Helping the Homeless Quit Smoking: Q&A with Michael Businelle and Darla Kendzor, The University of Texas School of Public Health
Not surprisingly, a recent study in the American Journal of Public Health found that homeless smokers struggle with quitting more than economically disadvantaged smokers who have their own housing. The study compared homeless smokers receiving treatment at a shelter-based smoking cessation clinic to people enrolled in a smoking cessation program at a Dallas, Texas, safety-net hospital.
“On average, homeless people reported that they found themselves around about 40 smokers every day, while the group getting cessation care at the hospital reported that they were more likely to be around three to four smokers every day,” said Michael S. Businelle, PhD, assistant professor of health promotion and behavioral sciences at The University of Texas School of Public Health Dallas Regional Campus, and the lead author of the study. “Imagine if you had an alcohol problem and were trying to quit drinking—it would be almost impossible to quit if you were surrounded by 40 people drinking every day. That is the situation homeless folks have to overcome when they try to quit smoking.”
Businelle said research shows that about 75 percent of homeless people smoke and that smoking is a leading cause of death in this population. And although homeless smokers are just as likely to try to quit smoking as are other smokers, they are far less successful at quitting, according to Businelle’s work. He said tailored smoking cessation programs are needed for homeless people, including smoke-free zones in shelters.
NewPublicHealth recently spoke with Businelle and his wife, Darla Kendzor, PhD, who is a co-author of the recent study on smoking and the homeless, as well as an assistant professor at The University of Texas.
NPH: Why did you embark on the study?
Michael Businelle: The smoking prevalence in this population is so high and homeless people are not enrolled in clinical trials so we don’t know what will work best for them. We’ve developed, over the last 50 years, really good treatments for the general population of smokers, but there are very few treatments that have been tested in homeless populations.
Darla Kendzor: And cancer and cardiovascular disease, which are in large part due to tobacco smoking, are the leading causes of death among homeless adults. So quitting smoking would make a big difference for them.
Businelle: Most shelters across the United States have substance abuse programs, but very few of them have smoking cessation programs, even though shelter residents are far more likely to die of tobacco use. Other gains for homeless people who quit smoking would be the ability to accept supportive housing if the building is smoke free, as well as increases in available economic resources. Another study that Darla and I have worked on found that, on average, homeless individuals spend about 22 percent of their income on cigarettes.
NPH: What are the strategies that you have tried and what seems to be effective so far?
Businelle: In the study, one approach we tried was to test small financial incentives—an intervention that provided small amounts of money or gift cards—and comparing that to people who just got standard smoking cessation care at the shelter. We found that the incentives substantially increased quit rates. We hope to publish soon on the long-term effectiveness of that approach.
NPH: What’s next in your research?
Businelle: I’m applying for a follow-up grant for a larger financial incentives homeless shelter study to follow more people for a longer period of time, and I’m also applying for a grant that looks at care management. In all of our studies we give participants cell phones that they carry around with them for two-to-four weeks. The phone rings four or five times a day and a prompt asks them several related questions, such as how high their urge is to smoke, about their mood, whether they felt they had been discriminated against the previous day and how much stress they’re experiencing. We’re using these variables to predict whether a homeless individual will be able to quit smoking on the day they set aside at the beginning of cessation programming as their quit date.
The phone is a smartphone which tracks the data and looks at patterns such as whether a person’s mood is getting better or worse, whether their urges are getting better or worse and whether their coping ability is getting better or worse over time. That can help predict whether someone will be able to quit smoking on their quit date. If the phone data shows they may not, they’d get some extra interventions, such as a phone prompt asking if they’d like to speak with a cessation counselor.
NPH: What has your work with people who are homeless told you in terms of strategies you can translate from a homeless population to a non-homeless population?
Businelle: What’s really interesting is that because the gold standard treatments don’t work as well in the homeless population, if we can develop treatments that do work for that group—which has so much stress, mental health issues and substance abuse—then they may also translate into other groups.
Kendzor: We’re also working on some other modifiable risk factors, too, not just smoking. We’re starting to realize that there’s actually interest among homeless shelter residents in improving their diets and getting more physical activity in their lives. I recently received an American Cancer Society grant to look at fruit and vegetables and exercise interventions in a homeless population.