Evaluation of Tobacco Control Policies in San Francisco Homeless Housing Programs

Abstract

Background The 2014 Surgeon General’s Report noted that high smoking rates in vulnerable populations such as the homeless have been a persistent public health problem; smoking prevalence among individuals experiencing homelessness exceeds 70%. Historically, service providers for the homeless have not enacted comprehensive tobacco control policies. Method We conducted a qualitative study of homeless housing programs in San Francisco. Administrators representing 9 of the city’s 11 homeless service agencies were interviewed to assess institutional smoking-related policies and cessation programs and perceived barriers and receptivity to instituting tobacco control interventions. Results Respondents indicated that although most programs had adopted smoke-free grounds and some had eliminated evidence of staff smoking, the smoking status of clients was assessed only when required by funders. None of the programs offered smoking cessation interventions. Most administrators were receptive to adopting policies that would promote a tobacco-free culture; however, they noted that their clients had unique challenges that made traditional smoking cessation programs unfeasible. Conclusions Homeless housing programs in San Francisco have not yet adopted a tobacco-free culture. Existing policies were created in response to external mandates, and smoking cessation programs may need to be modified in order to effectively reach clients.

A community-based tobacco cessation program for individuals experiencing homelessness

“…(Hughes, 2007) Nicotine mitigates the neurocognitive deficits associated with schizophrenia; smoking cessation worsens these deficits. (Dolan, Sacco, & Termine, 2004) Environmental cues to smoking, including the presence of cigarette litter or smoke breaks can create a culture of tobacco use in homeless service settings, (Businelle et al, 2015;Pratt et al, 2019;Sung & Apollonio, 2017;Vijayaraghavan & Pierce, 2015) negatively impacting quit attempts (Reitzel, Kendzor, & Nguyen, 2014). Partial smoke-free policies, meaning smoking is not permitted indoors but allowed outdoors on shelter grounds, are acceptable to residents and associated with increased interest in smoking cessation.…”

Embedding smoking cessation support in community service organisations

“…Approximately half the included studies used quantitative methods such as cross-sectional surveys; the remainder employed qualitative or mixed methods. Of the 19 studies, 12 included services explicitly for people with a mental illness 17-19, 10, 20-27 , two explicitly for Aboriginal and/or Torres Strait Islander people 28,21 , six for people living in low socioeconomic areas 19,20,29,26,27,30 , and two for young people aged 12-24 years. 21,31 The population focus of five studies 32,33,10,20,34 was unclear; however, a number of studies included organisations providing supported housing and serving diverse population groups.…”

“…Lack of staff expertise, knowledge, skill or confidence supporting cessation 20,28,21,23,25,34,27 Cost of nicotine replacement therapy (NRT) 19,20 Lack of staff time and capacity within their existing workload 18,32,19,25,34 Lack of external referral options 23 Access to NRT and integration with primary care services 25 Belief services users were not interested in quitting 17, 19-21, 29, 25 Time required to deliver intervention 10 Lack of resources and tobacco-related programs for clients 29,34,27 Cost of external tobacco treatments 23 Timing of when support was provided, specifically, service users having to be 'stable' for intervention to be effective 19 View that support would be better provided by other expert agencies 32,19,10 Intervention difficult to deliver 10 Lack of training 32,22 Cessation support perceived as a low priority (or not their role) 32,22,31 Extended periods between receiving training and delivering intervention 25 Lack of organisational support 28,34…”

“…Belief that service users have a right to smoke 18,20,34 Lack of prompts to remind staff to provide care 23 Lack of supportive policies 18 Role of tobacco use in building trust with service users or that addressing it may be perceived as judgmental 32,22,24 Requirement for participants to attend for cessation support 29 Conflicting work priorities 19 Belief that quit attempts were too stressful for service users in the context of dealing with other issues 22,27 High staff turnover 20 Belief that smoking helped service users 19,29 Concern addressing tobacco use may cause relapse in mental health recovery 17…”

A UK medical student’s view to ‘inclusion of the homeless in health equity curricula: a needs assessment study’

“…We hope that exposure to homelessness in the medical school curriculum will enable greater inclusion of homeless patients in our healthcare system on three levels. Individual clinician bias towards homeless patients is well documented, thus increased educational exposure may lead to future clinicians who can address their biases and subsequently prove more competent and sympathetic in managing these patients [ 5 ]. Secondly, recognising the difficulty homeless patients have navigating our current medical system, may reflect not only the individual deficits of the homeless patients, but also the structural problems of the medical system.…”