The Role of Mental Health and Substance Use in Homeless Adults' Tobacco Use and Cessation Attempts

Association between psychosocial factors and co-morbid cigarette smoking and alcohol use in a population experiencing homelessness

The prevalence of combustible cigarette smoking in populations experiencing homelessness in the United States is five times that of the general population. The psychosocial well-being of persons who smoke and experience homelessness is poorer if such persons also use alcohol heavily. The PTQ2 study was a randomized clinical trial among persons experiencing homelessness who were also current smokers and heavy alcohol consumers. Secondary data analysis of the PTQ2 baseline data was conducted to examine associations among psychosocial variables (anxiety, depression, hopelessness, social network size), heaviness of smoking (cigarettes/day) and alcohol consumption (drinking days/month), and duration and frequency of homelessness. Among the 420 participants, the majority were male (75%), black (70%) and non-Hispanic (94%) with a mean age of 46.6 years (SD = 11.6).  Bivariate analyses show that heaviness of smoking was positively correlated with social network size (r = 0.16, p = .001). Heaviness of drinking was positively correlated with the MINI anxiety score (r = 0.13, p = .009) and marijuana use (median total number of drinks in past 30 days among those who used marijuana in past 30 days vs. did not use: 50 vs. 24, p < .0001), and associated with frequency of homelessness (median total number of drinks in past 30 days among those experiencing homelessness once vs. >1 time: 30 vs. 44, p = .022). The findings highlight the psychosocial factors that warrant consideration when addressing heavy smoking and alcohol consumption in persons experiencing homelessness.

Tobacco use, trauma exposure and PTSD: a systematic review

Tobacco use remains one of the most significant preventable public health problems globally and is increasingly concentrated among vulnerable groups, including those with trauma exposure or diagnosed with PTSD. The goal of this systematic review was to update and extend previous reviews. Of the 7224 publications that met the initial criteria, 267 were included in the review. Summary topic areas include conceptual frameworks for the relation between trauma or PTSD and tobacco use; associations between trauma exposure or PTSD and tobacco use; number and type of trauma exposures and tobacco use; PTSD symptoms and tobacco use; Treatment-related studies; and the examination of causal relations. Evidence continues to indicate that individuals exposed to trauma or diagnosed with PTSD are more likely to use tobacco products, more nicotine dependent and less likely to abstain from tobacco even when provided evidence-based treatments than individuals without trauma. The most commonly cited causal association proposed was use of tobacco for self-regulation of negative affect associated with trauma. A small proportion of the studies addressed causality and mechanisms of action. Future work should incorporate methodological approaches and measures from which we can draw causal conclusions and mechanisms to support the development of viable therapeutic targets.

Depression, Anxiety, and Cigarette Smoking Among Patients with Tuberculosis

Smoking adversely affects tuberculosis (TB) outcomes and may be associated with depression and anxiety among people diagnosed with TB in Botswana. We conducted a cross-sectional study among patients newly diagnosed with TB in Gaborone, Botswana, evaluating factors associated with self-reported cigarette smoking. We performed Poisson regression analyses with robust variance to examine whether depressive and anxiety symptoms were associated with smoking. Among 180 participants with TB enrolled from primary health clinics, depressive symptoms were reported in 47 (26.1%) participants and anxiety symptoms were reported in 85 (47.2%) participants. Overall, 45 (25.0%) participants reported current smoking. Depressive symptoms were associated with a higher prevalence of smoking (adjusted prevalence ratio [aPR]: 2.04; 95% confidence interval [CI]: 1.29-3.25) in the adjusted analysis. The association between anxiety symptoms and smoking did not reach statistical significance (aPR: 1.26; 95% CI: 0.77-2.05). Future studies should further investigate these associations when addressing TB care.

Psychosocial factors influencing smoking relapse among youth experiencing homelessness: A qualitative study

OBJECTIVES

In the United States, up to 70% of youth experiencing homelessness smoke cigarettes. Many are interested in quitting; however, little is known about psychosocial factors influencing smoking relapse in this population. This study, part of a larger project to develop an optimized smoking cessation intervention for youth experiencing homelessness, aimed to describe how psychosocial factors influence smoking relapse in this group.

METHODS

This study describes the smoking relapse experiences of 26 youth tobacco users, aged 14-24 years, who were recruited from a homeless drop-in center in Ohio. We conducted semi-structured interviews to understand how stress, opportunity, and coping contribute to smoking relapse.

RESULTS

Five themes emerged from the data: (1) smoking as a lapse in emotional self-regulation in response to stress; (2) smoking as active emotional self-regulation in response to stress; (3) social opportunities facilitate smoking in the context of emotion-focused stress coping; (4) problem-focused stress coping; and (5) opportunity facilitates smoking relapse.

CONCLUSIONS

Stress was a primary driver of smoking relapse among youth experiencing homelessness, yet social and environmental opportunities to smoke also precipitated relapse. Interventions to improve abstinence among this population should target foundational stressors, coping skills, social supports, and nicotine dependence.

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.].

Ongoing tobacco use in women who experience homelessness and unstable housing: A prospective study to inform tobacco cessation interventions and policies

BACKGROUND

Tobacco use is common in people who experience homelessness. However, despite biological differences in use by sex and lower quit rates in women, research in homeless and unstably housed (HUH) women is sparse. We identified correlates of use specific to this population, with the goal of informing tobacco cessation programs tailored for HUH women.

METHODS

We conducted a prospective study among HUH women recruited from San Francisco homeless shelters, street encampments, free meal programs and low-income hotels. Between June 2016 and January 2019, study participants completed six monthly interviews to examine factors associated with tobacco use, defined as urinary cotinine >10 pg/mL or self-reported prior 30-day use.

RESULTS

Among 245 participants, 40% were Black, the median age was 53, 75% currently used tobacco and 89% had ≥one 24-hour quit attempt in the prior year. Tobacco use was more common in women with PTSD (66% vs. 48%) and depression (54% vs. 35%) compared to women without these conditions. Adjusted odds of tobacco use decreased significantly with increasing age (OR_{/5 yrs}: 0.81; 95% CI:0.68, 0.96) and increased with an increasing number of additional substances used (OR: 2.52; 95% CI: 1.88, 3.39).

CONCLUSION

Outside of a treatment setting and within a community-recruited sample population composed of HUH women, the number of additional substances used is a primary correlate of ongoing tobacco use. Tailored cessation interventions that prioritize the issue of multiple substance use, and public health policies that allocate funding to address it, may increase tobacco cessation in this population.

Homeless women's perspectives on smoking and smoking cessation programs: A qualitative study

BACKGROUND

Individuals who are unsheltered or experiencing homelessness are more likely to smoke than those in the general population and have a higher prevalence of tobacco-related illnesses. Those who are unhoused make quit attempts at rates similar to the general population, however rates of successful quitting are much lower. Women bear a higher burden of smoking-related diseases and are less successful in their cessation efforts than men. Despite these increased risks and challenges, cessation programs specifically designed to meet the needs of women experiencing homelessness are extremely rare.

METHODS

To examine perceptions of smoking cessation programs among women who are unstably housed, we conducted in-depth, semi-structured interviews with twenty-nine women experiencing homelessness or unstable housing who had histories of tobacco and substance use. Interviews explored the social context of smoking, as well as interest in, barriers to, and facilitators of quitting. We used a grounded theory approach to analyze the transcripts.

RESULTS

Participants reported a number of structural barriers to cessation. They reported obstacles to participating in existing cessation programs, including chronic stress related to experiences of being unsheltered and fear of being exposed to neighborhood violence. These conditions were paired with a strong need to self-isolate in order to maintain personal safety, which runs counter to traditional group-based cessation programs.

CONCLUSION

A dissonance exists between current smoking cessation programs and the needs of women who are unsheltered or unstably housed. Alternative cessation treatment delivery models that address extremely high levels of chronic stress violence, and avoidance of group settings are needed, as are programs that provide options for safe participation.