Studies have consistently demonstrated that people experiencing homelessness have high rates of tobacco use and high-risk smoking practices, including the misuse of tobacco products.
Approximately three quarters of adults who are experiencing homelessness are cigarette smokers—a prevalence four times that in the U.S. adult population and 2.5 times that among Americans in general who are impoverished.1
Individuals experiencing homeless and who smoke have the desire to quit, preferring nicotine replacement therapy like patches and lozenges to other smoking cessation tools, and are interested in the prospect of utilizing e-cigarettes as well.2
Individuals without homes also make efforts to quit at rates similar to their housed counterparts, though their success rates are lower.3
Barriers to quitting for individuals who are experiencing homeless include high levels of nicotine dependence, depressed mood, stress, restlessness, and lack of readiness to quit on the stages of change.4
What We Know About What Works
The literature suggests that people who formerly smoked and who are homeless want to help others quit and people who smoke are more ready to quit if they have support. Additionally, cessation is more likely if the person attempting cessation knows other people who have quit.5
Motivational interviewing has a positive impact on smoking cessation and is a delivery approach used for a variety of medical and behavioral health issues in many health care settings for people who are experiencing homelessness.6
At the individual level, tobacco-cessation interventions should be tailored to the unique characteristics of people who smoke and are experiencing homelessness while incorporating evidence from related populations, such as people who smoke and who have a mental illness and substance-use disorders. Interventions should be delivered at or near shelters and drop-in facilities to enhance participation and lessen the burden of competing life priorities.7
The first known study exploring the feasibility of offering Nicotine Anonymous (NicA) meetings for people experiencing homelessness showed that it is feasible to implement NicA within a health care setting in some locations for people experiencing homelessness. Success of the intervention varied depending on participant familiarity with meeting facilitators, accessibility of meeting spaces, other services available in the meeting settings, where participants were in their homeless trajectories and readiness to quit smoking, content of meetings, religious beliefs of participants, and literacy levels of participants.
Individuals recovering from alcoholism who also wanted to stay nicotine-free spearheaded the creation of NicA as they felt the 12-step model was helpful in managing their nicotine. Therefore, the model may be more attractive to those who have had positive experiences with other 12- step programs versus those who have not had similar experiences. Given that smoking among people experiencing homelessness is associated with a history of alcohol and drug use and with coping with mental health issues, NicA is an appropriate smoking cessation support group model to test among individuals experiencing homelessness.8
The Break Free Alliance, one of six national networks funded by the Centers for Disease Control and Prevention, Office on Smoking and Health hosted a panel in 2009 to identify appropriate policy and cessation models for populations of people experiencing homelessness. They concluded that while it is not clear if the best practices outlined in the CDC document are effective among persons experiencing homelessness, the following promising interventions aimed at reducing tobacco use among this population should be considered by state tobacco control programs, community-based organizations and others who fund and implement tobacco control programming:
Integrate motivational interviewing techniques into service delivery systems that serve individuals experiencing homelessness.
Integrate tobacco cessation counseling into drop-in visits at clinics, shelters and other service centers. Staff should be trained in brief intervention counseling techniques to ask clients if they use tobacco, if they want to quit, and provide them with tobacco cessation resources.
Provide cessation classes, state quitline referral information and other resources for staff who work with peopleexperiencing homelessness. Likewise, train staff who have one-on-one interactions with clients to provide tobacco cessation counseling for them.
Develop cessation curricula specifically tailored to individuals experiencing homelessness and to service delivery systems for those people.9
What’s Relevant in Pennsylvania
As of January 2019, Pennsylvania had an estimated 13,199 individuals experiencing homelessness on any given day, as reported by Continuums of Care to the U.S. Department of Housing and Urban Development (HUD). Of that Total, 1,569 were family households, 857 were Veterans, 737 were unaccompanied young adults (aged 18-24), and 1,863 were individuals experiencing chronic homelessness.10
In collaboration with the Pennsylvania Department of Health, the American Lung Association offered the Freedom from Smoking program to individuals in homeless shelters and those seeking housing placement.
What Other States Are Doing
New York University’s “bundle” model for tobacco cessation programming in service agencies for people experiencing homelessness in which:
Facilities must be smoke-free
At least one staff is identified as a site champion to oversee cessation programming
All staff are trained and competent in providing brief cessation counseling
Intensive interventions easily accessible/tailored for clients with substance abuse disorders and mental illness
Clients have access to sufficient supplies of pharmacotherapy (e.g. NRT)
Staff who are experiencing tobacco dependency are given assistance to quit11
References and Resources
The Public Health Law Center Tobacco Control Legal Consortium published Tobacco Use Among the Homeless Population: FAQ in 2016 with policies and approaches for states and local organizations to reduce the use of tobacco in the homeless population.
Stand Downs are one part of the Department of Veterans Affairs’ (VA) efforts to provide services to veterans experiencing homelessness. Stand Downs are typically one to three-day events providing services to veterans experiencing homelessness such as food, shelter, clothing, health screenings, VA and Social Security benefits counseling, and referrals to a variety of other necessary services, such as housing, employment and substance abuse treatment. Stand Downs are collaborative events, coordinated between local VAs, other government agencies, and community agencies who serve the homeless.12