Developing Tobacco Control Interventions in Permanent Supportive Housing for Formerly Homeless Adults

Opportunistic smoking cessation interventions for people accessing financial support settings: A scoping review

AIM

The aim of this work was to systematically scope the evidence on opportunistic tobacco smoking cessation interventions for people accessing financial support settings.

METHODS

We searched MEDLINE, Embase, PsycINFO and the Cochrane Tobacco Addiction Group specialized register to 21 March 2023. We duplicate screened 20% of titles/abstracts and all full texts. We included primary studies investigating smoking cessation interventions delivered opportunistically to people who smoked tobacco, within settings offering support for problems caused by financial hardship, for example homeless support services, social housing and food banks. Data were charted by one reviewer, checked by another and narratively synthesized.

RESULTS

We included 25 studies conducted in a range of financial support settings using qualitative (e.g. interviews and focus groups) and quantitative (e.g. randomized controlled trials, surveys and single arm intervention studies) methodologies. Evidence on the acceptability and feasibility of opportunistic smoking cessation advice was investigated among both clients and providers. Approximately 90% of service providers supported such interventions; however, lack of resources, staff training and a belief that tobacco smoking reduced illicit substance use were perceived barriers. Clients welcomed being asked about smoking and offered assistance to quit and expressed interest in interventions including the provision of nicotine replacement therapy, e-cigarettes and incentives to quit smoking. Six studies investigated the comparative effectiveness of opportunistic smoking cessation interventions on quitting success, with five comparing more to less intensive interventions, with mixed results.

CONCLUSIONS

Most studies investigating opportunistic smoking cessation interventions in financial support settings have not measured their effectiveness. Where they have, settings, populations, interventions and findings have varied. There is more evidence investigating acceptability, with promising results.

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.

The smoke-free home study: study protocol for a cluster randomized controlled trial of a smoke-free home intervention in permanent supportive housing

Background

Formerly chronically homeless adults who live in permanent supportive housing (PSH) have high prevalence of smoking. It is uncommon to find smoke-free policies in PSH because of the concern that such policies contradict PSH’s harm reduction framework and could increase homelessness should residents lose their housing because of the policy. However, in the absence of such policies, non-smoking PSH residents face the harmful effects of secondhand smoke exposure while residents who smoke see increased risks from high rates of smoking throughout their residence. Our pilot work highlighted the feasibility and acceptability of an intervention designed to promote voluntary adoption of a smoke-free home. Here we report a protocol for a cluster randomized controlled trial of the smoke-free home intervention for formerly chronically homeless residents in PSH.

Methods

The smoke-free home intervention provides face-to-face counseling and instruction to PSH residents on how to adopt a smoke-free home and offers training for PSH staff on how to refer residents to tobacco cessation services. We will randomize 20 PSH sites in the San Francisco Bay Area to either the intervention or wait-list control arms. We will enroll 400 PSH residents who smoke cigarettes in their housing unit and 120 PSH staff who work at the sites. At baseline, three- and six-months follow-up, we will ask residents to report their tobacco use and cessation behaviors and adoption of smoke-free homes. We will ask staff to answer questions on their knowledge, attitudes, practices, and barriers related to supporting residents’ smoking cessation. The primary outcome for PSH residents is adoption of smoke-free homes for 90 days or more at six-months follow-up, and the secondary outcome is point prevalence tobacco abstinence. The primary outcome for PSH staff is change in Smoking Knowledge Attitudes Practices survey score.

Discussion

Voluntary adoption of smoke-free homes is a promising approach for reducing exposure to secondhand smoke and reducing tobacco use among a population facing high rates of tobacco-related disease, and is aligned with PSH’s harm reduction framework. Findings from this study have the potential to inform adoption of tobacco control policies among vulnerable populations most at risk for smoking-related harms.

Trial registration

This study was registered with the U.S. National Institute of Health Clinical Trials register on April 22, 2021: NCT04855357.

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.

Harm reduction outcomes and practices in Housing First: A mixed-methods systematic review

BACKGROUND

Harm reduction is a central tenet of Housing First. As the intervention has been shown to stably house people experiencing chronic homelessness across the lifespan with complex behavioural health needs, it is critical to understand the harm reduction outcomes and practices in Housing First.

METHODS

A systematic review following PRISMA guidelines was conducted of five databases: PsycINFO, MEDLINE, Embase, CINAHL, and Google Scholar. Harm reduction outcomes and practices in Housing First were examined in four domains: substance-related harms, viral health, sexual health, and harm reduction service use.

RESULTS

A total of 35 articles were included in the review, 23 of which examined harm reduction outcomes and 12 of which investigated harm reduction practices in Housing First. Harm reduction outcome studies focused mostly on nonspecific substance use problems, with Housing First being found to have minimal effects in this domain. More severe harms, such as delirium tremens and substance use-related deaths, have been minimally explored, though preliminary evidence is promising. Viral health, sexual health, and harm reduction service use outcomes were the focus of few studies. Research on harm reduction practices highlighted that Housing First providers experience both flexibility and ambiguity in their work using a harm reduction approach, and the importance of empathetic working relationships for engagement in harm reduction work.

CONCLUSIONS

Harm reduction outcomes in Housing First remain underexamined and any conclusions of the intervention's impacts in this domain would be premature. Effective harm reduction practices in Housing First require strong working relationships between staff and tenants.

Smoke-Free Home Intervention in Permanent Supportive Housing: A Multifaceted Intervention Pilot

INTRODUCTION

Smoke-free homes (SFHs), the voluntary adoption of home smoking restrictions, are associated with reduced secondhand smoke exposure. However, SFHs are uncommon in permanent supportive housing (PSH) for formerly homeless adults, who have fivefold higher smoking rates than the general population. We pilot-tested a brief intervention to increase voluntary adoption of SFHs among PSH residents in the San Francisco Bay Area.

AIMS AND METHODS

We pilot-tested a brief intervention to increase voluntary adoption of SFHs among PSH residents in the San Francisco Bay Area. Rest of the methods, PSH residents (n = 100) and staff (n = 62) from 15 PSH sites participated in the intervention between October 2017 and February 2018. Research staff provided counseling to PSH residents on how to adopt an SFH and trained PSH staff on how to counsel residents on smoking cessation. The primary outcome was self-reported voluntary adoption of an SFH for ≥90 days, and the secondary outcome was carbon monoxide-verified PPA at 6-month follow-up. PSH staff completed the Smoking Knowledge, Attitudes, and Practices survey at baseline and 3-month follow-up.

RESULTS

At 6 months, 31.3% of PSH residents had adopted an SFH (vs. 13.0% at baseline) and 16.9% reported carbon monoxide-verified PPA. A positive attitude toward an SFH policy was associated with increased odds of SFH adoption (adjusted odds ratio = 8.68, 95% confidence interval: 2.42, 31.17). Voluntary SFH adoption was associated with increased PPA (adjusted odds ratio = 26.27, 95% confidence interval: 3.43, 201.30). PSH staff reported improved attitudes toward and self-efficacy in delivering cessation care, and decreased barriers to discussing smoking cessation among PSH residents between baseline and 3-month follow-up.

CONCLUSIONS

In this single-arm study, a brief intervention increased SFH adoption and PPA among PSH residents.

IMPLICATIONS

To date, few interventions have addressed SFHs and their association with tobacco use among PSH residents. A "ground-up" approach that relies on buy-in from residents and that promotes voluntary SFHs is an innovative way to increase smoke-free living environments in PSH. This approach could pave a pathway for smoke-free policy implementation in these sites. PSH can play a role in reducing the burden of tobacco use by empowering its residents to adopt voluntary SFHs, which could increase smoking cessation among residents.

Responses to Graphic Warning Labels among Low-income Smokers

Objective: Graphic warning labels (GWLs) are effective in communicating tobacco-related harms. Methods: In this mixed-methods study, we used purposive sampling to recruit 100 low-income smokers in the San Francisco Bay Area between October 2017 and February 2018 to participate in an intervention promoting smoke-free homes. We presented the 2009 Food and Drug Administration-proposed GWLs and explored perceptions of affect, efficacy, and appeal using questionnaires at baseline, 3- and 6-months follow-up. Because of participants' interest in this topic, we subsequently conducted a qualitative sub-study among 20 participants exploring perceived efficacy of GWLs on smoking cessation. Results: In all, 87.3% and 59.2% agreed that GWLs were useful and would motivate cessation behaviors, respectively, at baseline. We found that the most common responses were shock (61.8%) and disgust (55.3%), whereas anger (29.0%) and annoyance (19.7%) were less common. Participants also reported that GWLs unequivocally illustrating smoking's harmful effects were more appealing than non-specific images, as were images that depicted positive cessation-related effects. Conclusions: GWLs appear to be an important health communication among low-income smokers. Future studies on GWLs should examine the association of negative affect and cessation among this population.

Smoke-Free or Not: Attitudes Toward Indoor Smoke-Free Policies Among Permanent Supportive Housing Residents

Purpose:

Interventions for tobacco dependence are most effective when combined with smoke-free policies, yet such policies are rare in permanent supportive housing (PSH) for formerly homeless adults. We aimed to provide in-depth analysis of attitudes and barriers to and facilitators of implementing smoke-free policies in PSH.

Approach:

Current smokers living in PSH completed a questionnaire and participated in in-depth, semistructured interviews on smoking history, attitudes toward smoke-free policies, and perceived barriers to cessation.

Setting:

We collaborated with 6 San Francisco Bay Area PSH agencies.

Participants:

Thirty-six residents in PSH.

Methods:

Interviews, conducted by trained interviewers, were digitally recorded, transcribed, and analyzed using content analysis methods. Participants were recruited until we reached thematic saturation, or no new themes emerged from the interviews.

Results:

Over half of participants (52.8%, n = 19) reported depression, and 97.2% (n = 35) reported current substance use. Support for indoor smoking bans in living areas was modest (33.1%), although most residents anticipated cutting down (61%) and reported they would not move because of a smoking ban (77.8%). There was interest in quitting smoking, although co-use of tobacco with other substances was a major barrier.

Conclusion:

This study is the first to explore attitudes toward smoke-free policies in PSH. We found that residents in PSH support smoke-free policies and consider them feasible if implementation processes are sound. Our findings underscore the need to address barriers to adopting smoke-free policies and accessing smoking cessation services. In particular, interventions must address the co-use of tobacco with other substances and the impact of smoking on financial and housing stability.