Smoking cessation in a homeless population: there is a will, but is there a way?

Contingency management to promote smoking cessation in people experiencing homelessness: Leveraging the electronic health record in a pilot, pragmatic randomized controlled trial

BACKGROUND

Cigarette smoking is disproportionately high among people experiencing homelessness (PEH). Contingency management (CM) is a strategy that has shown considerable efficacy for smoking cessation and has been used in short-term studies of smoking abstinence in PEH. We describe a pilot, pragmatic randomized controlled trial protocol, which leverages an electronic health record (EHR) infrastructure to assess the feasibility and acceptability of an extended CM intervention to improve long-term abstinence in PEH.

METHODS

We will conduct the study at three safety-net clinics in San Francisco among 90 adults experiencing homelessness who smoke cigarettes currently and have a desire to quit. We will encourage all participants to receive smoking cessation services that include behavioral counseling and pharmacotherapy through their clinics. We will randomly assign participants to an extended CM intervention group with escalating incentives contingent on abstinence or to a control group with fixed incentives for attending study visits. We will use the EHR to recruit participants, track receipt of counseling and pharmacotherapy during clinical care, and communicate with providers on participants' progress. CM participants will get escalating incentives for demonstration of carbon monoxide-verified abstinence over 6 months, with a total possible earnings of $475. Control participants will receive a fixed incentive of $5 for attending study visits, totaling $125. We will conduct the carbon-monoxide verified abstinence assessments-which will determine CM incentive amounts-daily during week 1, bi-weekly through week 4, weekly through week 13, and monthly through week 24. Measures of feasibility and acceptability, both quantitative and qualitative, will include assessments of screening and recruitment, adherence to study visits, engagement in smoking cessation clinical care, retention, and participant satisfaction. One of the primary clinical outcomes will be biochemically verified 7-day point prevalence abstinence at 6 months. We will measure secondary outcomes, which will include 7-day point prevalence abstinence at 2 weeks, 3 and 12 months.

DISCUSSION

This trial will allow us to assess the feasibility and acceptability of a CM cessation intervention among PEH. The protocol's clinical setting and use of EHRs gives it significant potential for scalability. If found to be feasible, acceptable, and subsequently efficacious in a larger trial, the intervention could reduce tobacco-related health disparities by increasing long-term smoking abstinence among this vulnerable population.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04982952. Registered on July 29, 2021.

Health behaviours and mental and physical health status in older adults with a history of homelessness: a cross-sectional population-based study in England

OBJECTIVES

This study compared (1) levels of engagement in lifestyle risk behaviours and (2) mental and physical health status in individuals who have previously been homeless to those of individuals who have not.

DESIGN

Cross-sectional.

PARTICIPANTS

Data were from participants (n=6931) of the English Longitudinal Study of Ageing. : Measures : Participants reported whether they had ever been homeless. We used regression models to analyse associations between homelessness and (1) cigarette smoking, daily alcohol consumption and physical inactivity, adjusting for sociodemographic covariates (age, sex, ethnicity, highest level of education, marital status and household non-pension wealth) and (2) self-rated health, limiting long-standing illness, depressive symptoms, life satisfaction, quality of life and loneliness, adjusting for sociodemographics and health behaviours.

RESULTS

104 participants (1.5%) reported having been homeless. Individuals who had been homeless were significantly more likely to be physically inactive (OR 1.62, 95% CI 1.44 to 2.52), report fair/bad/very bad self-rated health (OR 1.75, 95% CI 1.07 to 2.86), have a limiting long-standing illness (OR 2.66, 95% CI 1.65 to 4.30) and be depressed (OR 3.06, 95% CI 1.85 to 5.05) and scored lower on measures of life satisfaction (17.34 vs 19.96, p<0.001) and quality of life (39.02 vs 41.21, p=0.013). Rates of smoking (20.2% vs 15.4%, p=0.436), daily drinking (27.6% vs 22.8%, p=0.385) and loneliness (27.1% vs 21.0%, p=0.080) were also elevated.

CONCLUSIONS

Those who were once homeless have poorer mental and physical health outcomes and are more likely to be physically inactive. Interventions to improve their health and quality of life are required.

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.

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.

Posttraumatic Stress Symptoms and Their Association With Smoking Outcome Expectancies Among Homeless Smokers in Boston

INTRODUCTION

Cigarette smoking and traumatic life experiences are each common among homeless adults, but the prevalence and correlates of posttraumatic stress disorder (PTSD) symptoms among homeless smokers are not known. We assessed symptoms of PTSD and their association with smoking outcome expectancies in a sample of homeless smokers in Boston.

METHODS

We used time-location sampling to conduct an in-person survey of homeless adult smokers using Boston Health Care for the Homeless Program clinical services. We assessed symptoms of PTSD with the PTSD Checklist-Civilian version and considered scores at least 14 as positive. We used the Smoking Effects Questionnaire to assess positive and negative smoking outcome expectancies. We modeled the associations between PTSD screening status and smoking expectancies using design-adjusted linear regression.

RESULTS

Eighty-six percent of eligible individuals participated (N = 306). Sixty-eight percent of participants screened positive for PTSD. Screen-positive respondents were younger (P = .001), more likely to report fair/poor health (P = .01), chronic obstructive pulmonary disease (P = .02), and past-month hallucinations (P = .004), and had greater drug (P < .001) and alcohol (P < .001) use severity and cigarette dependence (P = .002). In analyses controlling for these confounders, PTSD screen-positive participants more strongly endorsed smoking to reduce negative affect (P = .01), smoking for social benefits (P = .002), and smoking for weight control (P = .03). Exploratory analyses suggested that these associations were driven by avoidance/numbing and re-experiencing symptoms.

CONCLUSIONS

Symptoms of posttraumatic stress are common among homeless smokers and strongly associated with positive smoking outcome expectancies. Tobacco cessation programs for this population should consider screening for PTSD and fostering a trauma-sensitive treatment environment.

IMPLICATIONS

In this study of homeless cigarette smokers in Boston, over two-thirds of participants screened positive for PTSD. PTSD screen-positive respondents more strongly endorsed multiple positive smoking outcome expectancies than screen-negative individuals. These findings suggest that the psychological sequelae of trauma may be a pervasive but under-recognized factor impacting the persistence of smoking among homeless people. Tobacco cessation programs for this population should consider screening for PTSD, fostering a trauma-sensitive treatment environment, and incorporating strategies that have shown promise in smokers with PTSD.

Retention of Homeless Smokers in the Power to Quit Study

INTRODUCTION

Concerns about retention are a major barrier to conducting studies enrolling homeless individuals. Since smoking is a major problem in homeless communities and research on effective methods of promoting smoking cessation is needed, we describe strategies used to increase retention and participant characteristics associated with retention in smoking cessation study enrolling homeless adults.

METHODS

The parent study was a 2-group randomized controlled trial with 26-week follow-up enrolling 430 homeless smokers from emergency shelters and transitional housing units in Minneapolis/Saint Paul, MN, USA. Multiple strategies were used to increase retention, including conducting visits at convenient locations for participants, collecting several forms of contact information from participants, using a schedule that was flexible and included frequent low-intensity visits, and providing incentives. Participant demographics as well as characteristics related to tobacco and drug use and health status were analyzed for associations with retention using univariate and multivariate analysis.

RESULTS

Overall retention was 75% at 26 weeks. Factors associated with increased retention included greater age; having healthcare coverage; history of multiple homeless episodes, lower stress level; and higher PHQ-9 (Patient Health Questionnaire-9) score. A history of excessive drinking and drug use were associated with decreased retention.

CONCLUSIONS

It is possible to successfully retain homeless individuals in a smoking cessation study if the study is designed with participants' needs in mind.

Alternative tobacco product use and smoking cessation among homeless youth in los angeles county

INTRODUCTION

Approximately 70% of homeless youth smoke cigarettes, but their use of alternative tobacco products (ATPs) is unknown. This paper reports on ATP use among past-month smokers in Los Angeles County, including whether it differs by demographic characteristics, homelessness severity, past-year quit attempts, and readiness to quit smoking. Given the growing popularity of e-cigarettes, we also report on perceptions of harm and reasons for using this product.

METHODS

We surveyed 292 unaccompanied homeless youth who were randomly sampled from street sites. Participants had smoked at least 100 cigarettes during their lifetime and 1 cigarette during the past month.

RESULTS

Seventy-two percent of youth reported past-month ATP use (e-cigarettes = 51%; little cigars/cigarillos = 46%; hookah = 31%; other smokeless tobacco product = 24%; chewing tobacco/moist snuff = 19%). Current ATP use was unrelated to most demographic characteristics or having a past-year quit attempt. However, youth who planned to quit smoking in the next 30 days were significantly less likely to report current use of hookahs, other smokeless tobacco products, or e-cigarettes. Among lifetime e-cigarette users, the most common reasons for use included not having to go outside to smoke (38%) and being able to deal with situations or places where they cannot smoke (36%); it was less common to report using e-cigarettes to quit smoking (17%-18%).

DISCUSSION

Dual use of ATPs among homeless youth smokers is common and is more likely among those who have no immediate plans to quit smoking. Effective and easily disseminable strategies for reducing all forms of tobacco use among homeless youth are urgently needed.

Smoking cessation in homeless populations: who participates and who does not

INTRODUCTION

Although homeless individuals smoke at an alarmingly high rate, few smoking cessation clinical trials have focused on this vulnerable population. Little is known about recruitment efforts and suitable eligibility criteria for tobacco control research in homeless populations.

METHODS

The aim of this article is to describe the recruitment, eligibility, and enrollment of homeless smokers who participated in the Power to Quit smoking study, a randomized smoking cessation clinical trial funded by the National Institutes of Health. The study compared motivational interviewing and standard counseling while participants received an 8-week treatment of the nicotine patch.

RESULTS

Working with local emergency shelters, a total of 839 adult smokers were screened for study eligibility, 580 of whom (69.1%) met eligibility criteria. Of those eligible, 430 (74.1%) returned for randomization. Those who returned for randomization were older and more likely to have a phone number compared with eligible participants not enrolled. The most common reasons for exclusion included exhaled carbon monoxide levels less than or equal to 5 parts per million (indicating nonsmoking status), use of smoking cessation aid during the past 30 days, and not meeting the study definition of homelessness.

CONCLUSION

Knowledge of these factors may help researchers tailor criteria that accurately identify and include homeless smokers in future research.

Novel setting for addressing tobacco-related disparities: a survey of community welfare organization smoking policies, practices and attitudes

Research in the United States and Australia acknowledges the potential of non-government social and community service organizations (SCSOs) for reaching socially disadvantaged smokers. This study aimed to describe SCSO smoking policies and practices, and attitudes of senior staff towards smoking and cessation. It also investigated factors associated with positive tobacco control attitudes. In 2009, a cross-sectional telephone survey was undertaken of senior staff in Australian SCSOs, 149 respondents representing 93 organizations completed the survey (response rate=65%; 93/142). Most service clients (60%) remained in programs for 6 months plus, and 77% attended at least weekly. Although 93% of respondents indicated they had an organizational smoking policy, it often did not include the provision of smoking cessation support. Most respondents indicated that client smoking status was not recorded on case notes (78%). Attitudes were mostly positive towards tobacco control in SCSOs, with a mean (standard deviation) score of 8.3 (2.9) of a possible 13. The practice of assessing clients' interest in quitting was the only statistically significant factor associated with high tobacco control attitude scores. The results suggest that SCSOs are appropriate settings for reaching socially disadvantaged smokers with cessation support. Although generally receptive to tobacco control, organizations require further support to integrate smoking cessation support into usual care. In particular, education, training and support for staff to enable them to help their clients quit smoking is important.

Smoking characteristics and comorbidities in the power to quit randomized clinical trial for homeless smokers

INTRODUCTION

Smoking prevalence in homeless populations is strikingly high (∼70%); yet, little is known about effective smoking cessation interventions for this population. We conducted a community-based clinical trial, Power To Quit (PTQ), to assess the effects of motivational interviewing (MI) and nicotine patch (nicotine replacement therapy [NRT]) on smoking cessation among homeless smokers. This paper describes the smoking characteristics and comorbidities of smokers in the study.

METHODS

Four hundred and thirty homeless adult smokers were randomized to either the intervention arm (NRT + MI) or the control arm (NRT + Brief Advice). Baseline assessment included demographic information, shelter status, smoking history, motivation to quit smoking, alcohol/other substance abuse, and psychiatric comorbidities.

RESULTS

Of the 849 individuals who completed the eligibility survey, 578 (68.1%) were eligible and 430 (74.4% of eligibles) were enrolled. Participants were predominantly Black, male, and had mean age of 44.4 years (S D = 9.9), and the majority were unemployed (90.5%). Most participants reported sleeping in emergency shelters; nearly half had been homeless for more than a year. Nearly all the participants were daily smokers who smoked an average of 20 cigarettes/day. Nearly 40% had patient health questionnaire-9 depression scores in the moderate or worse range, and more than 80% screened positive for lifetime history of drug abuse or dependence.

CONCLUSIONS

This study demonstrates the feasibility of enrolling a diverse sample of homeless smokers into a smoking cessation clinical trial. The uniqueness of the study sample enables investigators to examine the influence of nicotine dependence as well as psychiatric and substance abuse comorbidities on smoking cessation outcomes.

Addressing tobacco use in homeless populations: recommendations of an expert panel

A diverse group of panelists met for one day on October 21, 2009, in Washington, DC, for the purpose of addressing the high tobacco use prevalence rates in homeless populations; identifying appropriate policy, cessation practices and models for implementation in this population; and providing targeted recommendations for researchers, homeless service providers, tobacco control advocates, and policy makers. The panel was convened by Break Free Alliance, one of six national networks funded by the Centers for Disease Control and Prevention, Office on Smoking and Health. The panelists worked through a process of problem identification, generation of responses, analysis and prioritization, development of recommendations, and arrival of final decisions reached by consensus. The resulting recommendations for addressing tobacco use in homeless populations focused on tobacco non-use policy implementation, cessation programming, and expansion of partnerships and collaborations between tobacco control advocates and social service providers. The panel also identified unanswered research questions that can serve to develop a framework for future initiatives to reduce tobacco use among homeless persons. The expert panel model serves as one approach for engaging nontraditional partners and building consensus among leaders from a variety of sectors to address tobacco use in special populations.

Nicotine dependence and its risk factors among users of veterans health services, 2008-2009

INTRODUCTION

Tobacco use is the leading preventable cause of death in the United States and is disproportionately higher among veterans than nonveterans. We examined the prevalence of nicotine dependence and its associated risk factors among veterans who used health services in the US Department of Veterans Affairs (VA) system.

METHODS

Using a case-control design, we compared all VA health service users in fiscal year 2008-2009 (N = 5,031,381) who received a nicotine dependence diagnosis with those who did not. Independent risk and protective factors associated with receiving a nicotine dependence diagnosis were identified using logistic regression analysis. We conducted subgroup analyses on 2 groups of particular policy concern: homeless veterans and veterans who served in Iraq and Afghanistan.

RESULTS

Among all recent VA health service users, 15% (n = 749,353) received a diagnosis of nicotine dependence. Substance abuse, other mental health diagnoses, and homelessness were identified as major risk factors. Veterans who served in Iraq and Afghanistan were not found to be at increased risk compared to veterans from other war eras. Major risk and protective factors within the subgroups of homeless veterans and veterans who served in Iraq and Afghanistan were broadly similar to those in the general VA population.

CONCLUSION

Given that other studies have found higher rates of nicotine dependence among veterans, this risk behavior may be underdiagnosed in VA medical records. Veterans who are homeless or have mental health or substance abuse problems are at highest risk and should be targeted for smoking prevention and cessation interventions. These results support, in principle, efforts to integrate smoking cessation programs with mental health and homeless services.

Smoking and predictors of nicotine dependence in a homeless population

OBJECTIVE

To assess prevalence rates of tobacco use and dependence in a sample of homeless individuals and to investigate trends for demographic and clinical characteristics across different levels of nicotine dependence (nonsmokers vs. lowly dependent smokers vs. highly dependent smokers).

METHODS

A cross-sectional study of 489 homeless men and women in 3 Canadian cities. Each subject was assessed using structured clinical interviews and the Fagerström Test for Nicotine Dependence (FTND). Cochran-Armitage trend tests were applied to determine unadjusted trends in sociodemographic and clinical variables across levels of nicotine dependence. A generalized logit model was computed to adjust for potential confounding.

RESULTS

The mean age was 37.9 years; 39.2% of the participants were women. About 80.8% were current smokers; the mean FTND score was 5.0. Although no significant differences were found between nonsmokers and smokers with low nicotine dependence, smokers with high nicotine dependence were only half as likely as nonsmokers to be Aboriginal, were 2.39 times more likely to have ever been incarcerated, and 2.44 times more likely to have current drug dependence. There were significant trends for the use of cocaine, opioids, and alcohol, with nonsmokers having the lowest and highly dependent smokers having the highest rates of using these substances.

CONCLUSIONS

Available public health smoking cessation treatment opportunities should be made available within health care services for the homeless. There is also a need for developing and implementing tobacco dependence treatment programs, which are accessible and tailored to meet the needs of this specific population, accounting for polysubstance use and concurrent substance dependence and mental health disorders.

Delivering smoking cessation support to disadvantaged groups: a qualitative study of the potential of community welfare organizations

Reaching disadvantaged groups for smoking cessation represents a significant challenge. Not-for-profit community service organizations (CSOs) represent a promising setting for the delivery of quit smoking support to disadvantaged smokers. However, their potential has not yet been explored. This qualitative study examined the acceptability of community service-delivered smoking cessation care. In-depth interviews and focus groups were conducted with 8 managers, 35 staff and 32 clients of CSOs between December 2008 and March 2009 in New South Wales, Australia. Discussions were audiotaped, transcribed and analysed using thematic analysis techniques. Quantitative surveys were also conducted to explore preferences for cessation support. Results showed that the acceptability of providing and receiving cessation support in the community service setting was high. Staff perceived the provision of quit support to be compatible with their role but reported barriers to providing care including competing priorities, insufficient resources and inadequate staff training. Brief intervention approaches were preferred by managers and staff, while financial incentives and access to free or subsidized nicotine replacement therapy (NRT) were desired by clients. The community service setting represents a promising access point for engaging disadvantaged smokers for cessation and further research exploring the effectiveness of support delivered in this setting is clearly warranted.

Gender, race, and education differences in abstinence rates among participants in two randomized smoking cessation trials

INTRODUCTION

Smoking is the leading preventable cause of morbidity and mortality in the United States, but this burden is not distributed equally among smokers. Women, Blacks, and people with low socioeconomic status are especially vulnerable to the health risks of smoking and are less likely to quit.

METHODS

This research examined cessation rates and treatment response among 2,850 participants (57.2% women, 11.7% Blacks, and 9.0% with less than a high school education) from two large cessation trials evaluating: nicotine patch, nicotine lozenge, bupropion, bupropion + lozenge, and nicotine patch + lozenge.

RESULTS

Results revealed that women, Blacks, and smokers with less education were less likely to quit smoking successfully than men, Whites, and smokers with more education, respectively. Women did not appear to benefit more from bupropion than from nicotine replacement therapy, but women and smokers with less education benefited more from combination pharmacotherapy than from monotherapy.

DISCUSSION

Women, Blacks, and smokers with less education are at elevated risk for cessation failure, and research is needed to understand this risk and develop pharmacological and psychosocial interventions to improve their long-term cessation rates.

Higher prevalence of smoking and lower BMI, waist circumference, cholesterol and triacylglyceride levels in Prague's homeless compared to a majority of the Czech population

Background

Homeless people have higher morbidity and mortality rates than the general population. Research has shown that cardiovascular disease is the leading cause of death in older homeless adults. This study was undertaken to describe the prevalence of cardiovascular risk factors in the homeless population in Prague.

Methods

Data was obtained from a cross-sectional study carried out in 2003. Body mass index (BMI), waist circumference (WC), total cholesterol (TC), triacylglycerides (TAG) and smoking habits were assessed. The homeless participants in the study were recruited from a homeless center run by a Prague charitable organization called Naděje ("Hope") and at Prague's main railway station. Most participants were assessed at the Naděje center (134 persons) while the rest were assessed at Prague's Bulovka University Hospital (67 persons).

Results

A total of 201 homeless (174 males and 27 females) aged 19 – 70 years were examined. Mean values of BMI, WC, TC and TAG in homeless men and women were within normal limits. Compared with the majority of the Czech population, the homeless had significantly lower mean levels of TC and TAG and lower BMI and WC values. When compared to the majority of the Czech population, the incidence of smoking among the homeless was significantly higher. Among smokers in both populations, no differences were found in the number of cigarettes smoked per day.

Conclusion

Classical cardiovascular risk factors such as TC, TAG, BMI and WC, are significantly lower in Prague's homeless minority than in the majority of the Czech population. However, the prevalence of smoking is much higher in the homeless population.