TABLE 4.

Representative Quotes: Perceived Barriers to Instituting Tobacco Control Policies

Barrier Types	Comments
Cultural: Quitting smoking is a low priority	“I mean I hate to say it but smoking cessation tends to fall pretty far down the list as far as urgencies. There are things that are really jeopardizing people’s ability to remain in the shelter.… So [smoking cessation] is something I would obviously love to see more of but sometimes I feel it’s lower down on the priority list.”
	“There are so many underlying issues.… So many of our clients, just at the top of their list of things they want to resolve, they want to talk about the substance use, mental health issues, or their children’s health. So smoking, if it has not become a problem to them, then they just [continue].”
Cultural: Smoking is a reasonable coping mechanism	“Like, you know, you’re facing a lot of stress and a lot of hardship in your life, and smoking is one way to cope with stress, so you take that away, what are you going to replace that coping mechanism with. There has to be something else that they have to fall back on.”
	“It’s kind of like the tea kettle needs to let off steam. So I mean on some level we do try to be respectful of the fact that this is their coping mechanism and they need it right now.”
Cultural: Tobacco use is socially and legally accepted	“I would agree that it’s kind of considered the lesser of the evils, and so then if you were trying to get people to address one thing it tends to be the thing that’s impairing their functioning most. When working with the homeless population, if the goal is we’re trying to get them a house, they can’t go meet a landlord drunk, but they could go meet a landlord with a cigarette. It’s that different level.”
	“I think it is, but it’s not so much their primary goal and I think in the harm reduction spectrum we are trying to help people with the—we’re trying to support the coping strategies they use that are less detrimental or dangerous than some others. Usually compared to their crack use, cigarette [use] is not the primary barrier to keeping their housing, so most staff [members] don’t see it as the biggest problem either.”
	“I’m more concerned that they’re not smoking crack or shooting up drugs, like in the scheme of harm reduction if you can reduce use of those other things and you’re still smoking, I can live with that. That’s a bit of the attitude we have just because our folks are often dealing with much, much more severe illicit drug use.”
Cultural: Preventive health is a secondary concern	“A lot of our folks see a lot of people die in their buildings and they’re not thinking about when they’re 80 or when they’re 70, they’re much more focused on the immediate. I think in looking at smoking cessation it would have to be tied to the immediate benefit they would see in their lives.”
Administrative: Lack of resources regarding smoking cessation services	“I think it would be getting a staff member trained in that specific program. If one of the staff wanted to do that group, getting some programming around it, like what are the philosophies behind helping people quit, [be]cause I don’t know what they are. I think it would just be getting more resources. Figuring out if other people are doing the groups and what are they talking about, how are they structuring it.”
Administrative: Format of traditional cessation service is not appropriate for clients	“It’s just the format of those resources for smoking cessation, our tenants have not been super successful sticking with those. They’re more likely to take a pill or a patch or something that is a medical intervention to reduce their cravings than to learn cognitive behavioral therapy over months.… The likelihood of having people come to one group, yes, two groups, maybe, three consecutive groups over three weeks, you would get different people every group. The traditional 8-week, 10-week programs, or models that have the most success for smoking cessation are not ideal [for our clients].”
	“So it’s a lot due to their illness, like being disorganized and having difficulty … not always knowing oh, it’s Tuesday, the drop-in hours of that clinic are Tuesdays at 3:00, the logistics of knowing where to go and when, so they often need some guidance in the big picture and follow-up.”