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Abstract
BackgroundThree-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.MethodsWe 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.ResultsSubsistence 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.ConclusionsHomeless 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 registrationClinicalTrials.gov: NCT02565381.
Highlights
IntroductionCompeting priorities for shelter, food, and other subsistence needs may be one explanation for low smoking cessation rates in this population
randomized controlled trial (RCT) participants reported generally similar levels of difficulty meeting these subsistence needs (Fig 1; Panel b). Those with the highest level of subsistence difficulty (N = 105) were younger, less likely to have completed high school, less likely to have worked in the past month, more likely to have slept rough in the past week, and more likely to report fair or poor health (Table 3)
Subsistence difficulties and smoking cessation readiness, confidence, and barriers Among survey participants, subsistence difficulty level was not associated with either readiness to quit or confidence to quit in unadjusted and adjusted analyses (Table 4)
Summary
Competing priorities for shelter, food, and other subsistence needs may be one explanation for low smoking cessation rates in this population. Homeless adults with specific subsistence difficulties, such as getting enough food to eat, are more likely than their food-sufficient counterparts to have unmet needs for medical or surgical care, prescription medications, and mental health care [17]. These adults are more likely to be medically or psychiatrically hospitalized and to be high users of emergency department services [18]
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