Advancing Housing and Health: Promoting Smoking Cessation in Permanent Supportive Housing

Cigarette smoking and homelessness are interconnected public health problems that contribute to health disparities. Smoking is common among persons with disabilities, mental health, and/or substance use disorders, as well as those living below the federal poverty level. These are the same populations living in permanent supportive housing, which is subsidized housing with closely linked or on-site voluntary social and/or medical services for formerly homeless adults. Among persons residing in permanent supportive housing, cigarette smoking not only presents an opportunity cost (ie, something that detracts from an essential need), threatening housing stability, but also leads to adverse health outcomes. Smoking cessation could improve health outcomes and free up funds to enhance housing stability. Smoke-free policies and cessation services, 2 evidence-based approaches, could provide the support needed for permanent supportive housing residents to quit smoking. However, such policies are uncommon in permanent supportive housing, in part because of concerns that they may increase evictions. We describe barriers to and opportunities for increasing access to comprehensive smoke-free policies and smoking cessation services in permanent supportive housing. By facilitating the implementation of such policies, permanent supportive housing could empower residents to engage in smoking cessation while avoiding unintended consequences.

Relationship Among Homelessness, Housing, and Smoking

In 2017, an estimated 376 086 persons lived in permanent supportive housing,¹ which is subsidized housing with closely linked voluntary medical and/or social services for formerly homeless adults and families.² Permanent supportive housing residents are typically persons who have experienced long-term homelessness; who may live with disabilities, mental illness, and/or substance use disorders; and who cycle in and out of various acute care services, including hospital emergency departments, inpatient hospital stays, psychiatric hospitals, jails, and prisons.² Permanent supportive housing is an evidence-based solution to ending chronic homelessness, not only helping to increase housing stability and health but also reducing costs related to the use of acute care services.² In some permanent supportive housing, residents are required to pay rent, which can amount to up to 30% of their income if they have an income, with the remainder covered by federal subsidies.^2,3 The US Department of Housing and Urban Development (HUD) is one of the primary sources of funding for permanent supportive housing programs.^2,3 Most permanent supportive housing uses a “housing first” approach, which provides housing without preconditions of abstinence from alcohol or substance use or a requirement to engage in case management services.^2,3

Cigarette smoking and homelessness are interconnected public health risk factors that contribute to and exacerbate health disparities.^4,5 Compared with the general population, the prevalence of cigarette smoking is markedly higher among many of the same populations that commonly live in permanent supportive housing, including persons with physical disabilities, mental illness, and substance use disorders and persons who live below the federal poverty level.^6,7 In 2017, approximately 70% of persons experiencing current homelessness and about half of formerly homeless residents living in permanent supportive housing currently smoked cigarettes.^5,8 Moreover, heart disease and cancer, which are major smoking-attributable health outcomes,⁴ are the leading causes of disability and death among homeless adults aged ≥45.^9,10 The risk of smoking-attributable health outcomes increases with age, and more than 40% of homeless persons entering permanent supportive housing are aged >50.¹ Furthermore, mortality among permanent supportive housing residents is double that of the general population,¹¹ and smoking-related diseases contribute to more than 60% of the all-cause mortality among formerly homeless persons.¹¹

In addition to causing substantial morbidity and mortality, smoking exacerbates poverty and housing instability. Among homeless adults, tobacco-related expenditures amount to 30% of monthly income,^12,13 an amount equivalent to the rent required to stay in permanent supportive housing. Smokers who are homeless and have a higher level of nicotine dependence are more likely than smokers who are homeless and have lower levels of nicotine dependence to have subsistence challenges, such as finding shelter, food, clothing, or somewhere to wash themselves.¹³ Among permanent supportive housing residents who smoke, tobacco-related expenditures amount to about 11% of residents’ monthly income (range, 6%-26%).^14,15 These smoking-related expenditures could interfere with residents’ ability to pay living expenses, including rent, which can place them at risk for eviction. In a mixed-methods study that included a survey of 23 permanent supportive housing sites in the San Francisco Bay Area, 17 sites did not offer on-site cessation services or discuss the effect of smoking on housing stability.¹⁶ Service staff members at these sites reported rent evasion and the resulting threat of eviction as some of the most common reasons for case management interventions in permanent supportive housing.¹⁶ Despite the potential effect of smoking on financial and/or housing instability, service staff members in these sites rarely engaged in discussion on the potential for smoking cessation to help alleviate the health or financial burden caused by smoking.¹⁶

Smoking Cessation in Permanent Supportive Housing: The Benefits of Smoke-Free Policies

Smoking cessation could play an important role in improving population-level health among persons living in permanent supportive housing by not only reducing smoking-attributable morbidity and mortality but also by freeing up funds to enhance housing stability and reduce food insecurity. Permanent supportive housing could provide an effective venue for smoking cessation because it offers a supportive environment for behavior change for permanent supportive housing residents.

Smoke-free policies are an evidence-based approach that could be the primary lever for supporting smoking cessation among permanent supportive housing residents’ and, in turn, increase their well-being. Research indicates that smoke-free policies are effective not only in reducing secondhand smoke exposure but also in promoting cessation among current smokers and preventing relapse among former smokers.^17,18 This evidence informed HUD’s decision to adopt a smoke-free policy in public housing in July 2018.¹⁹ However, the existing policy does not apply to permanent supportive housing, and most permanent supportive housing providers restrict smoking in indoor shared areas (eg, hallways) but permit smoking in living areas.¹⁶ Therefore, permanent supportive housing residents are susceptible to secondhand smoke exposure and its associated risks, as well as an environment that continues to normalize smoking.

Challenges and Opportunities for Smoke-Free Policies in Permanent Supportive Housing

Discussions about the adoption of smoke-free policies in permanent supportive housing must include a consideration of strategies to avoid unintended consequences (Table).¹⁶ First, a no-smoking policy may appear to contradict the housing-first approach of permanent supportive housing if it poses additional barriers to housing chronically homeless persons or has the unintended consequence of increasing the number of unsheltered homeless persons. Second, such policies should not lead to increasing eviction rates, which would contradict the primary goal of permanent supportive housing (ie, to keep persons successfully housed). Third, residents with disabilities, cognitive impairment, or severe mental illness may have difficulty complying with a smoke-free policy. Fourth, consequences for policy violations should be carefully considered, because eviction is neither an ethical nor an acceptable outcome for persons with a history of long-standing homelessness. Fifth, unlike public housing in which HUD oversees policy implementation, permanent supportive housing is operated by nonprofit housing providers, and policy implementation is left to their discretion. Therefore, the lack of a common regulatory authority could limit adoption of a uniform smoke-free policy. Sixth, the lack of culturally and linguistically appropriate cessation programs that could be integrated in permanent supportive housing in combination with smoke-free policies is another important barrier.

Table.

Barriers and opportunities to adopting smoke-free policies and cessation services in permanent supportive housing

Barriers	Opportunities
Smoke-Free Policy Implementation
Smoke-free policies are not feasible in permanent supportive housing.	Supporting a ground-up approach of voluntary smoke-free home adoption can pave a pathway for a building-wide smoke-free policy.
Persons with disabilities might be unable to adhere to the policy.	Identify and provide reasonable accommodations to help persons with disabilities adhere to smoke-free policies.
Evictions will increase as a result of nonadherence to the policy.	Designing repercussions to violations that do not include evictions is essential, including providing access to cessation resources to increase adherence.
High levels of nicotine dependence will pose a barrier to policy adherence.	Provide cessation medications to minimize withdrawal symptoms.
Access to Cessation Services
Tobacco screening and brief cessation services are not offered in permanent supportive housing.	Train service staff members to obtain information on smoking status of residents and provide brief cessation counseling upon residents’ entry into housing.
Medications for cessation are not offered in permanent supportive housing.	Provide on-site access to medications for cessation either through on-site medical clinics or by contracting with county medical services.
Missed opportunities for smoking cessation counseling.	Use case management encounters to draw parallels between smoking and difficulty paying rent, having financial hardship, and/or experiencing food insecurity.
Culturally and linguistically appropriate cessation counseling is unavailable.	Train service staff members on how to incorporate permanent supportive housing residents’ lived experiences (eg, mental health and/or substance use) into cessation counseling.

Despite these challenges, permanent supportive housing could play an integral role in promoting smoking cessation and reducing tobacco-related disease and death among formerly homeless adults residing in permanent supportive housing (Table). To facilitate an environment in which smoke-free policies are strongly supported by residents and unintended consequences are minimized, certain actions can be taken to promote smoke-free norms. For example, permanent supportive housing residents who report smoking indoors could be empowered through a “ground-up approach,” whereby they are educated on and encouraged to voluntarily adopt smoke-free home rules (ie, voluntary no-smoking rules in indoor living areas) and engage in cessation services. Permanent supportive housing sites that are considering becoming smoke-free could initiate policy implementation using a ground-up approach by encouraging voluntary adoption of smoke-free homes, followed by a top-down approach in which a building-wide smoke-free policy is implemented. This implementation process could ensure resident support for the policy while minimizing subsequent violations and punitive repercussions to violations. This process could also lead to a social norm effect of other residents in a building voluntarily adopting smoke-free homes. Providing “reasonable accommodations,” such as housing residents with disabilities on the ground floor and close to exits, may also facilitate policy adherence.

To mitigate the concerns that a smoke-free policy in permanent supportive housing may lead to an increased eviction rate or may lead persons to decline permanent supportive housing because of the policy, permanent supportive housing providers could use methods to enforce policies in a way that encourages policy adherence and minimizes punitive consequences. HUD’s public housing experience could provide important lessons for permanent supportive housing providers that are interested in becoming smoke-free. For example, public housing authorities provide residents who have not complied with the policy with several verbal and/or written warnings about the violations, along with resources for cessation.¹⁹ As a result, housing providers have not reported a rise in eviction rates related to the smoke-free policy.²⁰ Such strategies have also been adopted by permanent supportive housing providers that have become smoke-free, without any evidence of eviction.^8,16 As the field evolves, new studies will likely describe other strategies and solutions to implementing and enforcing these policies in permanent supportive housing while minimizing unintended consequences.

Moreover, the academic community can play an important role in disseminating evidence on the benefits of smoke-free policies and successful implementation strategies to permanent supportive housing providers. For example, activities such as writing policy briefs, giving webinars, or facilitating local symposia can help in translating evidence into practice and policy. Academic conferences focused on tobacco control interventions can be broadly tailored to audiences that provide services to these populations, including the option to gain continuing medical education credits to maintain licensing requirements. Such incentives could increase stakeholder commitment to promote knowledge about smoking and implement interventions to increase delivery of smoking cessation care to permanent supportive housing residents. The academic community can play a role in helping to evaluate the effect of these policies on the behaviors of permanent supportive housing residents, such as engaging with smoke-free rules and cessation services and smoking cessation. In addition, the academic community can evaluate delivery and receipt of smoking cessation interventions in permanent supportive housing sites.

Importance of Cessation Resources

For policies to be successfully implemented in permanent supportive housing, it is critical that they be accompanied by efforts to increase access to and use of proven cessation interventions. Many persons who live in permanent supportive housing are interested in quitting smoking but may face barriers to smoking cessation, such as lack of access to smoking cessation services.¹⁴ Behavioral counseling and pharmacotherapy are proven smoking cessation interventions, and the likelihood of success is higher when these interventions are combined rather than used individually.^4,21 These engagement strategies could be reinforced when persons enter permanent supportive housing, including screening for tobacco use and providing brief interventions for smoking cessation. Case managers can integrate cessation counseling into discussions of rent evasion, food insecurity, or financial hardship. To have these nuanced discussions, service staff members in these sites could benefit from additional training on how to integrate the lived experiences (eg, experiences of chronic homelessness, challenges with mental health and/or substance use disorders) of permanent supportive housing residents into smoking cessation counseling.

It is also important for cessation services to be culturally and linguistically tailored to the needs of permanent supportive housing residents who belong to racial/ethnic minority groups and/or have limited English proficiency. Bilingual case managers or substance use counselors working in permanent supportive housing programs can be trained to provide culturally relevant cessation counseling. Permanent supportive housing programs can also use the lay health worker or peer support models to provide cessation outreach to their residents.²² A lay health worker or peer shares the same race/ethnicity, language, and cultural background of the target population and, although he or she is not a health professional, has received training in communicating health-related messages to the target population. These models could help improve access to culturally relevant cessation care.

Furthermore, on-site access to medications for cessation could facilitate smoking cessation among permanent supportive housing residents and minimize withdrawal symptoms that might hinder adherence to a smoke-free policy. Although some permanent supportive housing offers an integrated care model with on-site primary care and behavioral health services, most contract with county departments of public health or community health clinics to deliver these services. This integrated model of care, whether delivered by the housing organization’s or the county’s service staff members, offers a useful infrastructure for permanent supportive housing to provide cessation services, including Medicaid-covered pharmacotherapy.

Conclusion

For housing to fulfill its promise as the foundation for good health,^23,24 an environment that is supportive of smoking cessation is essential. Smoking places an enormous health and financial toll on persons experiencing homelessness, and permanent supportive housing is an untapped opportunity to reduce the burden of tobacco use on this already vulnerable population. Implementing comprehensive smoke-free policies in coordination with evidence-based smoking cessation services in permanent supportive housing that help residents quit can improve health outcomes and well-being for this underserved population. In addition, permanent supportive housing providers can serve an important role in facilitating the implementation of such policies in a manner that empowers permanent supportive housing residents and avoids unintended consequences.

ORCID iD

Maya Vijayaraghavan https://orcid.org/0000-0002-3747-984X