Engaging Adults Experiencing Homelessness in Smoking Cessation Through Large-Scale Community Service Events

Abstract

Cigarette smoking contributes substantially to the increased financial- and health-related burdens among adults experiencing homelessness. We describe findings from a case study of a model to increase access to cessation services among adults experiencing homelessness. In partnership with Project Homeless Connect (PHC), we piloted a unique service delivery model that involved providing brief cessation counseling and pharmacotherapy to smokers from this population attending large-scale service events in San Francisco, with the goal of connecting them to long-term smoking cessation care. We participated in three service events between October 2017 and March 2018. We offered brief smoking cessation counseling to 45 individuals, and smoking cessation counseling and pharmacotherapy to 7 individuals experiencing homelessness. This model could improve public health if expanded to other cities, particularly the 200 other cities in the United States offering PHC service events.

ASSESSMENT OF NEED

Seventy percent of individuals experiencing homelessness smoke, and tobacco use is the leading contributor to their increased morbidity and mortality (Baggett, Tobey, & Rigotti, 2013). Smoking also incurs a substantial financial toll: Adults experiencing homelessness spend a third of their monthly income on cigarettes (Baggett, Rigotti, & Campbell, 2016). Adults experiencing homelessness attempt to quit smoking as frequently as the general population but have success rates about 5 times lower. Barriers to cessation include high rates of mental health and substance use disorders, lack of exposure to smoke-free living environments, and inadequate access to cessation services (Porter, Houston, Anderson, & Maryman, 2011; Vijayaraghavan, Hurst, & Pierce, 2016). While trials have established the feasibility of cessation (Okuyemi et al., 2013), there have been no comprehensive public health approaches to promote smoking cessation services among individuals experiencing homelessness.

DESCRIPTION OF STRATEGY

In March 2017, we began collaborating with San Francisco Project Homeless Connect (PHC), a nonprofit funded by the Mayor’s office and the Department of Public Health, to increase access to tobacco cessation among individuals experiencing homelessness. PHC uses a unique approach that the federal government has declared a national best practice model. Its offerings include 1-day drop-in events (community days of service) providing services that typically take months to procure, including medical, dental, and vision care; mental health and substance use services; and housing assistance and more (see Figure 1). Services are delivered onsite and free of cost, and events are scheduled approximately every 2 months. Each event takes place in central San Francisco and is directed toward people who may be unsheltered, sheltered in emergency or transitional shelters, marginally housed, or living in permanent supportive housing.

FIGURE 1. Spotlight of Participants Served at PHC Events in 2016.

NOTE: PHC = Project Homeless Connect; LGBTQ = lesbian, gay, bisexual, transgender, queer. Figure from 2016 PHC Impact Report (p. 8).

PHC proposed that we provide smoking cessation resources to event attendees, and we began offering behavioral counseling and pharmacotherapy in October 2017. For clients who expressed interest, we offered (a) a 2-week supply of nicotine replacement therapy (NRT: gum, patches, or both); (b) a coupon for a free 4-week smoking cessation class at the UCSF Fontana Treatment Center; (c) a “quit kit” from San Francisco Department of Public Health that contained nail files, tea bags, a list of resources, mints, toothpicks, and lip balm; (d) a 1–800-NO-BUTTS card; (e) a list of local tobacco cessation resources; and (f) soft mints. We repeated the intervention in December 2017 and March 2018.

EVALUATION AND OUTCOMES

Our primary objective in intervening at community day of service events was to introduce this vulnerable population to smoking cessation services. Our secondary objectives were to raise awareness of available cessation strategies and increase engagement with primary care.

Our pilot occurred at PHC 68 in October 2017 (1,198 attendees) and included one table, staffed by a counselor, a pharmacy student, a health care provider, and the project leaders (MV and DA). We did not offer NRT during the pilot. Afterward we determined that the intervention would have broader reach if colocated with medical services, providing access to all visitors that sought medical care. As a result, for PHC 69 and PHC 70, we had two tables, one staffed by a counselor and located at the center of the auditorium and the other staffed by the project leaders at medical services.

We developed a template of questions to guide our individually directed counseling, asking clients about current smoking, the number of cigarettes smoked per day, whether they had made a prior quit attempt, whether they had used NRT or other pharmacotherapy, whether they were housed, and whether they had a primary care provider (PCP). Clients who obtained brief counseling from the central table were offered referrals to a free 4-week cessation program and were escorted to the medical services table for additional counseling and a 2-week supply of NRT if desired. Clients without a PCP could begin the process of obtaining one at medical services.

Confidentiality requirements prevent tracking or surveying clients at PHC events; as a result, we summarize our results qualitatively. We offered brief counseling to 45 individuals over three events and distributed a 2-week supply of NRT to 7 people. Most reported that they had made multiple prior quit attempts, usually without assistance. One person reported substituting cannabis use for tobacco and two reported reducing consumption when prescribed bupropion for depression while incarcerated; both were previously unaware that bupropion was a cessation aid. Smokers stated that they had reduced their smoking (ranging between 3 and 4 cigarettes/week and 1.5 packs/day) since the implementation of California’s $2-per-pack tax increase in April 2017.

While we were unable to follow-up directly with individuals, we received personal testimonials from two clients. One client attended the 4-week cessation program while another client wrote that he had followed up with PCP to obtain a larger supply of NRT; both continued to be abstinent.

CHALLENGES AND NEXT STEPS

To support this intervention, we needed funding for NRT, which we secured through a grant, and at least one health care provider with prescribing authority. We experienced barriers to scheduling providers. While there was substantial interest, events are scheduled no more than 6 weeks in advance, which is too short a time for providers to cancel ongoing commitments. To circumvent this barrier, we compiled an extended list of interested faculty and trainees. For future events, we plan to implement an online data entry form for gathering information. We will continue to encourage clients who have attended counseling sessions to volunteer contact after events.

IMPLICATIONS FOR PRACTICE

PHC events are highly accessible: Each of the events we attended in 2017 had over 1,000 visitors, and the model has been replicated in 200 cities in the United States, Canada, and Australia. The events provide an introduction to services for those interested in smoking cessation and connect them to longer term interventions. If expanded to other sites, the intervention could substantially increase access to tobacco cessation for individuals experiencing homelessness. In addition, PHC events offer a platform to train future providers on how to communicate with and treat smokers in vulnerable populations. In summary, PHC service events offer a critical, nonclinical venue to reach a large, diverse group of individuals experiencing homelessness and provide brief tobacco cessation services.