Depression Symptoms Among Homeless Smokers: Effect of Motivational Interviewing

Discrimination, Mental Health, and Readiness to Quit Smoking

We conducted a cross-sectional study, examining the mediation effects of depression and anxiety on the association between discrimination and readiness to quit cigarette smoking among African American adult cigarette smokers experiencing homelessness. Using a convenience sample, participants were recruited from a homeless shelter in Southern California. Scores of discrimination, depressive, and anxiety symptoms, and readiness to quit smoking were analyzed using linear regression modeling. We enrolled 100 participants; 58 participants were male. In the final model, discrimination had no association with readiness to quit (b = 0.02; 95% CI [-0.04, 0.08]; p = 0.47). The indirect effects of depression (b = 0.04, [0.01, 0.07]; p = 0.02) and anxiety (b = 0.03; [0.01, 0.05]; p = 0.04) reached statistical significance; the direct effects of depression (b = -0.01; [-0.09, 0.04]; p = 0.70) and anxiety (b = -0.00; [-0.09, 0.06]; p = 0.86) did not. Future studies should explore these associations to enhance smoking cessation programs for this population.

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 We also searched trial registries to identify unpublished studies.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.

A cluster feasibility trial to explore the uptake and use of e-cigarettes versus usual care offered to smokers attending homeless centres in Great Britain

Smoking rates in the UK are at an all-time low but this masks considerable inequalities; prevalence amongst adults who are homeless remains four times higher than the national average. The objective of this trial was to assess the feasibility of supplying free e-cigarette starter kits to smokers accessing homeless centres and to estimate parameters to inform a possible future larger trial. In this feasibility cluster trial, four homeless centres in Great Britain were non-randomly allocated to either a Usual Care (UC) or E-Cigarette (EC) arm. Smokers attending the centres were recruited by staff. UC arm participants (N = 32) received advice to quit and signposting to the local Stop Smoking Service. EC arm participants (N = 48) received an EC starter kit and 4-weeks supply of e-liquid. Outcome measures were recruitment and retention rates, use of ECs, smoking cessation/reduction and completion of measures required for economic evaluation. Eighty (mean age 43 years; 65% male) of the 153 eligible participants who were invited to participate, were successfully recruited (52%) within a five-month period, and 47 (59%) of these were retained at 24 weeks. The EC intervention was well received with minimal negative effects and very few unintended consequences (e.g. lost, theft, adding illicit substances). In both study arm, depression and anxiety scores declined over the duration of the study. Substance dependence scores remained constant. Assuming those with missing follow up data were smoking, CO validated sustained abstinence at 24 weeks was 3/48 (6.25%) and 0/32 (0%) respectively for the EC and UC arms. Almost all participants present at follow-up visits completed data collection for healthcare service and health-related quality of life measures. Providing an e-cigarette starter kit to smokers experiencing homelessness was associated with reasonable recruitment and retention rates and promising evidence of effectiveness and cost-effectiveness.

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.

Motivational interviewing for smoking cessation

BACKGROUND

Motivational Interviewing (MI) is a directive patient-centred style of counselling, designed to help people to explore and resolve ambivalence about behaviour change. It was developed as a treatment for alcohol abuse, but may help people to a make a successful attempt to stop smoking.

OBJECTIVES

To evaluate the efficacy of MI for smoking cessation compared with no treatment, in addition to another form of smoking cessation treatment, and compared with other types of smoking cessation treatment. We also investigated whether more intensive MI is more effective than less intensive MI for smoking cessation.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialised Register for studies using the term motivat* NEAR2 (interview* OR enhanc* OR session* OR counsel* OR practi* OR behav*) in the title or abstract, or motivation* as a keyword. We also searched trial registries to identify unpublished studies. Date of the most recent search: August 2018.

SELECTION CRITERIA

Randomised controlled trials in which MI or its variants were offered to smokers to assist smoking cessation. We excluded trials that did not assess cessation as an outcome, with follow-up less than six months, and with additional non-MI intervention components not matched between arms. We excluded trials in pregnant women as these are covered elsewhere.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methods. Smoking cessation was measured after at least six months, using the most rigorous definition available, on an intention-to-treat basis. We calculated risk ratios (RR) and 95% confidence intervals (CI) for smoking cessation for each study, where possible. We grouped eligible studies according to the type of comparison. We carried out meta-analyses where appropriate, using Mantel-Haenszel random-effects models. We extracted data on mental health outcomes and quality of life and summarised these narratively.

MAIN RESULTS

We identified 37 eligible studies involving over 15,000 participants who smoked tobacco. The majority of studies recruited participants with particular characteristics, often from groups of people who are less likely to seek support to stop smoking than the general population. Although a few studies recruited participants who intended to stop smoking soon or had no intentions to quit, most recruited a population without regard to their intention to quit. MI was conducted in one to 12 sessions, with the total duration of MI ranging from five to 315 minutes across studies. We judged four of the 37 studies to be at low risk of bias, and 11 to be at high risk, but restricting the analysis only to those studies at low or unclear risk did not significantly alter results, apart from in one case - our analysis comparing higher to lower intensity MI.We found low-certainty evidence, limited by risk of bias and imprecision, comparing the effect of MI to no treatment for smoking cessation (RR = 0.84, 95% CI 0.63 to 1.12; I² = 0%; adjusted N = 684). One study was excluded from this analysis as the participants recruited (incarcerated men) were not comparable to the other participants included in the analysis, resulting in substantial statistical heterogeneity when all studies were pooled (I² = 87%). Enhancing existing smoking cessation support with additional MI, compared with existing support alone, gave an RR of 1.07 (95% CI 0.85 to 1.36; adjusted N = 4167; I² = 47%), and MI compared with other forms of smoking cessation support gave an RR of 1.24 (95% CI 0.91 to 1.69; I² = 54%; N = 5192). We judged both of these estimates to be of low certainty due to heterogeneity and imprecision. Low-certainty evidence detected a benefit of higher intensity MI when compared with lower intensity MI (RR 1.23, 95% CI 1.11 to 1.37; adjusted N = 5620; I² = 0%). The evidence was limited because three of the five studies in this comparison were at risk of bias. Excluding them gave an RR of 1.00 (95% CI 0.65 to 1.54; I² = n/a; N = 482), changing the interpretation of the results.Mental health and quality of life outcomes were reported in only one study, providing little evidence on whether MI improves mental well-being.

AUTHORS' CONCLUSIONS

There is insufficient evidence to show whether or not MI helps people to stop smoking compared with no intervention, as an addition to other types of behavioural support for smoking cessation, or compared with other types of behavioural support for smoking cessation. It is also unclear whether more intensive MI is more effective than less intensive MI. All estimates of treatment effect were of low certainty because of concerns about bias in the trials, imprecision and inconsistency. Consequently, future trials are likely to change these conclusions. There is almost no evidence on whether MI for smoking cessation improves mental well-being.

Additional behavioural support as an adjunct to pharmacotherapy for smoking cessation

BACKGROUND

Pharmacotherapies for smoking cessation increase the likelihood of achieving abstinence in a quit attempt. It is plausible that providing support, or, if support is offered, offering more intensive support or support including particular components may increase abstinence further.

OBJECTIVES

To evaluate the effect of adding or increasing the intensity of behavioural support for people using smoking cessation medications, and to assess whether there are different effects depending on the type of pharmacotherapy, or the amount of support in each condition. We also looked at studies which directly compare behavioural interventions matched for contact time, where pharmacotherapy is provided to both groups (e.g. tests of different components or approaches to behavioural support as an adjunct to pharmacotherapy).

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialised Register, clinicaltrials.gov, and the ICTRP in June 2018 for records with any mention of pharmacotherapy, including any type of nicotine replacement therapy (NRT), bupropion, nortriptyline or varenicline, that evaluated the addition of personal support or compared two or more intensities of behavioural support.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials in which all participants received pharmacotherapy for smoking cessation and conditions differed by the amount or type of behavioural support. The intervention condition had to involve person-to-person contact (defined as face-to-face or telephone). The control condition could receive less intensive personal contact, a different type of personal contact, written information, or no behavioural support at all. We excluded trials recruiting only pregnant women and trials which did not set out to assess smoking cessation at six months or longer.

DATA COLLECTION AND ANALYSIS

For this update, screening and data extraction followed standard Cochrane methods. The main outcome measure was abstinence from smoking after at least six months of follow-up. We used the most rigorous definition of abstinence for each trial, and biochemically-validated rates, if available. We calculated the risk ratio (RR) and 95% confidence interval (CI) for each study. Where appropriate, we performed meta-analysis using a random-effects model.

MAIN RESULTS

Eighty-three studies, 36 of which were new to this update, met the inclusion criteria, representing 29,536 participants. Overall, we judged 16 studies to be at low risk of bias and 21 studies to be at high risk of bias. All other studies were judged to be at unclear risk of bias. Results were not sensitive to the exclusion of studies at high risk of bias. We pooled all studies comparing more versus less support in the main analysis. Findings demonstrated a benefit of behavioural support in addition to pharmacotherapy. When all studies of additional behavioural therapy were pooled, there was evidence of a statistically significant benefit from additional support (RR 1.15, 95% CI 1.08 to 1.22, I² = 8%, 65 studies, n = 23,331) for abstinence at longest follow-up, and this effect was not different when we compared subgroups by type of pharmacotherapy or intensity of contact. This effect was similar in the subgroup of eight studies in which the control group received no behavioural support (RR 1.20, 95% CI 1.02 to 1.43, I² = 20%, n = 4,018). Seventeen studies compared interventions matched for contact time but that differed in terms of the behavioural components or approaches employed. Of the 15 comparisons, all had small numbers of participants and events. Only one detected a statistically significant effect, favouring a health education approach (which the authors described as standard counselling containing information and advice) over motivational interviewing approach (RR 0.56, 95% CI 0.33 to 0.94, n = 378).

AUTHORS' CONCLUSIONS

There is high-certainty evidence that providing behavioural support in person or via telephone for people using pharmacotherapy to stop smoking increases quit rates. Increasing the amount of behavioural support is likely to increase the chance of success by about 10% to 20%, based on a pooled estimate from 65 trials. Subgroup analysis suggests that the incremental benefit from more support is similar over a range of levels of baseline support. More research is needed to assess the effectiveness of specific components that comprise behavioural support.

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.

Effect of Motivational Interviewing on depression scale scores of adolescents with obesity and overweight

The aim of this study was to compare the effect of motivational interview (MI) with conventional care on the depression scale scores of adolescents with obesity/overweight. It was a controlled cluster randomized trial with parallel design, including two groups: intervention group [Motivational Interview Group (MIG)], control group [Conventional Intervention Group (CIG)].

INTERVENTION

three face-to-face 30min' interviews three months apart (only MIG interviews were based on MI principles).

OUTCOMES

change in Children Depression Inventory (CDI) scores. We used a mixed repeated-measures ANOVAs analysis to assess the group vs time interaction. Effect size was calculated for ANOVA with difference of means of the total score (DOMTS). CDI scores were compared by a paired t-test. Eighty-three (84%) adolescents finished the intervention. There was a significant time vs group interaction both groups. While in the CIG scores significantly increased, in the MIG the scores significantly decreased. The DOMTS was significantly different between the two groups. We concluded that MI showed a positive effect on depression scale scores over time relatively to conventional intervention.