Borrelli Responds

Previously, I proffered a definition of “underserved smoker” and presented data to support the hypothesis that smokers with mobility impairments are an underserved group.^1,2 In their commentary, Glasser and Hirsch call our attention to the high smoking rates among homeless people. Indeed, people with mobility impairments^1,2 and homeless people³ are more likely to smoke and are less likely to successfully quit than are smokers in the general population, despite comparable numbers of attempts and desire to quit. High smoking prevalence, in the context of high motivation to quit, suggests that these groups face systemic barriers to smoking cessation at multiple levels. On an individual level, it is equivocal whether existing Evidenced Based Treatments (EBTs) can reach, motivate, and be of sufficient intensity to help underserved smokers quit. For example, one study randomized homeless smokers to EBTs versus standard care and did not find significant differences in smoking cessation.⁴ Criteria have been established to determine whether there is a reasonable threat of failure of EBTs to warrant cultural adaption of an EBT with the goal of improving cessation rates among underserved smokers.¹ Smokers with mobility impairments, for example, need treatments that eliminate architectural access issues but also take into account their unique constellation of risk factors for continued smoking (e.g., depression, activity restriction, medical comorbidities).⁵

On a macro level, policy changes have had the greatest impact on smoking prevalence but their implementation and impact on smoking among the underserved has not been sufficiently addressed. For example, only a minority of homeless shelters have smoking bans or smoke-free areas, although these policies are supported by both homeless smokers and nonsmokers⁶ and could change the norms and culture at shelters to promote quitting.⁷ Glasser and Hirsch point out that, in Rhode Island, neither shelters nor the state have the resources to support cessation. Indeed, more than 99% of the tobacco settlement money awarded to Rhode Island has been spent on balancing the state budget. Clinic-based programs, such as co-location of cessation programs within medical homes, has been suggested to reach underserved smokers, but this has not been effective in reaching homeless populations.⁸ For underserved smokers, strategies at multiple levels are needed, with additional attention given to finding creative methods to weave smoking cessation into the fabric of their daily lives. Given that there are no disparities in mobile phone use,^9,10 mHealth may be a promising avenue to reach underserved groups, and should be a direction for future research.