%. Although there was no clear evidence on which cessation methods work best, layered approaches with additions to usual care seemed to offer modest enhancements in quit rates. Key barriers to cessation exist around the priority of smoking, beliefs around negative impact on mental health and substance use, and environmental influences.

Conclusions

Homeless smokers will benefit from layered interventions which support many of their competing needs. To best understand what works, future recommendations include the need for consensus on the reporting of cessation outcomes.

Association of Fear and Mistrust with Stress Among Sheltered Homeless Adults and the Moderating Effects of Race and Sex

In shelter settings, homeless individuals often congregate and sleep in proximity to one another, with limited secure places for belongings: a living environment that may engender perceived vulnerability to victimization. Fear of victimization and mistrust of others in the shelter environment may result in greater stress, and racial minority residents and women may be particularly affected. Here, we aimed to examine the associations between fear, mistrust, and fear and mistrust, and stress among sheltered homeless adults, and explore moderation by race and sex. Data were from a convenience sample of adults from a homeless shelter in Dallas, TX (N = 225; 67% black; 27% women). Participants completed the fear and mistrust scale and the urban life stressors scale. Linear regressions were used to measure associations of fear, mistrust, and fear and mistrust with stress, adjusted for age, education, sex, race, history of schizophrenia/schizoaffective disorder, and discrimination. Moderation was assessed with interaction terms. Adjusted results indicated that fear, mistrust, fear and mistrust was positively associated with stress (p < 0.001). Race, but not sex, was a significant moderator of associations between fear and stress, whereby black adults with high levels of fear were more likely than white adults to experience high stress levels. Thus, although more research is needed, results suggest that interventions aimed at reducing fear of victimization may reduce stress for black adults. Given the association of stress with myriad undesirable health outcomes that can further exacerbate known health disparities, further work in this area is critical. Future research should investigate environmental sources of fear to provide further direction for interventions.

Exposure to Violence and Sleep Inadequacies among Men and Women Living in a Shelter Setting

Background

Exposure to violence may explain sleep inadequacies reported by homeless adults, with women being potentially more susceptible to violence and sleep disturbances than men. This study examined the association between violence and sleep inadequacies among homeless adults and explored differences by sex.

Methods

Adult participants were recruited from a shelter (N=194; 71.1% men, M_age = 43.8±12.2). Participants self-reported victimization and/or witnessing violence (mugging, fight, and/or sexual assault) at the shelter, sleep duration (over an average 24 hours), insufficient sleep (days without sufficient rest/sleep), and unintentional daytime sleep (days with unintentional sleep) in the past month. Linear regressions were used to estimate associations between violence and sleep inadequacies, controlling for sex, age, race, months homeless, and depression. Moderation by sex was examined via an interaction term following mean-centering of variables.

Results

Overall, 20.6% of participants (n=40) reported victimization since moving to the shelter. In the last month, participants reported witnessing an average of 2.9±5.1 acts of violence. Over the same timeframe, participants reported 6.9±2.0 hours of sleep nightly, 11.2±10.7 days of insufficient sleep, and 6.2±8.8 days with unintentional daytime sleep. In adjusted analyses, witnessing violence was associated with insufficient sleep (p=.001). Men and women differed only in age and race in unadjusted analyses; sex was not a significant moderator of any association between violence and sleep in adjusted analyses.

Conclusions

Links between witnessing violence and sleep inadequacies should be considered in shelter health promotion efforts. Successful efforts to minimize violence may reduce insufficient sleep amongst both sexes.

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.

Income associations with cigarette purchasing behaviors and quit attempts among people experiencing homelessness

INTRODUCTION

Cigarette purchasing behavior may reflect quitting intentions. Little is known about how income could modify the association between cigarette purchasing behaviors and quit attempts among smokers experiencing homelessness.

METHODS

Homeless, current smokers completed a questionnaire on the amount spent weekly on cigarettes (≤$20/week versus >$20/week), source of cigarettes (store versus other source), quantity of cigarettes purchased (<pack versus ≥pack), and past-year quit attempts. The association of participant income and these cigarette purchasing behaviors were examined. The relationship between cigarette purchasing behaviors and quit attempts was also examined and monthly income (none versus any) was explored as a potential moderator of this relationship.

RESULTS

Of the 472 currently smoking individuals, 55% reported spending >$20/week on cigarettes, 83% reported purchasing cigarettes from a store, and 86% reported purchasing ≥pack during their last purchase. Those who reported an income spent a third of their monthly income on cigarettes, and were more likely to spend >$20/week on cigarettes. The amount spent weekly on cigarettes and the source of cigarettes was not associated with quit attempts, nor did income moderate these relationships. Persons without an income who bought a pack or more of cigarettes made fewer quit attempts (β = -0.4, 95% CI -0.7, -0.2), whereas the association between quantity of cigarettes purchased and quit attempts was not significant for those with an income (β = -0.2, 95% CI -0.4, 0.1).

CONCLUSIONS

Current smokers experiencing homelessness and who are without an income may find it particularly challenging to engage in attempts to quit smoking. Smoking cessation interventions that highlight relief of financial hardship as a potential benefit of successfully quitting smoking may be useful among this population.

Physical activity and sleep problems in homeless adults

Background

For the estimated 554,000 homeless individuals on any given night in the United States, obtaining quality sleep is often challenging. This group is known to have multiple health disparities, potentially affected by sleep problems; therefore, identifying lifestyle factors–such as physical activity–that are associated with improving both quality and quantity of sleep has important implications for public health. Here, we examine associations of physical activity with subjective sleep problems within a large sample of homeless adults.

Methods

Participants were homeless adults recruited from Dallas and Oklahoma (N = 747; 66.1% men, M_age = 43.7±12.1). Participants self-reported insufficient sleep (number of days without sufficient rest/sleep in the last month; categorized as 0, 1–13, 14–29, or ≥30 days), sleep duration (over average 24 hours; categorized as ≤6 [short sleeper], 7–9 [optimal sleeper], or ≥10 hours [long sleeper]), and unintentional daytime sleep (number of days with unintentional sleep in the last month; categorized as 0 vs ≥30 days). Physical activity was assessed subjectively using the BRFSS Physical Activity Questionnaire. Regression analyses were performed to examine the associations between physical activity and sleep problems, controlling for age, sex, race, education, body mass, months homeless, at-risk drinking, self-rated health, serious mental illness, smoking status, and recruitment city.

Results

Failure to meet/exceed physical activity guidelines was associated with higher likelihood of being a long sleeper (OR = 2.64, 95% CI: 1.46, 4.78) but a lower likelihood of having ≥30 days of insufficient rest/sleep (OR = 0.52, 95% CI: 0.29, 0.93).

Conclusions

Findings suggest that physical activity promotion may hold promise for addressing the problem of too much sleep, but not other manifestations of sleep problems among this vulnerable group.

Cumulative Risk Factors Associated with Food Insecurity among Adults who Experience Homelessness

Introduction

There is a dearth of research on the determinants of food insecurity among adults who experience homelessness. According to cumulative risk theory, it is the accumulation of risk factors that places individuals in jeopardy for negative health consequences. Building on the cumulative risk theory, domain specific indices were created to examine the relationship between four cumulative risk factors and food insecurity among adults who experience homelessness.

Methods

Adult participants were recruited from six-area shelters in Oklahoma City (N = 565) during July - August 2016. Participants who affirmatively responded to two-six items of the six-item USDA Food Security Scale-Short form were categorized as food insecure. Four indices of cumulative risk were created based on affirmative survey responses: poor health & risky health behaviors index, personal and sexual victimization index, household disruption, and financial strain. Covariate-adjusted logistic regression models predicted the odds of adults experiencing food insecurity.

Results

Seventy-eight percent of the sample experienced food insecurity. Higher scores for the poor health and risky health behaviors index predicted higher odds of experiencing food insecurity (OR = 1.80, CI: 1.51 - 2.14). Higher scores for the personal and sexual victimization index predicted higher odds of experiencing food insecurity (OR = 1.57, CI: 1.20 - 2.04).

Conclusion

To facilitate food security among adults experiencing homelessness, shelters and community-based programs need to consider homelessness and food insecurity to be multi-faceted public health problems that are inter-related.

Smoking Policy Change Within Permanent Supportive Housing

Smoke-free policies effectively reduce secondhand smoke (SHS) exposure among non-smokers, and reduce consumption, encourage quit attempts, and minimize relapse to smoking among smokers. Such policies are uncommon in permanent supportive housing (PSH) for formerly homeless individuals. In this study, we collaborated with a PSH provider in San Diego, California to assess a smoke-free policy that restricted indoor smoking. Between August and November 2015, residents completed a pre-policy questionnaire on attitudes toward smoke-free policies and exposure to secondhand smoke, and then 7-9 months after policy implementation residents were re-surveyed. At follow-up, there was a 59.7% reduction in indoor smoking. The proportion of residents who identified as current smokers reduced by 13% (95% CI: -38, 10.2). The proportion of residents who reported never smelling SHS indoors (apartment 24.2%, 95% CI: 4.2, 44.1; shared areas 17.2%, 95% CI: 1.7, 32.7); in outdoor areas next to the living unit (porches or patio 56.7%, 95% CI: 40.7, 72.8); and in other outdoor areas (parking lot 28.6%, 95% CI: 8.3, 48.9) was lower post-policy compared with pre-policy. Overall, resident support increased by 18.7%; however, the greatest increase in support occurred among current smokers (from 14.8 to 37.5%). Fewer current smokers reported that the policy would enable cessation at post-policy compared to pre-policy. Our findings demonstrate the feasibility of implementing smoke-free policies in PSH for formerly homeless adults. However, policy alone appears insufficient to trigger change in smoking behavior, highlighting the need for additional cessation resources to facilitate quitting.

The moderating effect of perceived social support on the relation between heaviness of smoking and quit attempts among adult homeless smokers

BACKGROUND

Over 70% of homeless adults smoke cigarettes. Despite the desire to quit, this group rarely receives the external support to make or maintain a successful quit attempt (SQA; intentional quit attempt lasting >24 h). The Heaviness of Smoking Index (HSI) is a cigarette dependence measure that independently predicts SQAs among domiciled adults. For homeless adults, social support may be a way to buffer the impact of cigarette dependence on SQAs.

METHODS

The association of the HSI and past-year SQAs, and the potential moderating role of social support, was examined among 445 homeless smokers (Mage = 43.2 + 11.8, 65% male, 57.5% white). Support was measured by the International Support Evaluation List (ISEL-12) and its 3 subscales: tangible, belonging, & appraisal support.

RESULTS

The HSI was negatively correlated with SQAs (r=-.283, p < .01) and in a regression model controlling for age, sex, and race/ethnicity, appraisal support significantly moderated this relationship (p < .05). The HSI was significantly related to SQAs across low, moderate, and high levels of appraisal support [mean, +1 SD; low (β=-.657, p < .001), medium (β=-.457, p < .001), and high (β=-.258, p < .05)]. Neither the ISEL-12 total nor the other subscales were moderators.

CONCLUSION

The perceived availability of someone to talk to about one's problems appeared to attenuate the strength of the inverse relationship between the heaviness of smoking and SQAs. Fostering appraisal support for homeless smokers through group treatment may reduce the impact of cigarette dependence on making quit attempts. Social support coupled with the increased availability of empirically-supported cessation aids may improve dismal quit rates among homeless adults.

Using mHealth to Increase Treatment Utilization Among Recently Incarcerated Homeless Adults (Link2Care): Protocol for a Randomized Controlled Trial

Background

There is a significant revolving door of incarceration among homeless adults. Homeless adults who receive professional coordination of individualized care (ie, case management) during the period following their release from jail experience fewer mental health and substance use problems, are more likely to obtain stable housing, and are less likely to be reincarcerated. This is because case managers work to meet the various needs of their clients by helping them to overcome barriers to needed services (eg, food, clothing, housing, job training, substance abuse and mental health treatment, medical care, medication, social support, proof of identification, and legal aid). Many barriers (eg, limited transportation, inability to schedule appointments, and limited knowledge of available services) prevent homeless adults who were recently released from incarceration from obtaining available case management, crisis management, substance abuse, and mental health services.

Objective

The aim of the Link2Care study is to assess the effectiveness of a smartphone app for increasing case management and treatment service utilization, and in turn reduce homelessness and rearrest. The goals of this research are to (1) assess the impact of an innovative smartphone app that will prompt and directly link recently incarcerated homeless adults to community-based case management services and resources and (2) utilize in-person and smartphone-based assessments to identify key variables (eg, alcohol or drug use, social support, psychological distress, and quality of life) that predict continued homelessness and rearrest.

Methods

Homeless adults (N=432) who enroll in a shelter-based Homeless Recovery Program after release from the Dallas County Jail will be randomly assigned to one of the three treatment groups: (1) usual case management, (2) usual case management plus smartphone, and (3) usual case management with a study-provided smartphone that is preloaded with an innovative case management app (smartphone-based case management). Those assigned to smartphone-based case management will receive smartphones that prompt (twice weekly) connections to shelter-based case managers. The app will also offer direct links to case managers (available during normal business hours) and crisis interventionists (available 24 hours a day, 7 days a week) with the touch of a button.

Results

Recruitment began in the spring of 2018, and data collection will conclude in 2021.

Conclusions

This research represents an important step toward integrated service connection and health care service provision for one of the most underserved, high need, and understudied populations in the United States.

Trial Registration

ClinicalTrials.gov NCT03399500; https://clinicaltrials.gov/ct2/show/NCT03399500 (Archived by WebCite at http://www.webcitation.org/6zSJwdgUS)

Registered Report Identifier

RR1-10.2196/9868

Concurrent nicotine and tobacco product use among homeless smokers and associations with cigarette dependence and other factors related to quitting

BACKGROUND

Cigarette smoking rates among homeless adults are exceptionally high, contributing to health disparities experienced by this disadvantaged population. Concurrent nicotine and tobacco product use have been shown to result in greater health problems than cigarette smoking alone, and little is known about the rates, motives, and perceived impacts of concurrent use in this group. The purpose of this study is to explore concurrent use rates and constructs of interest among homeless adult daily smokers and to examine differences between concurrent users and non-concurrent users on cigarette dependence, perceived risk of smoking, readiness to quit, and the receipt of recent cessation intervention.

METHODS

Participants (N = 396) were recruited from six homeless-serving agencies and/or shelters in Oklahoma City. Enrolled participants completed self-report questionnaires.

RESULTS

The rate of concurrent use was high -67.2%. Participants most frequently endorsed lower cost and a desire to cut down on cigarette smoking as motives for concurrent product use. Concurrent users indicated both a greater likelihood of developing a smoking-related disease if they did not quit for good and a greater number of past year quit attempts relative to non-concurrent users. There was no significant difference between concurrent users and non-concurrent users on readiness to quit or having received recent smoking cessation intervention.

CONCLUSION

The need for cessation efforts that account for concurrent use for homeless adult smokers is great. Study findings indicate that concurrent users are commonly pursuing the reduction or elimination of cigarette usage and should be specifically targeted for cessation intervention.

Content analysis of homeless smokers' perspectives on established and alternative smoking interventions

BACKGROUND

Cigarette smoking is 5 times more prevalent among homeless individuals than in the general population, and homeless individuals are disproportionately affected by smoking-related morbidity and mortality. Homeless smokers report interest in changing their smoking behavior; however, established smoking cessation interventions are neither desirable to nor highly effective for most members of this population. The aim of this study was to document homeless smokers' perceptions of established smoking interventions as well as self-generated, alternative smoking interventions to elucidate points for intervention enhancement.

METHODS

Participants (N=25) were homeless smokers who responded to semistructured interviews regarding smoking and nicotine use as well as experiences with established and alternative smoking interventions. Conventional content analysis was used to organize data and identify themes.

RESULTS

Participants appreciated providers' initiation of conversations about smoking. They did not, however, feel simple advice to quit was a helpful approach. Instead, they suggested providers use a nonjudgmental, compassionate style, offer more support, and discuss a broader menu of options, including nonabstinence-based ways to reduce smoking-related harm and improve health-related quality of life. Most participants preferred engaging in their own self-defined, alternative smoking interventions, including obtaining nicotine more safely (e.g., vaping, using smokeless tobacco) and using behavioral (e.g., engaging in creative activities and hobbies) and cognitive strategies (e.g., reminding themselves about the positive aspects of not smoking and the negative consequences of smoking). Abrupt, unaided quit attempts were largely unsuccessful.

CONCLUSIONS

The vast majority of participants with the lived experience of homelessness and smoking were uninterested in established smoking cessation approaches. They did, however, have creative ideas about alternative smoking interventions that providers may support to reduce smoking-related harm and enhance quality of life. These ideas included providing information about the relative risks of smoking and the relative benefits of alternative strategies to obtaining nicotine and avoiding smoking.

Cigarette Purchasing Patterns, Readiness to Quit, and Quit Attempts Among Homeless Smokers

Introduction

Cigarette purchasing patterns may be linked with greater readiness to make a quit attempt and more quit attempts among domiciled samples. However, little is known about the cigarette purchasing patterns of homeless smokers or their potential relations to quitting intention and behaviors. This study redressed this gap among a convenience sample of homeless adult smokers from a large shelter in Dallas, Texas.

Methods

Participants (N = 207; Mage = 43; 71.5% male) smoked ≥100 cigarettes over the lifetime and endorsed current daily smoking. Variables assessed included cigarette dependence (time to first cigarette of the day), monthly income, quantity of cigarettes most recently purchased, average money spent on cigarettes weekly, readiness/motivation to quit smoking, and the number intentional quit attempts lasting ≥24h in the past year. Regression analyses were conducted to characterize associations of cigarette purchasing patterns with readiness to quit and quit attempts controlling for sex, age, cigarette dependence, and income.

Results

Most participants purchased cigarettes by the pack (61.4%), and more than half the sample spent ≤$20 on cigarettes per week. Results indicated that spending less money per week on cigarettes was associated with greater readiness to quit (P = .016), even when controlling for income, cigarette dependence, and other covariates. Stratified analyses indicated that this association was significant only for homeless smokers reporting no regular monthly income.

Conclusions

Homeless daily smokers with no reported income who spend little money on cigarettes may make particularly apt targets for cessation interventions due to potential associations with quitting motivation.

Implications

Adults who are homeless smoke at greater rates and quit at lower rates than domiciled adults, leading to significant smoking-related health disparities among this group. Findings suggest that cigarette purchasing patterns are linked with readiness to quit smoking among smokers who are homeless. Results elucidate one of the myriad factors that contribute to tobacco-related disparities among this group and findings may have implications for cessation interventions in homeless shelters and other contexts where resources are limited.

Evaluation of Tobacco Control Policies in San Francisco Homeless Housing Programs

BACKGROUND

The 2014 Surgeon General's Report noted that high smoking rates in vulnerable populations such as the homeless have been a persistent public health problem; smoking prevalence among individuals experiencing homelessness exceeds 70%. Historically, service providers for the homeless have not enacted comprehensive tobacco control policies.

METHOD

We conducted a qualitative study of homeless housing programs in San Francisco. Administrators representing 9 of the city's 11 homeless service agencies were interviewed to assess institutional smoking-related policies and cessation programs and perceived barriers and receptivity to instituting tobacco control interventions.

RESULTS

Respondents indicated that although most programs had adopted smoke-free grounds and some had eliminated evidence of staff smoking, the smoking status of clients was assessed only when required by funders. None of the programs offered smoking cessation interventions. Most administrators were receptive to adopting policies that would promote a tobacco-free culture; however, they noted that their clients had unique challenges that made traditional smoking cessation programs unfeasible.

CONCLUSIONS

Homeless housing programs in San Francisco have not yet adopted a tobacco-free culture. Existing policies were created in response to external mandates, and smoking cessation programs may need to be modified in order to effectively reach clients.

Tobacco Cessation Behaviors Among Older Homeless Adults: Results From the HOPE HOME Study

INTRODUCTION

Tobacco-attributable deaths contribute significantly to the increased mortality observed among homeless adults aged 50 years or more. Little is known about the epidemiology of tobacco use among older homeless individuals. This longitudinal cohort study examines smoking behaviors and factors associated with smoking cessation among homeless individuals aged 50 years or more.

METHODS

We recruited a prospective cohort of 350 homeless individuals sampled from the community in Oakland, California. At 6 months follow-up, participants reported their cigarette quit attempts and 30-day abstinence. We used multivariable logistic regression to examine factors associated with making a quit attempt at follow-up, hypothesizing that heavier smokers would be less likely to make a quit attempt.

RESULTS

Of the 272 ever-smokers, 229 (84.2%) were current smokers (quit ratio 15.8). Among current smokers at enrollment who had a follow-up interview at 6 months, 43.6% (n = 71) reported making a quit attempt during the follow-up. Of those who reported making a quit attempt, 14.3% (n = 10) reported 30-day abstinence at follow-up. Among those who had reported making a quit attempt at follow-up, 22.5% had used nicotine replacement therapy (NRT). Staying in shelters (adjusted odds ratio [AOR] = 2.5, 95% confidence interval [CI] = 1.0-5.8) was associated with higher odds of making a quit attempt at follow-up. Higher cigarette consumption was associated with lower odds of making a quit attempt (AOR = 0.9, 95% CI = 0.8-0.9).

CONCLUSIONS

In this study of tobacco use in older homeless adults, rates of quit attempts were similar to that observed in the general population, but successful quitting was lower.

IMPLICATIONS

The current study is among the first studies to focus specifically on tobacco use and cessation behaviors among older homeless adults. The high prevalence of smoking and the low rates of successful quitting highlight numerous opportunities to intervene to increase quitting rates among this population. Among these, increasing access to smoke-free living environments and identifying effective cessation therapies will be critical to reducing tobacco-related disease burden among older homeless adults.

Interest in Smoking Cessation Related to a Smoke-Free Policy Among Homeless Adults

Homeless adults have among the highest rates of cigarette smoking. Few studies have explored the potential of smoke-free policies as facilitators of smoking cessation or harm reduction among sheltered homeless adults. We focused on clients of a homeless shelter in San Diego, California. The facility prohibited smoking indoors and outdoors within five blocks of the building, and permitted smoking during four smoking breaks during the day in designated smoking zones away from the building. Current and former smokers who were residents of the facility were interviewed on smoking behaviors and attitudes toward these policies. Of the 170 ever smokers, 75.3% were current smokers. The average daily cigarette consumption was 6.6 cigarettes per day (SD 4.3). More than half of the participants (57.8%) attempted to quit smoking in the past year. Of the current smokers, three-fourths agreed that the facility policies were associated with their reduced consumption, and about half agreed that the policies were associated with either making a quit attempt or getting ready to quit completely. Sixty percent agreed that further restrictions on smoking, beyond the current policies, would be associated with increased interest in quitting smoking completely. Less than 10% agreed that they were unhappy to stay in the facility because of the policies. Findings suggest that smoke-free policies may not influence occupancy rates in shelters serving clientele with high rates of cigarette smoking. Smoke-free policies in homeless service settings present an important and un-tapped opportunity to reduce smoking behaviors among homeless adults.

Implementing Tobacco Control Programs in Homeless Shelters

Background. Tobacco-related chronic diseases contribute significantly to the increased morbidity and mortality observed in the homeless population. Few homeless service settings address tobacco use among their clients. Method. Directors and staff from emergency and transitional shelters in San Diego County completed a questionnaire on no-smoking policies and smoking cessation services and participated in in-depth, semistructured interviews to examine the barriers to and facilitators of implementing smoke-free policies and cessation services in their facilities. Results. Facilities differed in outdoor restrictions around smoking: 61.5% reported having an outdoor designated smoking zone, and 25% reported having a campus-wide ban on smoking. About one-third of the facilities offered on-site resources for smoking cessation. Although directors and staff supported smoke-free policies, they reported that the increased resources needed to “police” the policy created barriers to implementation. Almost all directors and staff expressed interest in developing an on-site tobacco control program, but they reported that lack of expertise among staff posed challenges to implementing such a program. Conclusion. Our findings suggest that for a tobacco control program to be effective in homeless shelters, it should include training and incentives for staff to implement smoke-free policies and cessation services.

The Potential Explanatory Role of Perceived Stress in Associations Between Subjective Social Status and Health-Related Quality of Life Among Homeless Smokers

Homeless individuals smoke at high rates relative to the general population and are at heightened risk of tobacco-related illnesses and poor health-related quality of life (HRQoL). Homeless smokers also report low subjective social status (SSS) or perceived social standing relative to others. SSS may contribute to poor HRQoL, potentially through perceived stress. The current study examined the role of perceived stress in the association of SSS and HRQoL among 227 (70.9% male, Mage = 43.2) homeless smokers. Participants completed self-report measures of SSS, perceived stress, and HRQoL. Perceived stress partially explained the relation between SSS (United States and Community) and HRQoL in covariate-adjusted analyses. Results suggested that perceived stress is a pathway through which SSS contributes to HRQoL among homeless smokers. Findings broaden current understanding of the impact of social disadvantage and perceived stress on HRQoL among homeless smokers.

Perceived cessation treatment effectiveness, medication preferences, and barriers to quitting among light and moderate/heavy homeless smokers

INTRODUCTION

Homeless individuals smoke at disproportionately high rates and quit at disproportionately low rates relative to domiciled smokers. Targeted research is needed to inform future interventions. Socio-demographic characteristics of homeless adults suggest that light smoking may be prevalent, and the relation between smoking level and treatment-related preferences/needs is unknown. The current study addressed these gaps in a sample of homeless smokers.

METHODS

Participants (N=237) were homeless adult daily light (1-10 cigarettes per day) and moderate/heavy (>10 cigarettes per day) smokers recruited from a single shelter that offered cessation treatment. Survey items assessed perceived treatment effectiveness, pharmacological intervention preferences, and barriers to quitting smoking. Logistic regressions were used to assess differences in treatment-related factors by smoking level.

RESULTS

The prevalence of light smoking (44.7%) was higher than in previously studied samples of domiciled smokers. Relative to moderate/heavy smokers, light smokers smoked for fewer years, had more quit attempts in the last year, and were more likely to smoke menthol cigarettes. They were less likely to believe that medications would give them the greatest chance of quitting and more likely to believe that group counseling would be helpful. Light smokers did not differ from moderate/heavy smokers on specific pharmacological intervention preferences or on perceived barriers to quitting smoking, including craving.

CONCLUSIONS

The promotion of pharmacotherapy to address cravings may be necessary for light smokers, who represent a sizeable proportion of homeless smokers and who may make apt intervention targets given their higher rates of purposeful quit attempts relative to heavier smoking counterparts.