People Experiencing Homelessness

People Experiencing Homelessness

Tobacco use and associated morbidity and mortality

  • Homelessness has been on the rise in the U.S. since 2017, with an overall increase of 6%.1
     
  • Based on the January 2022 point-in-time counts (i.e., a method used to count the number of people experiencing homelessness), 582,462 people in the U.S. were experiencing homelessness. This represents 18 out of every 10,000 people.1
     
  • An estimated 4.2 million youth and young adults experience homelessness in the United States.2 People of color, young parents, LGBTQ+, and youth who identify as racial/ethnic minorities are more likely to experience youth homelessness.
     
  • The prevalence of tobacco use among people experiencing homelessness is estimated to be between 57% and 82%, a rate that has not changed in the past 50 years.3 Recent estimates from a 2023 statewide study on homelessness in California showed a rate of 70%.4 In comparison, tobacco use rate in the general population is 11%.5

  • Individuals with severe mental-health disorders, substance-use disorders,6 or both, who identify as racial/ethnic minorities, who are older, or who self-identify as a gender and sexual minority 7 are disproportionately represented in populations experiencing homelessness. 8,9 These populations carry a high burden of tobacco use and tobacco-caused morbidity and mortality.10,11

  • Persons experiencing homelessness are three to five times more likely to die prematurely than those who are not homeless, 12,13and tobacco-caused chronic diseases are the leading causes of morbidity and mortality among those aged 45 and older.14,15

  • Among younger homeless-experienced adults (aged less than 45 years), the incidence of tobacco-caused chronic diseases is three times higher than the incidence in age-matched non-homeless adults.16

Patterns of tobacco use
 

  • People experiencing homelessness have high levels of nicotine dependence. Average daily cigarette consumption is between 10 and 13 cigarettes a day, and more than one-third smoke their first cigarette within 30 minutes of waking 17,18

  • Over 60% who report current smoking, report using other forms of tobacco or nicotine products. People experiencing homelessness also have high rates of concurrent use of alternative tobacco products such as little cigars, smokeless tobacco, and e-cigarettes.19-22

Reasons for high rates of tobacco use
 

  • Structural inequities including racism and discrimination,23 social determinants of health such as housing,24 and commercial determinants including industry marketing are associated with high rates of tobacco use among people experiencing homelessness.25

  • Social norms of pervasive smoking, lack of access to tobacco treatment, and limited access to smoke-free housing are other reasons for high rates of tobacco use.26,27

  • Disproportionately high rates of post-traumatic stress disorder (PTSD) among people experiencing homelessness can lead to positive associations with smoking.28

  • Substance use, including stimulant, opioid, alcohol and cannabis use, are strongly related to current cigarette smoking.29,30

Barriers to quitting
 

  • People experiencing homelessness (PEH) attempt to quit at the same rate as the general population (~40% attempted to quit in the past year) but face barriers to successful quitting. 31-33Relapse rates are high, and the proportion of those who successfully quit is low.18,34,35  

  • Sustained access to effective interventions that address the high levels of nicotine dependence, co-occurring psychiatric and substance use disorders,33,36 and environmental and social triggers for tobacco use among PEH37-39 are needed to support long-term abstinence.18,34,35
     
  • Social norms of pervasive smoking in homeless services settings,39,40 and the use of tobacco to bridge therapeutic alliance between providers and clients are known barriers to quitting.41
     
  • While mental health and substance use could pose barriers to quitting, treating tobacco use does not pose barriers to substance use recovery and may even improve mental health outcomes. 42,43
     

Youth and tobacco use
 

  • Tobacco use is three times more prevalent among youth experiencing homelessness (ages 14 to 25 years) compared to the general population of youth and young adults.
     
  • Among a sample of 460 youth and young adults experiencing homelessness in Los Angeles county, 90% reported smoking regular cigarettes. 44Other commonly used tobacco products include roll your own tobacco, little cigars, e-cigarettes, cigars, and hookah.  
     
  • Youth who were exposed to others who used alternative tobacco products were more likely to use themselves.44
     

Promising approaches to quitting
 

  • Behavioral counseling and pharmacotherapy are the mainstay of tobacco treatment. 45,46
     
  • Pharmacotherapy approaches include using the five forms of nicotine replacement therapy, varenicline, and bupropion. Varenicline and/or combination NRT are the preferred approaches for pharmacotherapy.46 Combining counseling with pharmacotherapy is recommended over one or the other approach. 46
     
  • Most interventions for tobacco use among people experiencing homelessness use some combination of behavioral counseling and pharmacotherapy. There are 11 randomized controlled trial studies that have included behavioral counseling and/or pharmacotherapy, with adjunctive treatments like contingent reinforcements or e-cigarettes for PEH.47-57  
     
  • Interventions that are more intensive and that integrate tobacco use within the context of other life stressors are more effective than brief interventions or only addressing tobacco use, respectively.58
     
  • Interventions that leverage community-based resources like community pharmacies can increase reach and access to tobacco treatment for people experiencing homelessness. 17,59

  • These interventions that use various combinations of behavioral counseling and pharmacotherapy have shown abstinence rates between 9% and 17% at 6 months follow-up (compared to 30% to 40% in the general population). 49,50

  • Contingency management interventions where individuals are paid money to quit have yielded among the highest quit rates, but larger studies are needed to demonstrate long-term efficacy of this approach. Interventions that did use contingent reinforcements had abstinence rates of 22% to 48% at 4 to 8 weeks follow-up,48,52 and 21% at 6-months follow-up57 

  • Women experiencing homelessness and/or individuals who identify as a sexual and gender minority might prefer other trauma-informed approaches that address high levels of chronic stress and avoidance of group settings that are potentially triggering for mental health and substance use behaviors.60,61
     
  • While approaches might differ and may be tailored to unique experiences and populations (youth vs. young adults or older adults), the consensus is that all people who smoke should be offered tobacco treatment to quit smoking.
     

References

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2.         Legislatures NCoS. Youth Homelessness Overview. Accessed at: https://wwwncslorg/human-services/youth-homelessness-overview#:~:text=Each%20year%2C%20an%20estimated%2042,by%20a%20parent%20or%20guardian. 2023;

3.         Baggett TP, Tobey ML, Rigotti NA. Tobacco use among homeless people--addressing the neglected addiction. N Engl J Med. Jul 18 2013;369(3):201-4. doi:10.1056/NEJMp1301935

4.         Kushel M, Moore, T., et al. . Toward a New Understanding: The California Statewide Study of People Experiencing Homelessness. Available at: https://homelessnessucsfedu/sites/default/files/2023-06/CASPEH_Report_62023pdf. 2023;UCSF Benioff Homelessness and Housing Initiative.(Accessed on September 21, 2023)

5.         Cornelius ME, Loretan CG, Jamal A, et al. Tobacco Product Use Among Adults - United States, 2021. MMWR Morb Mortal Wkly Rep. May 5 2023;72(18):475-483. doi:10.15585/mmwr.mm7218a1

6.         Gutwinski S, Schreiter S, Deutscher K, Fazel S. The prevalence of mental disorders among homeless people in high-income countries: An updated systematic review and meta-regression analysis. PLoS Med. Aug 2021;18(8):e1003750. doi:10.1371/journal.pmed.1003750

7.         Kidd JD, Paschen-Wolff MM, Mericle AA, Caceres BA, Drabble LA, Hughes TL. A scoping review of alcohol, tobacco, and other drug use treatment interventions for sexual and gender minority populations. J Subst Abuse Treat. Feb 2022;133:108539. doi:10.1016/j.jsat.2021.108539

8.         Culhane DP, Metraux, S., Byrne, T., Stino, M and Bainbridge, J. The age structure of contemporary homelessness: evidencen and implications for public policy. Analysis of Social issues and public policy. 2013;13(1):228-244.

9.         Fazel S, Geddes JR, Kushel M. The health of homeless people in high-income countries: descriptive epidemiology, health consequences, and clinical and policy recommendations. Lancet. Oct 25 2014;384(9953):1529-40. doi:10.1016/S0140-6736(14)61132-6

10.       Prochaska JJ, Das S, Young-Wolff KC. Smoking, Mental Illness, and Public Health. Annu Rev Public Health. Mar 20 2017;38:165-185. doi:10.1146/annurev-publhealth-031816-044618

11.       Schroeder SA, Morris CD. Confronting a neglected epidemic: tobacco cessation for persons with mental illnesses and substance abuse problems. Annu Rev Public Health. Apr 21 2009;31:297-314 1p following 314. doi:10.1146/annurev.publhealth.012809.103701

12.       Baggett TP, Hwang SW, O'Connell JJ, et al. Mortality among homeless adults in Boston: shifts in causes of death over a 15-year period. JAMA Intern Med. Feb 11 2013;173(3):189-95. doi:1556797 [pii]

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13.       Hwang SW, Wilkins R, Tjepkema M, O'Campo PJ, Dunn JR. Mortality among residents of shelters, rooming houses, and hotels in Canada: 11 year follow-up study. BMJ. 2009;339:b4036.

14.       Cawley C, Kanzaria HK, Zevin B, Doran KM, Kushel M, Raven MC. Mortality Among People Experiencing Homelessness in San Francisco During the COVID-19 Pandemic. JAMA Netw Open. Mar 1 2022;5(3):e221870. doi:10.1001/jamanetworkopen.2022.1870

15.       Brown RT, Evans JL, Valle K, Guzman D, Chen YH, Kushel MB. Factors Associated With Mortality Among Homeless Older Adults in California: The HOPE HOME Study. JAMA Intern Med. Oct 1 2022;182(10):1052-1060. doi:10.1001/jamainternmed.2022.3697

16.       Baggett TP, Chang Y, Singer DE, et al. Tobacco-, alcohol-, and drug-attributable deaths and their contribution to mortality disparities in a cohort of homeless adults in Boston. Am J Public Health. Jun 2015;105(6):1189-97. doi:10.2105/AJPH.2014.302248

17.       De Los Reyes G, Ng A, Valencia Chavez J, et al. Evaluation of a Pharmacist-Linked Smoking Cessation Intervention for Adults Experiencing Homelessness. Subst Use Misuse. 2023;58(12):1519-1527. doi:10.1080/10826084.2023.2231060

18.       Vijayaraghavan M, Tieu L, Ponath C, Guzman D, Kushel M. Tobacco Cessation Behaviors Among Older Homeless Adults: Results From the HOPE HOME Study. Nicotine Tob Res. Feb 26 2016;doi:10.1093/ntr/ntw040

19.       Kish DH, Reitzel LR, Kendzor DE, Okamoto H, Businelle MS. Characterizing Concurrent Tobacco Product Use Among Homeless Cigarette Smokers. Nicotine Tob Res. Sep 2015;17(9):1156-60. doi:10.1093/ntr/ntu230

20.       Neisler J, Reitzel LR, Garey L, et al. Concurrent nicotine and tobacco product use among homeless smokers and associations with cigarette dependence and other factors related to quitting. Drug Alcohol Depend. Apr 1 2018;185:133-140. doi:10.1016/j.drugalcdep.2017.12.012

21.       Alizaga NM, Hartman-Filson M, Elser H, Halpern-Felsher B, Vijayaraghavan M. Alternative flavored and unflavored tobacco product use and cigarette quit attempts among current smokers experiencing homelessness. Addict Behav Rep. Dec 2020;12:100280. doi:10.1016/j.abrep.2020.100280

22.       Baggett TP, Campbell EG, Chang Y, Rigotti NA. Other tobacco product and electronic cigarette use among homeless cigarette smokers. Addict Behav. Sep 2016;60:124-30. doi:10.1016/j.addbeh.2016.04.006

23.       Pearson JL, Waa A, Siddiqi K, Edwards R, Nez Henderson P, Webb Hooper M. Naming Racism, not Race, as a Determinant of Tobacco-Related Health Disparities. Nicotine Tob Res. May 24 2021;23(6):885-887. doi:10.1093/ntr/ntab059

24.       Poghosyan H, Moen EL, Kim D, Manjourides J, Cooley ME. Social and Structural Determinants of Smoking Status and Quit Attempts Among Adults Living in 12 US States, 2015. Am J Health Promot. May 2019;33(4):498-506. doi:10.1177/0890117118792827

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27.       Vijayaraghavan M, King BA. Advancing Housing and Health: Promoting Smoking Cessation in Permanent Supportive Housing. Public Health Rep. Apr 30 2020:33354920922374. doi:10.1177/0033354920922374

28.       Baggett TP, Campbell EG, Chang Y, Magid LM, Rigotti NA. Posttraumatic Stress Symptoms and Their Association With Smoking Outcome Expectancies Among Homeless Smokers in Boston. Nicotine Tob Res. Jun 2016;18(6):1526-32. doi:10.1093/ntr/ntv238

29.       Riley ED, Delucchi K, Rubin S, et al. Ongoing tobacco use in women who experience homelessness and unstable housing: A prospective study to inform tobacco cessation interventions and policies. Addict Behav. Feb 2022;125:107125. doi:10.1016/j.addbeh.2021.107125

30.       Harris T, Winetrobe H, Rhoades H, Wenzel S. The Role of Mental Health and Substance Use in Homeless Adults' Tobacco Use and Cessation Attempts. J Dual Diagn. Apr-Jun 2019;15(2):76-87. doi:10.1080/15504263.2019.1579947

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35.       Creamer MR, Wang TW, Babb S, et al. Tobacco Product Use and Cessation Indicators Among Adults - United States, 2018. MMWR Morb Mortal Wkly Rep. Nov 15 2019;68(45):1013-1019. doi:10.15585/mmwr.mm6845a2

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