Distinct patterns of cigarette smoking intensity and other substance use among women who experience housing instability.

BACKGROUND: Recent insights into substance use cessation suggest that outcomes short of long-term abstinence are clinically meaningful and may offer more realistic incremental goals, particularly for highly vulnerable individuals. With the goal of informing tobacco treatment programs, we examined distinct patterns of cigarette smoking and their association with the ongoing use of other substances in women who experience housing instability. METHODS: We recruited participants from a longitudinal study of women experiencing housing instability. Between June 2017 and January 2019, participants completed six monthly survey interviews regarding social conditions and the use of multiple substances. We examined associations between cigarette smoking intensity, including number of cigarettes smoked per day, heavy smoking, and an increase in number of cigarettes smoked from the previous 30-days, and other substance use in the past 7-days. RESULTS: Of the 243 participants, 69 % were current smokers and 58 % were daily smokers. Number of cigarettes smoked per day (Adjusted odds ratio [AOR] 1.02, 95 % CI 1.00-1.03), heavy cigarette smoking, compared to none or light smoking (AOR 2.02, 95 % CI 1.46-2.79), and an increase in number of cigarettes smoked from the previous 30-days (AOR 1.06, 95 % CI 1.01-1.12) were all significantly associated with methamphetamine use in the past 7-days. Associations with other substance use were not as strong. CONCLUSIONS: In a sample of unstably housed women, where almost half used multiple substances, methamphetamine use was associated with higher cigarette smoking intensity. Our findings highlight a potential role for integrating tobacco and methamphetamine use treatment to reduce tobacco use among unstably housed women.

Factors Associated with Smoking Cessation and the Receipt of Cessation Services in a Public, Safety-Net Primary Care System.

BACKGROUND: Prevalence of smoking is high among patients receiving care in safety-net settings, and there is a need to better understand patient factors associated with smoking cessation and receipt of cessation services. OBJECTIVE: To identify patient factors associated with smoking cessation attempts and receipt of cessation counseling and pharmacotherapy in a large safety-net health system. DESIGN: We conducted a retrospective cohort analysis using EHR data in a safety-net system in San Francisco, CA. PARTICIPANTS: We included 7384 adult current smokers who had at least three unique primary care encounters with documented smoking status between August 2019 and April 2022. MAIN MEASURES: We assessed four outcomes using multivariate generalized estimating equation models: (1) any cessation attempt, indicating a transition in smoking status from "current smoker" to "former smoker"; (2) sustained cessation, defined as transition in smoking status from current smoker to former smokers for two or more consecutive visits; (3) receipt of smoking cessation counseling from healthcare providers; and (4) receipt of pharmacotherapy. KEY RESULTS: Of 7384 current adult smokers, 17.6% had made any cessation attempt, and of those 66.5% had sustained cessation. Most patients (81.1%) received counseling and 41.8% received pharmacotherapy. Factors associated with lower odds of any cessation attempt included being aged 45-64, non-Hispanic black, and experiencing homelessness. The factor associated with lower odds of sustained cessation was being male. Factors associated with lower odds of receiving counseling were being insured by Medicaid or being uninsured. Factors associated with lower odds of receiving pharmacotherapy included speaking languages other than English, being male, and identifying as racial and ethnic minorities. CONCLUSIONS: Health system interventions could close the gap in access to smoking cessation services for unhoused and racial/ethnic minority patients in safety-net settings, thereby increasing cessation among these populations.

E-Cigarettes and Stroke Risk-Present Uncertainties and Future Directions.

This Viewpoint describes the need for epidemiological studies of the association between e-cigarette use and risk of stroke to inform decision-making among patients, health care practitioners, and policy makers.

Evaluation of a Pharmacist-Linked Smoking Cessation Intervention for Adults Experiencing Homelessness.

Background: Interventions are needed to increase access to tobacco treatment for people experiencing homelessness. We developed a community pharmacist-linked cessation program for adults experiencing homelessness that included one-time, pharmacist-delivered counseling and furnishing nicotine replacement therapy (NRT) for 3 months. Methods: We conducted a single-arm, uncontrolled trial of the pharmacist-linked intervention among adults experiencing homelessness recruited from three homeless shelters in San Francisco, CA. We asked participants to complete questionnaires at baseline and during 12 weekly follow-up visits. We obtained information on cigarette consumption, use of NRT, and quit attempts at each visit, and reported cumulative proportions during the study interval. We used Poisson regression and logistic regression, respectively, to examine factors associated with weekly cigarette consumption and quit attempts. We conducted in-depth interviews with residents to understand barriers to and facilitators of engagement. Results: Among 51 participants, average daily cigarette consumption reduced 55% from 10 cigarettes per day at baseline to 4.5 cigarettes at 13 wk follow-up, and 56.3% had CO-verified abstinence. Use of medications in the past week was associated with a 29% reduction in weekly consumption (IRR 0.71, 95% CI 0.67-0.74), and increased the odds of a quit attempt (adjusted odds ratio (AOR), 2.37, 95% CI 1.13-4.99). While residents benefited from engaging in the pharmacist-linked program to increase quit attempts, they felt that to sustain abstinence, longitudinal tobacco treatment was needed. Conclusions: A pharmacist-linked smoking cessation program at transitional homeless shelters can reduce structural barriers to cessation care and reduce tobacco use among people experiencing homelessness.

Multi-Level Influences of Smoke-Free Policies in Subsidized Housing: Applying the COM-B Model and Neighborhood Assessments to Inform Smoke-Free Policies.

Smoke-free policies in multi-unit housing are associated with reduced exposure to secondhand smoke (SHS); however, attitudes toward comprehensive smoke-free policies among residents in subsidized multi-unit housing are unknown. In this mixed-methods study, we explored the socio-ecological context for tobacco and cannabis use and attitudes toward policies restricting indoor use of these products through interviews with residents (N = 134) and staff (N = 22) in 15 federally subsidized multi-unit housing in San Francisco, California. We conducted a geo-spatial and ethnographic environmental assessment by mapping alcohol, cannabis, and tobacco retail density using ArcGIS, and conducted systematic social observations of the neighborhood around each site for environmental cues to tobacco use. We used the Capability, Opportunity, and Motivation behavior (COM-B) model to identify factors that might influence implementation of smoke-free policies in multi-unit housing. Knowledge and attitudes toward tobacco and cannabis use, social norms around smoking, neighborhood violence, and cannabis legalization were some of the social-ecological factors that influenced tobacco use. There was spatial variation in the availability of alcohol, cannabis, and tobacco stores around sites, which may have influenced residents' ability to maintain smoke-free homes. Lack of skill on how to moderate indoor smoking (psychological capability), lack of safe neighborhoods (physical opportunity), and the stigma of smoking outdoors in multi-unit housing (motivation) were some of the barriers to adopting a smoke-free home. Interventions to increase adoption of smoke-free policies in multi-unit housing need to address the co-use of tobacco and cannabis and commercial and environmental determinants of tobacco use to facilitate smoke-free living.

Tobacco use behaviors and views on engaging in clinical trials for tobacco cessation among individuals who experience homelessness.

Background: Clinical trials that include contingency management for smoking cessation have shown promising results for short-term quitting, but none have explored this approach for long-term abstinence in people experiencing homelessness. We designed a clinical trial of an extended contingency management intervention for smoking cessation for people experiencing homelessness. This study has two aims: (1) to explore tobacco use behaviors, and views toward smoking cessation, and (2) to explore factors influencing acceptability of engaging in such a trial in a sample of adult smokers experiencing homelessness. Methods: We administered a questionnaire to obtain information on tobacco use behaviors and conducted in-depth, semi-structured interviews with 26 patients who had experienced homelessness and were patients at a safety net health clinic in San Francisco, California, where we planned to pilot the intervention. We obtained information on triggers for tobacco use, prior cessation experiences, attitudes toward cessation, attitudes toward engaging in a clinical trial for cessation, and factors that might influence participation in our proposed contingency management clinical trial. We analyzed transcripts using content analysis. Results: Participants described the normative experiences of smoking, co-occurring substance use, and the use of tobacco to relieve stress as barriers to quitting. Despite these barriers, most participants had attempted to quit smoking and most were interested in engaging in a clinical trial as a method to quit smoking. Participants noted that desirable features of the trial include: receiving financial incentives to quit smoking, having a flexible visit schedule, having the study site be easily accessible, and having navigators with lived experiences of homelessness. Conclusion: A patient-centric clinical trial design that includes incentives, flexible visits and navigators from the community may increase feasibility of engaging in clinical trials among individuals experiencing homelessness.

Contingency management to promote smoking cessation in people experiencing homelessness: Leveraging the electronic health record in a pilot, pragmatic randomized controlled trial.

BACKGROUND: Cigarette smoking is disproportionately high among people experiencing homelessness (PEH). Contingency management (CM) is a strategy that has shown considerable efficacy for smoking cessation and has been used in short-term studies of smoking abstinence in PEH. We describe a pilot, pragmatic randomized controlled trial protocol, which leverages an electronic health record (EHR) infrastructure to assess the feasibility and acceptability of an extended CM intervention to improve long-term abstinence in PEH. METHODS: We will conduct the study at three safety-net clinics in San Francisco among 90 adults experiencing homelessness who smoke cigarettes currently and have a desire to quit. We will encourage all participants to receive smoking cessation services that include behavioral counseling and pharmacotherapy through their clinics. We will randomly assign participants to an extended CM intervention group with escalating incentives contingent on abstinence or to a control group with fixed incentives for attending study visits. We will use the EHR to recruit participants, track receipt of counseling and pharmacotherapy during clinical care, and communicate with providers on participants' progress. CM participants will get escalating incentives for demonstration of carbon monoxide-verified abstinence over 6 months, with a total possible earnings of $475. Control participants will receive a fixed incentive of $5 for attending study visits, totaling $125. We will conduct the carbon-monoxide verified abstinence assessments-which will determine CM incentive amounts-daily during week 1, bi-weekly through week 4, weekly through week 13, and monthly through week 24. Measures of feasibility and acceptability, both quantitative and qualitative, will include assessments of screening and recruitment, adherence to study visits, engagement in smoking cessation clinical care, retention, and participant satisfaction. One of the primary clinical outcomes will be biochemically verified 7-day point prevalence abstinence at 6 months. We will measure secondary outcomes, which will include 7-day point prevalence abstinence at 2 weeks, 3 and 12 months. DISCUSSION: This trial will allow us to assess the feasibility and acceptability of a CM cessation intervention among PEH. The protocol's clinical setting and use of EHRs gives it significant potential for scalability. If found to be feasible, acceptable, and subsequently efficacious in a larger trial, the intervention could reduce tobacco-related health disparities by increasing long-term smoking abstinence among this vulnerable population. TRIAL REGISTRATION: ClinicalTrials.gov NCT04982952. Registered on July 29, 2021.

The smoke-free home study: study protocol for a cluster randomized controlled trial of a smoke-free home intervention in permanent supportive housing.

BACKGROUND: Formerly chronically homeless adults who live in permanent supportive housing (PSH) have high prevalence of smoking. It is uncommon to find smoke-free policies in PSH because of the concern that such policies contradict PSH's harm reduction framework and could increase homelessness should residents lose their housing because of the policy. However, in the absence of such policies, non-smoking PSH residents face the harmful effects of secondhand smoke exposure while residents who smoke see increased risks from high rates of smoking throughout their residence. Our pilot work highlighted the feasibility and acceptability of an intervention designed to promote voluntary adoption of a smoke-free home. Here we report a protocol for a cluster randomized controlled trial of the smoke-free home intervention for formerly chronically homeless residents in PSH. METHODS: The smoke-free home intervention provides face-to-face counseling and instruction to PSH residents on how to adopt a smoke-free home and offers training for PSH staff on how to refer residents to tobacco cessation services. We will randomize 20 PSH sites in the San Francisco Bay Area to either the intervention or wait-list control arms. We will enroll 400 PSH residents who smoke cigarettes in their housing unit and 120 PSH staff who work at the sites. At baseline, three- and six-months follow-up, we will ask residents to report their tobacco use and cessation behaviors and adoption of smoke-free homes. We will ask staff to answer questions on their knowledge, attitudes, practices, and barriers related to supporting residents' smoking cessation. The primary outcome for PSH residents is adoption of smoke-free homes for 90 days or more at six-months follow-up, and the secondary outcome is point prevalence tobacco abstinence. The primary outcome for PSH staff is change in Smoking Knowledge Attitudes Practices survey score. DISCUSSION: Voluntary adoption of smoke-free homes is a promising approach for reducing exposure to secondhand smoke and reducing tobacco use among a population facing high rates of tobacco-related disease, and is aligned with PSH's harm reduction framework. Findings from this study have the potential to inform adoption of tobacco control policies among vulnerable populations most at risk for smoking-related harms. TRIAL REGISTRATION: This study was registered with the U.S. National Institute of Health Clinical Trials register on April 22, 2021: NCT04855357.

System-Level Quality Improvement Initiatives for Tobacco Use in a Safety-Net Health System During the COVID-19 Pandemic.

INTRODUCTION: The shift from in-person care to telemedicine made it challenging to provide guideline-recommended tobacco cessation care during the COVID-19 pandemic. We described quality improvement (QI) initiatives for tobacco cessation during the COVID-19 pandemic, focusing on African American/Black patients with high smoking rates. METHODS: The QI initiatives took place in the San Francisco Health Network, a network of 13 safety-net clinics in San Francisco, California between February 2020 and February 2022. We conducted direct patient outreach by telephone and increased staff capacity to increase cessation care delivery. We examined trends in tobacco screening, provider counseling, and best practice for cessation care (ie, the proportion of patients receiving at least 1 smoking cessation service during a clinical encounter). RESULTS: In-person visits at the onset of the pandemic was 20% in April 2020 and increased to 67% by February 2022. During this time, tobacco screening increased from 29% to 74%. From March 2020 to March 2021, 34% more patients received provider counseling by telephone than in-person. The trend reversed from April 2021 to February 2022, where 23% more patients received counseling in-person than by telehealth. Best practice care increased by 23% from June 2020 to February 2022: 24% for African American/Black patients and 23% for other patients. CONCLUSIONS: Telehealth adaptations to the EHR, targeted outreach to patients, and a multi-disciplinary medical team may be associated with increases in cessation care delivery during the COVID-19 pandemic.

Barriers and Facilitators to Lung Cancer Screening: A Physician Survey.

PURPOSE: To describe barriers to lung cancer screening (LCS) among family medicine and general internal medicine primary care physicians (PCPs) and assess the association of barriers with discussion and referral for screening. DESIGN: Cross-sectional survey. SUBJECTS AND SETTINGS: Random sample of primary care physicians (PCPs) in California. MEASURES: PCP practices for discussion and referral for LCS and ratings of LCS barriers. ANALYSIS: We performed exploratory factor analysis to identify four barrier constructs: (1) Physician Visit-Level Barriers to screening referral; (2) Physician System and Evidence Barriers; (3) Patient Cost Barrier; and (4) Other Patient Barriers. We then performed multivariable logistic regression adjusted for physician and practice characteristics to assess the association between the physician-reported barriers and whether PCPs discussed or referred for LCS. RESULTS: 368 physicians responded (response rate 42%). Most worked in large metropolitan areas (80%) and large health systems (59%). After adjusting for physician and practice characteristics, we found that physician-reporting of System and Evidence Barriers was associated with lower odds of discussion or referral for LDCT (aOR .18, 95% CI 0.09-0.37), while physician-reported Visit-Level Barriers were associated with increased odds discussion or referral (aOR 2.65, 95% CI 1.30-5.04). CONCLUSIONS: While physicians reported numerous barriers to LCS, we found that barriers were differentially associated with discussion or referral for screening. As new LCS guidelines broaden screening eligibility, it is critical to address these barriers to achieve higher rates of evidence-based LCS.

Tobacco Industry Efforts to Respond to Smoke-Free Policies in Multi-Unit Housing: An Evaluation of Tobacco Industry Documents.

The tobacco industry's efforts to undermine clean indoor air policies in the hospitality industry, public spaces and workspaces is well documented, but less is known about their efforts to respond to the implementation of smoke-free policies in multi-unit housing (MUH). From 1988 to 2018, public and private multi-unit housing properties voluntarily implemented smoke-free polices in their buildings. We searched the UCSF's Truth Tobacco Industry Documents Library to examine whether the tobacco industry responded to the implementation of these smoke-free policies in MUH using the same strategies they deployed to respond to smoke-free policies in other industries. We found that the tobacco industry used two primary strategies to respond to smoke-free policies in multi-unit housing: (1) distortion, which included funding studies that downplayed the link between SHS and asthma among low-income, inner-city MUH residents; and (2) deflection, which included engaging in corporate responsibility for youth living in low-income MUH. Despite these efforts, local jurisdictions continued to voluntarily implement smoke-free policies in MUH, pointing to a potential counter strategy to the tobacco industry influence.

From Cancer Epidemiology to Policy and Practice: the Role of a Comprehensive Cancer Center.

Purpose of Review: Cancer incidence and mortality are decreasing, but inequities in outcomes persist. This paper describes the San Francisco Cancer Initiative (SF CAN) as a model for the systematic application of epidemiological evidence to reduce the cancer burden and associated inequities. Recent Findings: SF CAN is a multi-institutional implementation of existing evidence on the prevention and early detection of five common cancers (i.e., breast, prostate, colorectal, liver, and lung/tobacco-related cancers) accounting for 50% of cancer deaths in San Francisco. Five Task Forces follow individual logic models designating inputs, outputs, and outcomes. We describe the progress made and the challenges faced by each Task Force after 5 years of activity. Summary: SF CAN is a model for how the nation's Comprehensive Cancer Centers are ideally positioned to leverage cancer epidemiology for evidence-based initiatives that, along with genuine community engagement and multiple stakeholders, can reduce the population burden of cancer.

Guest Support for Outdoor Smoke-Free Policies within a Homeless Shelter.

Roughly 70-80% of adults experiencing homelessness smoke cigarettes. Smoke-free living/workplace policies are an empirically-supported tobacco control intervention. However, homeless shelters may be reluctant to implement smoke-free policies due to fears of it discouraging current/potential shelter guests from taking refuge there. The current study was meant to characterize guest support for on-property smoke-free policies within a homeless shelter with an extant indoor tobacco use ban amongst never smokers, former smokers, and current smokers to provide data on this point. Participants comprised a convenience sample of adult guests of a homeless shelter in Texas (N = 394, 28.2% women; 10.2% former; and 75.9% current smokers). Participant sociodemographics, smoking status, behavioral health diagnoses, and support for two versions of an on-property outdoor courtyard smoke-free policy (one partial, one complete) were assessed. Data were collected in two waves in a repeated cross-sectional design. Overall, 64.0% of participants supported a partial, and 32.0% a full smoking ban. Logistic regressions, controlling for wave of data collection, age, sex, and any additional significant predictors from a semi-adjusted model, examined associations between participant characteristics and policy support. Older participants (OR = 1.024, CI0.95 = 1.005-1.044), non-veterans (OR = 2.523, CI0.95 = 1.156-5.506), former smokers (OR = 2.730, CI0.95 = 1.191-6.258), and those without severe mental illness (OR = 1.731, CI0.95 = 1.061-2.824) had significantly greater odds of supporting a partial smoking ban. Relative to current smokers, never smokers (OR = 3.902, CI0.95 = 2.133-7.137) and former smokers (OR = 8.257, CI0.95 = 3.951-17.258) had significantly greater odds of supporting a complete smoking ban. The implementation of smoke-free living/workplace policies in homeless shelters may enjoy more support from guests-specifically, non-smokers-than anticipated by shelter administrators. Aside from reducing ambient smoke exposure for never and former smokers, these policies can help to reduce ubiquitous smoking cues for those who may want to quit, are undergoing a quit attempt, or are trying to maintain abstinence. Interventionists might partner with shelter guests, particularly smokers, to inform the roll-out of such policies for maximal acceptance and adoption.

Factors associated with smoking cessation attempts in a public, safety-net primary care system.

Smoking cessation rates are low in safety-net settings. We conducted a retrospective analysis using electronic health record (EHR) data on adults with at least three primary care visits from 2016 to 2019 in the San Francisco Health Network (SFHN), a network of clinics serving publicly insured and uninsured San Francisco residents. We used multivariable regression to identify factors associated with 1) any cessation attempt, defined as smoking status change from "current smoker" at the index visit to "former smoker" at visit 2 or 3, and 2) a sustained cessation attempt, defined as smoking status change from "current smoker" at the index visit to "former smoker" at visits 2 and 3. We identified 7,388 adults currently smoking at the index visit; 26% (n = 1,908) made any cessation attempt, and 9% (n = 650) made a sustained cessation attempt. Factors associated with greater odds of any and sustained cessation attempts included Latinx/Hispanic ethnicity, American Indian/Alaskan Native race, and Spanish as the primary language. Meanwhile, older age, Medicaid insurance, and Chinese (i.e., Cantonese/Mandarin) as the primary language were associated with lower odds of both outcomes. Patient factors such as older age, Medicaid insurance, and speaking Chinese represent targets for improving cessation rates. Targeting interventions for these specific factors could further improve smoking cessation rates for lower cessation groups.

A community-based tobacco cessation program for individuals experiencing homelessness.

BACKGROUND: Tobacco use is common among persons experiencing homelessness (PEH), and interventions are needed. We conducted a community-based, single-arm uncontrolled trial of a pharmacy-linked intervention for smoking cessation for PEH. METHODS: The intervention took place between September 2019 and June 2021 in homeless shelters in San Francisco, CA. We trained shelter staff on how to provide brief cessation counseling, then tested a program among PEH in two shelters that included one-time pharmacist-delivered cessation counseling and nicotine replacement therapy (NRT) for 3 months. We examined factors associated with cigarette consumption and quit attempts. RESULTS: We trained 69 staff from 8 shelters and selected 2 of those shelters as pilot sites for the program. Of the 52 participants, 71% were male and 49% were Black. The majority of participants reported making a quit attempt (70%) and using NRT (84%). Having an encounter with staff in the past week was associated with a 40% reduction in weekly consumption (Incidence rate ratio (IRR) 0.61, 95% CI 0.57-0.67) and using medications in the past week was associated with a 23% reduction in weekly consumption (IRR 0.78, 95% CI 0.75-0.81). Using medications in the past week increased the odds of a quit attempt 2.89 times compared to not using medications (Adjusted odds ratio (AOR), 2.89, 95% CI 1.45-5.77). CONCLUSIONS: Our findings highlight a role for leveraging community-based pharmacists to expand smoking cessation services in homeless shelters to reduce tobacco use among PEH.

Ongoing tobacco use in women who experience homelessness and unstable housing: A prospective study to inform tobacco cessation interventions and policies.

BACKGROUND: Tobacco use is common in people who experience homelessness. However, despite biological differences in use by sex and lower quit rates in women, research in homeless and unstably housed (HUH) women is sparse. We identified correlates of use specific to this population, with the goal of informing tobacco cessation programs tailored for HUH women. METHODS: We conducted a prospective study among HUH women recruited from San Francisco homeless shelters, street encampments, free meal programs and low-income hotels. Between June 2016 and January 2019, study participants completed six monthly interviews to examine factors associated with tobacco use, defined as urinary cotinine >10 pg/mL or self-reported prior 30-day use. RESULTS: Among 245 participants, 40% were Black, the median age was 53, 75% currently used tobacco and 89% had ≥one 24-hour quit attempt in the prior year. Tobacco use was more common in women with PTSD (66% vs. 48%) and depression (54% vs. 35%) compared to women without these conditions. Adjusted odds of tobacco use decreased significantly with increasing age (OR/5 yrs: 0.81; 95% CI:0.68, 0.96) and increased with an increasing number of additional substances used (OR: 2.52; 95% CI: 1.88, 3.39). CONCLUSION: Outside of a treatment setting and within a community-recruited sample population composed of HUH women, the number of additional substances used is a primary correlate of ongoing tobacco use. Tailored cessation interventions that prioritize the issue of multiple substance use, and public health policies that allocate funding to address it, may increase tobacco cessation in this population.

Homeless women's perspectives on smoking and smoking cessation programs: A qualitative study.

BACKGROUND: Individuals who are unsheltered or experiencing homelessness are more likely to smoke than those in the general population and have a higher prevalence of tobacco-related illnesses. Those who are unhoused make quit attempts at rates similar to the general population, however rates of successful quitting are much lower. Women bear a higher burden of smoking-related diseases and are less successful in their cessation efforts than men. Despite these increased risks and challenges, cessation programs specifically designed to meet the needs of women experiencing homelessness are extremely rare. METHODS: To examine perceptions of smoking cessation programs among women who are unstably housed, we conducted in-depth, semi-structured interviews with twenty-nine women experiencing homelessness or unstable housing who had histories of tobacco and substance use. Interviews explored the social context of smoking, as well as interest in, barriers to, and facilitators of quitting. We used a grounded theory approach to analyze the transcripts. RESULTS: Participants reported a number of structural barriers to cessation. They reported obstacles to participating in existing cessation programs, including chronic stress related to experiences of being unsheltered and fear of being exposed to neighborhood violence. These conditions were paired with a strong need to self-isolate in order to maintain personal safety, which runs counter to traditional group-based cessation programs. CONCLUSION: A dissonance exists between current smoking cessation programs and the needs of women who are unsheltered or unstably housed. Alternative cessation treatment delivery models that address extremely high levels of chronic stress violence, and avoidance of group settings are needed, as are programs that provide options for safe participation.

E-Cigarette Use among Current Smokers Experiencing Homelessness.

Two-thirds of cigarette smokers experiencing homelessness report using alternative tobacco products, including blunts, cigarillos (little cigars) or roll-your-own tobacco or electronic nicotine delivery systems such as e-cigarettes. We examined attitudes toward e-cigarette use and explored whether e-cigarette use patterns were associated with past-year cigarette quit attempts among current smokers experiencing homelessness. Among the 470 current cigarette smokers recruited from homeless service sites in San Francisco, 22.1% (n = 65) reported the use of e-cigarettes in the past 30 days ('dual users'). Compared to cigarette-only smokers, dual users considered e-cigarettes to be safer than cigarettes. Patterns of e-cigarette use, including the number of times used per day, duration of use during the day, manner of use and nicotine concentration were not associated with past-year cigarette quit attempts. Studies that examine the motivations for use of e-cigarettes, particularly for their use as smoking cessation aids, could inform interventions for tobacco use among people experiencing homelessness.

Smoke-Free Home Intervention in Permanent Supportive Housing: A Multifaceted Intervention Pilot.

INTRODUCTION: Smoke-free homes (SFHs), the voluntary adoption of home smoking restrictions, are associated with reduced secondhand smoke exposure. However, SFHs are uncommon in permanent supportive housing (PSH) for formerly homeless adults, who have fivefold higher smoking rates than the general population. We pilot-tested a brief intervention to increase voluntary adoption of SFHs among PSH residents in the San Francisco Bay Area. AIMS AND METHODS: We pilot-tested a brief intervention to increase voluntary adoption of SFHs among PSH residents in the San Francisco Bay Area. Rest of the methods, PSH residents (n = 100) and staff (n = 62) from 15 PSH sites participated in the intervention between October 2017 and February 2018. Research staff provided counseling to PSH residents on how to adopt an SFH and trained PSH staff on how to counsel residents on smoking cessation. The primary outcome was self-reported voluntary adoption of an SFH for ≥90 days, and the secondary outcome was carbon monoxide-verified PPA at 6-month follow-up. PSH staff completed the Smoking Knowledge, Attitudes, and Practices survey at baseline and 3-month follow-up. RESULTS: At 6 months, 31.3% of PSH residents had adopted an SFH (vs. 13.0% at baseline) and 16.9% reported carbon monoxide-verified PPA. A positive attitude toward an SFH policy was associated with increased odds of SFH adoption (adjusted odds ratio = 8.68, 95% confidence interval: 2.42, 31.17). Voluntary SFH adoption was associated with increased PPA (adjusted odds ratio = 26.27, 95% confidence interval: 3.43, 201.30). PSH staff reported improved attitudes toward and self-efficacy in delivering cessation care, and decreased barriers to discussing smoking cessation among PSH residents between baseline and 3-month follow-up. CONCLUSIONS: In this single-arm study, a brief intervention increased SFH adoption and PPA among PSH residents. IMPLICATIONS: To date, few interventions have addressed SFHs and their association with tobacco use among PSH residents. A "ground-up" approach that relies on buy-in from residents and that promotes voluntary SFHs is an innovative way to increase smoke-free living environments in PSH. This approach could pave a pathway for smoke-free policy implementation in these sites. PSH can play a role in reducing the burden of tobacco use by empowering its residents to adopt voluntary SFHs, which could increase smoking cessation among residents.