The Tobacco Related Disease Research Program has prioritized the homeless population as one of the disproportionately impacted populations in California in need of tailored smoking cessation strategies. Of the 3.5 million individuals experiencing homelessness yearly in the United States, approximately 70% are smokers. The rate of smoking in the homeless population is almost 4-fold higher than that in the general population (19%), and almost 6-fold higher than that in California (12%). Previous research has demonstrated that homeless adults are interested in quitting smoking and many engage in smoking cessation, but few are successful at quitting. Research has focused on individual-level barriers to smoking cessation such as substance use disorders, or systems-level barriers to smoking cessation such as access to health care or smoking cessation treatment. Few studies have focused on social and environmental factors that influence smoking cessation among homeless adults. Anti-tobacco social norms that support restrictions on smoking at work, home, or public places are associated with reduced cigarette consumption and increased smoking cessation.
In California, there is strong support for anti-tobacco social norms. These norms and their relation to smoking cessation have not been fully explored in homeless service settings such as shelters. Homeless shelters may be ideal settings in which to introduce smoking cessation services, as the clientele have high smoking rates and include smokers in all stages of readiness to quit. Homeless shelters could facilitate smoking cessation if they offered smoke-free living environments. While homeless shelters in California are required to implement indoor smoking restrictions under state laws that ban workplace smoking, there is little evidence that shelters implement and enforce these policies. The current proposal seeks to fill these gaps by examining the barriers to and facilitators of implementing and enforcing smoke-free policies in homeless shelters, and exploring homeless clients’ interest in smoking cessation and quit attempts in relation to these policies. We have partnered with emergency and transitional homeless shelters in San Diego County to survey and conduct key informant interviews with directors, staff, and homeless clients working or staying in these facilities.
We aim to use this formative research to develop an intervention that will improve shelters’ capacity to facilitate smoking cessation, focusing on improving and expanding smoke-free policies, minimizing environmental cues to smoking, and training staff to facilitate smoking cessation. We will pilot test the feasibility of the intervention in one shelter. We will develop and assess process outcomes during the intervention. We will assess smoking and quitting behaviors and acceptability of the intervention among staff and clients at enrollment and at 3-months follow-up. This exploratory/developmental proposal will enable us to generate preliminary data, which will serve as the foundation for a larger grant to test the efficacy of the capacity building intervention across multiple shelters. The findings from this study will inform development of anti-tobacco policies that will change norms around smoking in homeless service settings and prepare homeless individuals to work in smoke-free workplaces and live in smoke-free housing. We will disseminate findings from this study to other homeless services settings in California.
The long-term goal is to enable shelters to take a lead role in tobacco control by promoting smoke-free living environments and reducing environmental barriers to smoking cessation for populations experiencing homelessness. These steps have the potential to reduce tobacco use and its associated health disparities among the homeless population.