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R2P: A Look at Smoking and Homelessness
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Zerger, Suzanne
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Description: People who are homeless are more than three times as likely to smoke than those who are housed. Aside from the risks associated with homelessness and life on the streets, this is a dangerous health disparity. Sometimes it is easy to see smoking as a relatively harmless coping mechanism. HRC’s Suzanne Zerger takes a look at the research and promising practices to help people who are homeless to kick this habit.
Content: R2P: A Look at Smoking and Homelessness

For decades, about 7 in 10 adults who are homeless smoke (1). In contrast, only 2 out of 10 people in the general US population are smokers (2). Yet research on smoking cessation practices among people who are homeless is sparse.  Here is a brief snapshot of what we have learned from this small body of literature, including promising practices for promoting quitting.
 
The Research: Smoking and Homelessness

Risks of Smoking
The health risks from cigarette smoking are well-known. They include cardiovascular (heart) disease and hypertension (high blood pressure).  These risks are magnified by higher-risk smoking practices, such as heavy smoking.  There are other high-risk smoking behaviors as well. One study in Los Angeles in 1993 documented sharing cigarettes, smoking cigarettes remade from discarded cigarette butts and filters, smoking cigarettes remade by others, smoking discarded cigarette butts, and blocking filter vents (3).  More recent studies have found similar practices. They can all lead to greater risk of being exposed to toxins and transmitting infectious disease.

Motivation to Quit
A few studies with homeless adults have found that motivation to quit smoking is quite strong. Anywhere from one-third to three-quarters of subjects were motivated.  Some of the strongest predictors of motivation included greater social support, having an illness that a smoker believed was tobacco related, whether they had tried to quit in the past, and greater confidence in the ability to quit (4).  Julia Arnsten and colleagues reported that people who used alcohol and drugs were not any less likely to want to quit. They recommended co-locating smoking cessation programs in medical or drug treatment settings (5).

Barriers to Quitting
Despite strong motivation, homelessness poses challenges to quitting. As researcher Kola Okuyemi put it: “Homeless smokers are faced with unique social and environmental barriers that make quitting more difficult. (6)” Okuyemi and colleagues conducted a small study that found pervasive use and social acceptance of tobacco use in homeless settings. They also found that high levels of boredom and stress contribute to heavier smoking and riskier smoking behaviors.  

Anecdotally, homeless service providers have mixed feelings about the importance of quitting. Some consider it a relatively low priority compared to other drug use and health issues. An additional barrier is the overt efforts of the tobacco industry to market cigarettes to its “downscale” market. Typically, this sector has included people who experience homelessness and serious mental illness (7).

Promising Practices: Smoking Cessation

Although the barriers to quitting smoking while homeless are daunting, providers can help:

•    Cognitive Behavior Therapy: Second year medical students provided cognitive behavior therapy to people who were homeless. Six out of eleven subjects completed the process and cut down on smoking.

•    Motivational Interviewing: A randomized trial tested two motivational interviewing approaches. One targeted only smoking behaviors (“smoking only”). The other targeted smoking and other addictions or life events that might affect their ability to quit (“smoking plus”).  In addition to individual sessions, both groups attended six group meetings and were offered a choice of nicotine patches or lozenges.  Abstinence rates were higher and more consistent for those in the “smoking plus” group. At 26 weeks, 17.4% remained abstinent compared to 8.7% of the smoking only group (9).  

Check out these "Related Items" on the right of the screen about smoking and homelessness, and what you can do.

Footnotes
(1) Okuyemi, KS et al.  “Homelessness and Smoking Cessation: Insights from Focus Groups,” Nicotine and Tobacco Research, 8(2):287-96, Apr 2006.  Snyder, LD and MD Eisner. “Obstructive Lung Disease among the Urban Homeless,” Chest, 125(5):1719-25, May 2004.  Conner, SE et al.  “Smoking Cessation in a Homeless Population; There is a Will, but is there a Way?  Journal of General Internal Medicine, 17(5):369-72, may 2002.

(2) Morbidity and Mortality Weekly Report, Center for Disease Control and Prevention, 57(45):1221-26, Nov 14, 2008.

(3) Aloot, CB et al.  “Evaluation of High-Risk Smoking Practices Used by the Homeless,” Cancer Nursing, 16(2):123-30, Apr 1993.

(4) Arnsten, JH et al. “Smoking Behavior and Interest in Quitting among Homeless Smokers,” Addictive Behaviors, 29(6):1155-61, Aug 2004.  See also Connor, SE et al.  “Smoking Cessation in a Homeless Population – There is a Will, but is there a Way? Journal of General Internal Medicine, 17(%):369-72, May 2002.

(5) Arnsten, JH et al. “Smoking Behavior and Interest in Quitting among Homeless Smokers,” Addictive Behaviors, 29(6):1155-61, Aug 2004.

(6) Okuyemi, KS et al.  “Homelessness and Smoking Cessation: Insights from Focus Groups,” Nicotine and Tobacco Research, 8(2):287-96, Apr 2006, abstract.

(7) Apollonio, DE and RE Malone.  “Marketing to the Marginalized: Tobacco Industry Targeting of the Homeless and Mentally Ill,” Tobacco Control, 14(6):409-15, Dec 2005.

(8) Spector A, et al. “Smoking Cessation Delivered by Medical Students is Helpful to Homeless Population,” Academic Psychiatry, 31(5):402-5, Sept-Oct 2007.

(9) Okuyemi, KS et al.  “Smoking Cessation in Homeless Populations: A Pilot Clinical Trial,” Nicotine and Tobacco Research, 8(5):689-99, Oct 2006.
File(s)
Type of Resource: HRC Resource
Publication Date: 2009
Location: Newton Centre, MA
Phone: 617-467-6014
Irene Glasser from Bristol
August 18, 2009
6:36 PM
 
Has anyone tried Nicotine Anonymous (NicA) at homeless shelters? NicA is a 12 step cessation program modeled after AA. It is free and can be used by itself, as an adjunct, or as a follow up to other cessation programs.

There is a limited scholarly literature regarding NicA and no outcome studies as yet focused soley on NicA, from what I have reviewed.

Irene Glasser, Ph.D.


   
 
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