Trends in self-efficacy to quit and smoking urges among homeless smokers participating in a smoking cessation RCT

PROTOCOL: Effectiveness of behavioral interventions for smoking cessation among homeless persons: A systematic review and meta-analysis

This is the protocol for an updated Campbell systematic review. The objectives are as follows: To evaluate the effect of behavioral interventions on smoking cessation among homeless individuals.

"Cigarettes play the equalizer": discrimination experiences and readiness to quit cigarette smoking among African Americans experiencing homelessness: a qualitative analysis

BACKGROUND

Approximately 70-80% of people experiencing homelessness in the United States use tobacco. Smoking cessation programs specifically for this population have been found to be less effective for African American participants. The purpose of this study was to explore discrimination experiences and their impact on smoking habits and readiness to quit cigarette smoking while experiencing homelessness.

METHODS

In the qualitative phase of this mixed methods study, five focus groups were conducted for African Americans residing in a homeless shelter in Skid Row, Los Angeles, CA. Using a semi-structured interview guide, we asked participants about discrimination experiences, how smoking habits were impacted by these experiences, and tools needed to successfully abstain from cigarette smoking. Qualitative descriptive content analysis was used to explore discrimination experiences and its association with readiness to quit cigarette smoking.

RESULTS

Of the 17 participants, 14 (82.4%) were male, and the average age was 46.8 years. Using a qualitative In Vivo coding method, three themes were revealed: "Experiencing Discrimination while Black", "The Psychosocial Fabric-Why Quitting Cigarette Smoking is a Challenge", and "The Lesser of Two Evils-Choosing to Smoke over More Harmful Options." Participants discussed working in the blue-collar workforce while Black, identifying as a double minority, smoking to cope with stress, early exposure to cigarettes, smoking being a central part of one's belonging to a group, and the legality of cigarette smoking.

DISCUSSION

Our findings show that African Americans experiencing homelessness (1) may experience discrimination in multiple settings, regardless of housing status, (2) could have grown up around cigarette smoking and remain surrounded by it while experiencing homelessness, and (3) may experience a calming effect with smoking, which slows some from reacting negatively to adverse situations.

CONCLUSION

Barriers to successfully abstaining from smoking are multifactorial among African Americans experiencing homelessness and should be addressed individually. Future research should explore the cultural tailoring of interventions that support cessation efforts unique to minoritized populations to improve smoking cessation programs offered to this population.

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.

"A person who do not smoke will not understand a person who smokes and trying to quit…" Insights From Quit Smoking Clinics' Defaulters: A Qualitative Study

This study explored the factors contributing to discontinuation of people who smoke (PWS) from quit smoking clinic prior to achieving 6-month abstinence. Fifteen active PWS were interviewed via telephone and face-to-face. Interviews were audio-recorded, transcribed and analysed using thematic analysis. At individual level, low intrinsic motivation including unreadiness to quit, low self-efficacy and ambivalence on smoking cessation were barriers to attain successful cessation. Influence of extrinsic factors such as work-related factors, social interaction and ill-health burden lead to poor commitment with QSC. At the clinic level, healthcare professional's competency, personal attributes, pharmacotherapy's efficacy, safety and availability were important components that may affect a participant's effort to quit. Working commitment was highlighted as the primary barrier for a successful cessation. Hence, effective intervention and collaborative effort between healthcare facilities and employers are essential to optimise cessation adherence among employees who smoke which subsequently will enhance their abstinence rates.

Prevalence and Correlates of Cardiovascular, Pulmonary, Cancer, and Mental Health Comorbidities Among Adults With HIV Who Smoke

ABSTRACT

Using data from the D.C. Cohort Longitudinal HIV Study, we examined (a) diagnosed mental health and (b) cardiovascular, pulmonary, or cancer (CPC) comorbidity among adults with HIV who smoked. Among 8,581 adults, 4,273 (50%) smoked; 49% of smokers had mental health, and 13% of smokers had a CPC comorbidity. Among smokers, non-Hispanic Black participants had a lower risk for mental health (prevalence ratio [PR]: 0.69; 95% confidence interval [CI] [0.62-0.76]) but a higher risk for CPC (PR: 1.17; 95% CI [0.84-1.62]) comorbidity. Male participants had a lower risk for mental health (PR: 0.88; 95% CI [0.81-0.94]) and CPC (PR: 0.68; 95% CI [0.57-0.81]) comorbidity. All metrics of socioeconomic status were associated with a mental health comorbidity, but only housing status was associated with a CPC comorbidity. We did not find any association with substance use. Gender, socioeconomic factors, and race/ethnicity should inform clinical care and the development of smoking cessation strategies for this population.

Smoking Prevalence among Physicians: A Systematic Review and Meta-Analysis

BACKGROUND

Smoking is a major public health problem. Although physicians have a key role in the fight against smoking, some of them are still smoking. Thus, we aimed to conduct a systematic review and meta-analysis on the prevalence of smoking among physicians.

METHODS

PubMed, Cochrane, and Embase databases were searched. The prevalence of smoking among physicians was estimated and stratified, where possible, by specialties, continents, and periods of time. Then, meta-regressions were performed regarding putative influencing factors such as age and sex.

RESULTS

Among 246 studies and 497,081 physicians, the smoking prevalence among physicians was 21% (95CI 20 to 23%). Prevalence of smoking was 25% in medical students, 24% in family practitioners, 18% in surgical specialties, 17% in psychiatrists, 16% in medical specialties, 11% in anesthesiologists, 9% in radiologists, and 8% in pediatricians. Physicians in Europe and Asia had a higher smoking prevalence than in Oceania. The smoking prevalence among physicians has decreased over time. Male physicians had a higher smoking prevalence. Age did not influence smoking prevalence.

CONCLUSION

Prevalence of smoking among physicians is high, around 21%. Family practitioners and medical students have the highest percentage of smokers. All physicians should benefit from targeted preventive strategies.

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.

Resilience is associated with importance of quitting in homeless adult smokers

OBJECTIVE

The prevalence of cigarette smoking in homeless populations is disproportionately high with rates between 57 and 80%. Resilience may affect a smoker's ability to successfully quit smoking. This cross-sectional study examined the association between resilience levels and smoking behaviors in homeless adults.

METHOD

Fifty-nine homeless adults were recruited from a large multi-service homelessness agency in the northeast United States. Surveys were administered to measure smoking behaviors and resilience.

RESULTS

Most participants were current smokers (83.1%), with more than half (67.1%) identifying as "moderate smokers" (smoking 10-20 cigarettes per day). Of the current smokers, 93.9% reported smoking daily and 71.4% had tried to quit at least once in their lifetime. The number of quit attempts was significantly (p < 0.05) associated with one's contemplation of quitting (r = 0.29) and how one viewed importance of quitting (r = 0.33). Resilience levels were significantly associated with how participants ranked importance of quitting (r = 0.37). Smokers reported a high desire to quit smoking, but level of confidence in their ability to quit was low. Difficulty in finding stable housing and social support were reported as barriers to quitting.

CONCLUSIONS

This study demonstrates an association between importance of quitting and resilience levels in homeless adult smokers. Future work is needed to examine whether resilience is related to successful smoking cessation in homeless adults, and whether resilience levels can be increased with targeted interventions.

Exploratory and confirmatory factor analyses and invariance assessment of the perceived powerlessness scale among youth in Baltimore

Generalized perceived powerlessness is an important psychosocial construct that determines a wide range of health behaviors and outcomes. This study has two aims: (1) examine the structure of the newly developed perceived powerlessness scale using exploratory and confirmatory factor analyses and (2) assess the scale's invariance across key demographic variables using multi-group confirmatory factor analysis among a random household sample of African American and White youth (aged 15-24 years) residing in Baltimore, MD. Our study results demonstrated that the powerlessness scale is valid among a demographically diverse sample of urban youth, showing promise for use in future health behavior and outcome studies.

Everyday discrimination indirectly influences smoking cessation through post-quit self-efficacy

BACKGROUND

Although studies have shown an association between discrimination and current smoking, the influence of discrimination on smoking cessation is an understudied area in tobacco research. The current study evaluated the influence of everyday discrimination on smoking cessation and examined self-efficacy as a potential mediator of this association.

METHODS

Participants (N = 146), who were recruited from a safety-net hospital in Dallas County, Texas, from 2011 to 2013, completed a self-report measure of perceived discrimination one week before the scheduled quit attempt and self-efficacy for quitting was assessed one day after the scheduled quit date. Biochemically-verified 7-day point prevalence abstinence was assessed weekly, through the fourth week after the scheduled quit date. Structural equation modeling was used to evaluate the indirect effect of perceived discrimination on smoking cessation via self-efficacy for quitting.

RESULTS

Analyses indicated significant indirect effect of discrimination on smoking cessation through self-efficacy at Weeks 1 (B = .09, SE = .04, p = .02) and 4 (B = .07, SE = .03, p = .03). A higher frequency of discrimination was associated with lower self-efficacy one day after the scheduled quit date, and lower self-efficacy increased the likelihood of smoking one and four weeks after the scheduled quit attempt.

CONCLUSIONS

Findings suggest that perceptions of discrimination reduce the likelihood of smoking cessation via diminished self-efficacy. Future research is needed to identify intervention strategies to reduce the frequency of discrimination experiences and attenuate the negative impact of discrimination and low self-efficacy on smoking cessation.

Subsistence difficulties are associated with more barriers to quitting and worse abstinence outcomes among homeless smokers: evidence from two studies in Boston, Massachusetts

Background

Three-quarters of homeless people smoke cigarettes. Competing priorities for shelter, food, and other subsistence needs may be one explanation for low smoking cessation rates in this population. We analyzed data from two samples of homeless smokers to examine the associations between subsistence difficulties and 1) smoking cessation readiness, confidence, and barriers in a cross-sectional study, and 2) smoking abstinence during follow-up in a longitudinal study.

Methods

We conducted a survey of homeless smokers (N = 306) in 4/2014–7/2014 and a pilot randomized controlled trial (RCT) for homeless smokers (N = 75) in 10/2015–6/2016 at Boston Health Care for the Homeless Program. In both studies, subsistence difficulties were characterized as none, low, or high based on responses to a 5-item scale assessing the frequency of past-month difficulty finding shelter, food, clothing, a place to wash, and a place to go to the bathroom. Among survey participants, we used linear regression to assess the associations between subsistence difficulty level and readiness to quit, confidence to quit, and a composite measure of perceived barriers to quitting. Among RCT participants, we used repeated-measures logistic regression to examine the association between baseline subsistence difficulty level and carbon monoxide-defined brief smoking abstinence assessed 14 times over 8 weeks of follow-up. Analyses adjusted for demographic characteristics, substance use, mental illness, and nicotine dependence.

Results

Subsistence difficulties were common in both study samples. Among survey participants, greater subsistence difficulties were associated with more perceived barriers to quitting (p < 0.001) but not with cessation readiness or confidence. A dose-response relationship was observed for most barriers, particularly psychosocial barriers. Among RCT participants, greater baseline subsistence difficulties predicted less smoking abstinence during follow-up in a dose-response fashion. In adjusted analyses, individuals with the highest level of subsistence difficulty had one-third the odds of being abstinent during follow-up compared to those without subsistence difficulties (OR 0.33, 95% CI 0.11–0.93) despite making a similar number of quit attempts.

Conclusions

Homeless smokers with greater subsistence difficulties perceive more barriers to quitting and are less likely to do so despite similar readiness, confidence, and attempts. Future studies should assess whether addressing subsistence difficulties improves cessation outcomes in this population.

Trial registration

ClinicalTrials.gov: NCT02565381.