‘Tobacco Use among Homeless People . . .’

By Max R. Weller

homeless smoker

Read the article from the New England Journal of Medicine, published last summer. Quoting from it below:

Although the prevalence of smoking in the United States has declined, vulnerable and marginalized groups continue to use tobacco at high rates. One such group is the 2.3 to 3.5 million people nationwide who are homeless in any given year. Approximately three quarters of homeless adults are cigarette smokers — a prevalence 4 times that in the U.S. adult population and 2.5 times that among impoverished Americans in general. The coexisting psychiatric and addictive conditions and life circumstances of homeless smokers have long fueled a fatalistic attitude among health care professionals toward addressing tobacco use in this population. We believe that this approach should change.

Smoking-related deaths among homeless and marginally housed people occur at double the rate seen among more stably housed people and account for a considerable fraction of the absolute mortality disparities between these groups. In our study of more than 28,000 adults seen at the Boston Health Care for the Homeless Program in 2003 through 2008, cancer was the second-leading cause of death overall and the leading killer among adults 45 years of age or older. Malignant neoplasms of the trachea, bronchus, and lung caused more than one third of these deaths, a finding that underscores the excess burden of lung-cancer mortality in this population that has been documented elsewhere. Studies have also shown higher rates of death due to circulatory and respiratory diseases among homeless people than among people with homes.

Here in Boulder, CO the homeless shelter/services providers do not permit smoking inside their facilities, but it is allowed outside. For example, Boulder Shelter for the Homeless provides a patio area with seating and tables for the use of smokers at any time during their stay. It’s generally crowded, and for nonsmokers like me it’s impossible to step out there for a breath of fresh air. No other outdoor space is offered as a nonsmoking alternative on BSH property.

I’ve blogged about the bums hunting for “snipes” in the parking lot of the strip club next door, as I’m waiting for BSH to open at 6AM. The nicotine addicts don’t hesitate to pick up these discarded cigarette butts and smoke what’s left, even if it’s only a couple of puffs. Sometimes, a homeless smoker will collect dozens of snipes and use that waste tobacco to roll their own cigarettes. Pouch tobacco and rolling papers are also common. Homeless smokers will share the same cigarette, just as they pass around a joint.

The most common (and filthy) morning activity at any homeless shelter is the hacking and coughing and expectorating of smokers. And they’ll leave their phlegm in the lavatory sink rather than rinse it down the drain.

It’s no wonder that all sorts of respiratory and other illnesses are so prevalent in homeless shelters.

Continuing to quote the NEJM article:

Despite the common expectation that homeless smokers may not consider cessation a priority, evidence suggests that many are interested in quitting. However, confidence in the ability to quit is low, and few succeed in quitting, which indicates that interventions to support smoking cessation are needed in this population . . .

At the individual level, tobacco-cessation interventions should be tailored to the unique characteristics of homeless smokers while incorporating evidence from related populations, such as smokers with 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. The daily stressors of homelessness foster a present-oriented outlook that values immediacy over delay. Overcoming the immediate rewards of smoking will require intervention strategies that emphasize the short-term benefits of quitting, such as fewer smoking-related symptoms and saving money from not buying tobacco. Contingent monetary rewards for quitting might bolster this approach and have shown promise in other vulnerable groups of smokers. Adding pharmacotherapy to relieve nicotine withdrawal symptoms would complement these behavioral strategies.

For homeless smokers who are unable or unwilling to quit, we suggest consideration of pharmacotherapy and counseling to reduce cigarette consumption. Although there is limited evidence supporting this approach, it acknowledges the challenges faced by this population and may facilitate future quit attempts.

At the interpersonal level, smoking is a ubiquitous social phenomenon among homeless people that is strongly influenced by peer interactions. Homeless smokers with greater social support for quitting report greater readiness to quit, a finding that suggests that group-oriented or peer-based strategies may hold promise.

Many former alcoholics and drug abusers have told me that it was easier for them to end those addictions than to quit smoking, so it’s not surprising that tobacco kills more people annually than drinking and drugging combined. Clearly, there needs to be more help made available to homeless smokers who want to quit — and the logical places for it are the homeless shelter/services providers.


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