Harm Reduction Treatment for Smoking (HaRT-S): Findings from a Single-Arm Pilot Study with Smokers Experiencing Chronic Homelessness

Abstract

Background: Smoking prevalence and mortality is 5 times higher for the chronically homeless versus general population. Unfortunately, traditional smoking cessation treatment does not optimally engage this population. In a preliminary study, smokers experiencing chronic homelessness suggested providers avoid giving advice to quit and instead use a more compassionate, nonjudgmental style to discuss a broader menu of patient-driven options, including safer nicotine use. Most had negative perceptions of smoking cessation medications; however, 76% expressed interest in a switchover to electronic nicotine delivery systems (ENDS). Methods: Using a community-based participatory research approach, we codeveloped harm-reduction treatment for smoking (HaRT-S) together with people with lived experience of chronic homelessness and smoking and a community-based agency that serves them. In HaRT-S, interventionists embody a compassionate, advocacy-oriented “heart-set” and deliver manualized components: a) participant-led tracking of smoking-related outcomes, b) elicitation of harm-reduction goals and progress made toward them, c) discussion of relative risks of nicotine delivery systems, and d) distribution and instructions on use of safer nicotine products. We then conducted a single-arm, 14-week pilot of HaRT-S ( N = 44). Results: Participants rated procedures “totally acceptable/effective,” which was reflected in 26% overrecruitment within a 4-month period and 70% retention at the 14-week follow-up. For each week in the study, participants experienced an 18% increase in odds of reporting 7-day, biochemically verified, point-prevalence abstinence. All participants reporting abstinence used ENDS. Participants evinced reductions in cigarette dependence (−45%), frequency (-29%), and intensity (−78%; ps < .05). Participants who used ENDS experienced an additional 44% reduction in smoking intensity and a 1.2-point reduction in dependence compared to participants who did not. Conclusions: Harm-reduction counseling plus ENDS shows promise for smokers experiencing chronic homelessness. Randomized controlled trials are needed to establish the efficacy of this approach in decreasing smoking-related harm and improving health-related quality of life for this marginalized and disproportionately affected population.

An exploratory non-randomized study of a 3-month electronic nicotine delivery system (ENDS) intervention with people accessing a homeless supported temporary accommodation service (STA) in Ireland

“…Limited negative side effects possibly related to vaping (for example, a runny nose, a nosebleed, slight sweating, coughing and increased phlegm) were reported. This confirms literature that suggests that ENDS devices are well tolerated when compared to NRT [6]. However, there was an acute coughing episode in a participant who lived with COPD suggesting that extra precaution is required when introducing people with COPD to vaping.…”

“…Evidence suggests that ENDS devices can be used effectively in short-term interventions to reduce tobacco smoking with limited side effects [6,7]. This includes people accessing homeless services [4,5] which are highly likely to smoke and disproportionately experience smoking-related harms [2].…”

“…Recent studies indicate that people accessing homeless services can be receptive to approaches involving electronic nicotine delivery systems (ENDS) [4,5]. A pilot study by Collins et al [5] used an approach that combined education, counselling and the provision of an ENDS device to a population accessing homeless services and found this combined approach to be effective [6].…”

A Systematic Review of Alternative Nicotine Delivery System (ANDS)-Based Interventions on Smoking-Related Health Outcomes Among Marginalised Population Groups.

“…The average length of follow up was 20 weeks, ranging from 4 weeks 38 and 52 weeks. 39 Studies took place in homeless services; 25,[27][28]36 drug treatment services; 35,37,39 outpatient 24,26 prison; 34 a gay health clinic; 29 a community health clinic 30 and a veteran health clinic. 38…”

“…Several studies focussed on people with severe mental illness 11, 13-14, 17, 21, 30-32, 38-39 and people who use alcohol and other drugs. 12, 18, 20-21, 35, 37, 32 Other studies focussed on people experiencing homelessness 25,27,28,36 those involved with the criminal justice system 16,22,34 and those living with HIV. 16,[23][24]26 Three studies included indigenous groups 19,21,32 and LGBTQ+ populations.…”