BACKGROUND: Overall declines in smoking prevalence in many developed countries mask enormous disparities for some populations. Homelessness exemplifies this, with smoking rates 5 to 7 times higher than the general population. Homelessness also intersects with other predictors of tobacco dependence, including mental health, addiction, trauma and poverty. The average age of death for people who’ve been homeless is just 50 years, and tobacco use is a risk-factor for many of the common health conditions. Understanding barriers to smoking cessation for homeless populations is crucial to addressing these inequities.
METHODS: This paper draws on two pieces of complementary research in Western Australia (WA). Firstly, through a collaboration with a large primary healthcare provider for people experiencing homelessness, medical records were analysed to examine smoking status, cessation advice, attempts and quitting obstacles. Secondly, a project with the Cancer Council WA involved qualitative research (survey, focus groups/interviews) with community service organisations, many of which have clients experiencing homelessness. Cessation barriers and enablers were explored.
RESULTS: Current smokers comprised 77% of a cohort of 1082 Homeless Healthcare patients, with 31% smoking 20+ cigarettes/day. The medical note review identified a range of cessation barriers, including basic day-to-day survival, other health priorities, cost of cessation aids and the normalcy of smoking among peers. Similar barriers emerged in the research with community service organisations. Additionally, mainstream tobacco campaigns and materials were seen to have less traction with homeless and vulnerable populations, and staff can feel conflicted raising smoking as they view client rapport, choice and non-judgementalism as paramount.
CONCLUSIONS: Being mindful of the additional barriers and complexities to smoking cessation is an important starting point for broaching quitting with people experiencing homelessness and frontline services supporting them. Tailored strategies to tackle access and cost barriers to cessation support are needed to reduce disproportionate smoking and health inequalities among homeless populations.