9A.4 People experiencing homelessness

Last update: January 2024 Suggested citation: Hanley-Jones, S, Kalitsis, L, Greenhalgh, EM, & Scollo, MM. 9.A.4 People experiencing homelessness. In Greenhalgh, EM, Scollo, MM and Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2024. Available from:   https://www.tobaccoinaustralia.org.au/chapter-9-disadvantage/in-depth/9a4_people-experiencing-homelessness

 

People experiencing homelessness, and people at risk of homelessness, are among the most disadvantaged people in Australia. The Australian Institute of Health and Welfare (AIHW) defines a person as homeless if they are living in either:

• ”non-conventional accommodation or ‘sleeping rough’, or
• short-term or emergency accommodation due to a lack of other options.

Non-conventional accommodation (primary homeless) is defined as:

• living on the streets
• sleeping in parks
• squatting
• staying in cars or railway carriages
• living in improvised dwellings
• living in the long grass.

Short-term or emergency accommodation (secondary homeless) includes:

• refuges
• crisis shelters
• couch surfing or no tenure
• living temporarily with friends and relatives
• insecure accommodation on a short-term basis
• emergency accommodation arranged by a specialist homelessness agency (for example, in hotels, motels and so forth).”¹

More than 122,000 people were experiencing homelessness in Australia on Census night in 2021, representing 48 homeless persons for every 10,000 people.² In 2022–23, Australian Specialist Homelessness Services supported more than 273,600 clients, including 116,000 who were homeless when they presented for help and 130,000 who were at risk of homelessness.¹  

9A.4.1 Trends in the prevalence of smoking

A 2020 systematic review of studies quantifying tobacco use in people experiencing homelessness estimated that the smoking prevalence among this group ranges between 57% and 82%.³ In Melbourne, Australia, the smoking prevalence among people experiencing homelessness was self-reported as 77% in 1995–1996, including 71% for those in short-term or emergency accommodation and 93% for those in non-conventional accommodation i.e. “sleeping rough”.⁴ A later Australian study reported a smoking prevalence of 82% among clients of a homeless service in 2011.⁵ Many adults experiencing homelessness started smoking early in life, before the age of 16.³ Studies that have collected data on average daily cigarette consumption for current adult smokers experiencing homelessness have reported an average of 10 to 13 cigarettes per day.³ While one UK study reported an average of 19 cigarettes smoked per day.⁶

Despite the use of roll-your-own (RYO) cigarettes being less common among smokers in the US, one US study reported that RYO was used by 43% of young smokers experiencing homelessness. Among these smokers, 87% rolled their cigarettes with used tobacco from discarded cigarette butts, typically mixed with new tobacco.⁷ Several studies from the US have reported high rates of alternative tobacco/nicotine product use among young people experiencing homelessness,^8-11 including, e-cigarettes, little cigars/cigarillos, hookah, chewing tobacco, and snus. Concurrent use of multiple tobacco products, as well as co-use of tobacco with cannabis, is also common among young people experiencing homelessness.^{12, 13}

9A.4.2 Contribution of smoking to health outcomes and social inequality

Tobacco-related chronic diseases are among the leading causes of morbidity and mortality among people who have experienced homelessness.¹⁴ A 2015 US study found tobacco-attributable mortality rates to be three to five times higher among people who had experienced homelessness than the general public, with the leading cause of tobacco-attributable death being trachea, bronchus, and lung cancer, followed by ischemic heart disease, nonischemic heart disease and chronic obstructive pulmonary disease.¹⁴ Tobacco use also exacerbates other medical conditions that people who are experiencing homelessness are susceptible to, including HIV, diabetes, cancer, hepatitis C, and tuberculosis.¹⁵ People experiencing homelessness also suffer from medical conditions as a result of exposure to the elements, poor nutrition and hygiene, limited access to health services, as well as risky behaviours related to tobacco use.¹⁵

Risky behaviours related to tobacco use are common among people experiencing homelessness and can increase the risk of harm due to increased toxin exposure, susceptibility to and transmission of infectious diseases, and/or higher overall consumption.^{16, 17} Such behaviours include sharing a cigarette with another person, purchasing lower quality contraband tobacco, rolling tobacco without a filter, blocking filter vents, heavy tobacco use, poly-tobacco use, co-use of tobacco with cannabis, and adding drugs to re-made cigarettes.^16-20

Snipping is another risky behaviour that is common among people experiencing homelessness, which involves searching for and collecting used or discarded cigarette butts to smoke.¹⁶ Many report however, that they extract the unsmoked tobacco and re-roll it with a new filter, as this was seen as more acceptable.¹⁹ Nevertheless, snipping, along with sharing a single cigarette among one or more other people, puts people experiencing homelessness at risk of gum diseases, such as gingivitis and periodontitis. Left untreated, these conditions can lead to pain, tooth loss and other health problems.^{15, 17}

Children experiencing homelessness can be exposed to secondhand smoke in shelters that do not have comprehensive smoking bans in place. Asthma is common in children experiencing homelessness, with a reported incidence of between 28 and 40%, and environmental triggers such as secondhand smoke are barriers to optimal asthma management.²¹

Spending on tobacco can use a large portion of income for people experiencing homelessness. One study reported mean and median tobacco expenditure for someone experiencing homelessness to be 36% and 29% of one’s monthly income, respectively.²² This proportionally large expenditure on tobacco has been shown to make it more difficult to meet subsistence needs such as finding shelter, food, clothing, a place to wash and bathrooms.²²

9A.4.3 Explanations for higher smoking prevalence

Many adults experiencing homelessness started smoking early in life, before the age of 16.³

The prevalence of smoking is significantly higher among groups who are disproportionately represented among people experiencing homelessness, including people who suffer from severe mental health disorders or substance-use disorders, who belong to racial or ethnic minority groups, or who identify as LGBTQIA+.³

One study that compared smokers experiencing homelessness with domiciled (housed) but socioeconomically disadvantaged smokers highlighted additional obstacles specific to smokers experiencing homelessness. The study found that smokers experiencing homelessness had more mental health problems, were surrounded by more smokers, were exposed to substantially more stressors and discrimination, and had lower motivation and self-efficacy to quit.²³

A culture of smoking can be the norm among staff and clients at homelessness services.²⁴ Permissive policies can result in frequent exposure to smoking for both clients and staff—both those who smoke and those who do not—and social interactions with peers are often oriented around smoking.²⁴ A 2021 qualitative study exploring intrapersonal, social and environmental factors among young people aged 14–24 years old experiencing homelessness found that, of those who smoked, over 80% did so at homelessness services²⁵ . The younger participants (14–17 years old) reported smoking socially to engage with their peers, while the older participants reported more instances of smoking alone. The study also found that smoking was often used to manage stress associated with homelessness.²⁵

Traumatic life events are common among people experiencing homelessness, who may utilise smoking in an attempt to reduce or manage their symptoms of posttraumatic stress disorder (PTSD).²⁶ A US study found that people experiencing homelessness, who were also experiencing symptoms of PTSD, had higher cigarette dependence compared to those experiencing fewer or no symptoms. Moreover, PTSD symptoms were associated with smoking to reduce negative affect, as well as with smoking for positive social effects, and for weight control.²⁶ For more information on smoking and PTSD, see Section 9A.3.5.6 Post-traumatic stress disorder (PTSD).

9A.4.4 Interventions for reducing smoking

While the prevalence of smoking is high among people experiencing homelessness, many have an interest in quitting. One Australian study reported more than half (52%) of smokers experiencing homelessness wanted to quit smoking, while 64% had tried to quit or reduce their smoking in the previous three months.⁵

In 2020, a systematic review examined interventions to reduce tobacco use in people experiencing homelessness. The review found insufficient evidence to assess the effects of any tobacco cessation interventions. Although there was some evidence to suggest a modest benefit of more intensive behavioural smoking cessation interventions when compared to less intensive interventions, the certainty for the evidence was very low.³ Nonetheless, the authors note that, “as there is no reason to believe that established effective tobacco cessation treatments, such as behavioural support, nicotine replacement therapy and varenicline, would vary in efficacy in people experiencing homelessness when compared to the general population, the development of interventions to improve access and adherence to treatments we know to be effective might be especially useful.”³

Since 2020, multiple research pilots and trials have been conducted on interventions to reduce tobacco use in people experiencing homelessness.^27-33 Two research trials used text messaging-based interventions for smoking cessation among young people experiencing homelessness.^{28, 30} Results from the first study were promising, however further development and evaluation was needed.²⁸ The second study also reported promising preliminary effects of the intervention on smoking cessation.³⁰

A 2021 study pilot-tested a brief smokefree homes intervention as part of permanent supportive housing for formerly homeless adults. At 6 months, 31.3% of permanent supportive housing residents had made their home smokefree.²⁷

Several interventions have focused on encouraging smoking cessation within homelessness services.^{29, 31, 32} For example, a program trialled across multiple US services trained staff on how to provide brief cessation counselling, had one-time pharmacist-delivered cessation counselling sessions for clients, and provided nicotine replacement therapy (NRT) for 3 months. At the end of the trial, 70% of participants reported making a quit attempt, and 84% reported using NRT. Having an encounter with staff in the past week was associated with a 40% reduction in weekly cigarette consumption and using medications in the past week was associated with a 23% reduction in weekly cigarette consumption.²⁹ Further qualitative evaluation of this program demonstrated that one-time pharmacist-delivered cessation counselling sessions were beneficial for participants. However, participants reported that ongoing support from the pharmacist would improve cessation adherence and prevent future relapse.³²

A study based in Sydney, Australia, aimed to test the feasibility of providing varenicline in combination with NRT and motivational interviewing (MI) to adult male smokers attending a clinic in a hostel for homeless people. The intervention was associated with short-term smoking cessation and significant reduction in the number of cigarettes smoked per day.³¹

An Australian-based intervention involved a 12-week program for homeless smokers conducted in Melbourne, which offered weekly nurse-delivered smoking cessation appointments, doctor-prescribed free nicotine patch, bupropion or varenicline, and Quitline phone support. While quit rates were low, the program was feasible and acceptable, and led to meaningful benefits for participants including reduced consumption and butt smoking, significant financial savings, and psychological benefits.³⁴ Among a subset of 56 homeless men who attended the Quit Smoking Clinic more than once at a Sydney homeless men's shelter, four quit smoking for more than a month, and one for a year. Although quit rates were low, attendees significantly reduced the number of cigarettes smoked per day, which was subsequently confirmed by reduced carbon monoxide readings.³⁵

During the COVID-19 pandemic, a 2021 US study found that delivering tobacco cessation services through crisis services and providers could be a feasible and potentially acceptable way to reach people experiencing homelessness. A smoking-prevention organisation delivered smoking cessation training to emergency response teams in COVID-19 isolation centres. Of the 170 residents that were assessed for cigarette/e-cigarette use, 70.6% were smokers or e-cigarettes users, of which 41.7% accepted the cessation treatment provided by the emergency response teams.³⁶     

Relevant news and research

For recent news items and research on this topic, click  here. ( Last updated March 2024)

References

1. Australian Institute of Health and Welfare. Specialist homelessness services annual report 2022–23.  Canberra: AIHW, 2023. Available from: https://www.aihw.gov.au/reports/homelessness-services/specialist-homelessness-services-annual-report.

2. Australian Bureau of Statistics. Estimating Homelessness: Census. 2021. Available from: https://www.abs.gov.au/statistics/people/housing/estimating-homelessness-census/latest-release.

3. Vijayaraghavan M, Elser H, Frazer K, Lindson N, and Apollonio D. Interventions to reduce tobacco use in people experiencing homelessness. Cochrane Database of Systematic Reviews, 2020; 12:CD013413. Available from: https://www.ncbi.nlm.nih.gov/pubmed/33284989

4. Kermode M, Crofts N, Miller P, Speed B, and Streeton J. Health indicators and risks among people experiencing homelessness in Melbourne, 1995-1996. Australian and New Zealand Journal of Public Health, 1998; 22(4):464-70.

5. Maddox S and Segan C. Underestimation of homeless clients’ interest in quitting smoking: a case for routine tobacco assessment. Health Promotion Journal of Australia, 2017; 28(2):160-4. Available from: https://onlinelibrary.wiley.com/doi/abs/10.1071/HE15102

6. Dawkins L, Ford A, Bauld L, Balaban S, Tyler A, et al. A cross sectional survey of smoking characteristics and quitting behaviour from a sample of homeless adults in Great Britain. Addictive Behaviors, 2019; 95:35-40. Available from: https://www.sciencedirect.com/science/article/pii/S0306460318312632

7. Tucker JS, Shadel WG, Seelam R, Golinelli D, and Siconolfi D. Roll-your-own cigarette smoking among youth experiencing homelessness. Drug and Alcohol Dependence, 2019; 205:107632. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31678834

8. Alizaga NM, Hartman-Filson M, Elser H, Halpern-Felsher B, and Vijayaraghavan M. Alternative flavored and unflavored tobacco product use and cigarette quit attempts among current smokers experiencing homelessness. Addictive Behaviors Reports, 2020; 12:100280. Available from: https://www.ncbi.nlm.nih.gov/pubmed/32637560

9. Golinelli D, Siconolfi D, Shadel WG, Seelam R, and Tucker JS. Patterns of alternative tobacco product use among youth experiencing homelessness. Addictive Behaviors, 2019; 99:106088. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31445484

10. Tucker JS, Shadel WG, Golinelli D, and Ewing B. Alternative tobacco product use and smoking cessation among homeless youth in Los Angeles county. Nicotine & Tobacco Research, 2014; 16(11):1522-6. Available from: https://pubmed.ncbi.nlm.nih.gov/25145375/

11. Tucker JS, Shadel WG, Golinelli D, Seelam R, and Siconolfi D. Correlates of cigarette and alternative tobacco product use among young tobacco users experiencing homelessness. Addictive Behaviors, 2019; 95:145-51. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30921625

12. Glasser AM, Hinton A, Wermert A, Macisco J, and Nemeth JM. Characterizing tobacco and marijuana use among youth combustible tobacco users experiencing homelessness - considering product type, brand, flavor, frequency, and higher-risk use patterns and predictors. BMC Public Health, 2022; 22(1):820. Available from: https://www.ncbi.nlm.nih.gov/pubmed/35468777

13. Kish DH, Reitzel LR, Kendzor DE, Okamoto H, and Businelle MS. Characterizing Concurrent Tobacco Product Use Among Homeless Cigarette Smokers. Nicotine & Tobacco Research, 2015; 17(9):1156-60. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25358660

14. Baggett TP, Chang Y, Singer DE, Porneala BC, Gaeta JM, et al. Tobacco-, alcohol-, and drug-attributable deaths and their contribution to mortality disparities in a cohort of homeless adults in Boston. American Journal of Public Health, 2015; 105(6):1189-97. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25521869

15. No authors listed. Tobacco use among the homeless population : FAQ. Public Health Law Center (William Mitchell College of Law)  2016. Available from: http://www.publichealthlawcenter.org/sites/default/files/resources/tclc-homeless-tobacco-FAQ-2016.pdf.

16. Tucker JS, Shadel WG, Golinelli D, Mullins L, and Ewing B. Sniping and other high-risk smoking practices among homeless youth. Drug and Alcohol Dependence, 2015; 154:105-10. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26160458

17. Chen JS, Nguyen AH, Malesker MA, and Morrow LE. High-Risk Smoking Behaviors and Barriers to Smoking Cessation Among Homeless Individuals. Respir Care, 2016; 61(5):640-5. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26860400

18. Garg R, Croston MA, Thompson T, McQueen A, and Kreuter MW. Correlates of smoking discarded cigarettes in a sample of low-income adults. Addictive Behaviors, 2022; 128:107237. Available from: https://www.ncbi.nlm.nih.gov/pubmed/35074637

19. Garner L and Ratschen E. Tobacco smoking, associated risk behaviours, and experience with quitting: a qualitative study with homeless smokers addicted to drugs and alcohol. BMC Public Health, 2013; 13:951. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24112218

20. Tucker JS, Shadel WG, Seelam R, Golinelli D, and Siconolfi D. Co-use of tobacco and marijuana among young people experiencing homelessness in Los Angeles County. Drug and Alcohol Dependence, 2020; 207:107809. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31846847

21. Buu MC, Carter L, Bruce JS, Baca EA, Greenberg B, et al. Asthma, tobacco smoke and the indoor environment: a qualitative study of sheltered homeless families. The Journal of Asthma, 2014; 51(2):142-8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24147583

22. Baggett TP, Rigotti NA, and Campbell EG. Cost of Smoking among Homeless Adults. N Engl J Med, 2016; 374(7):697-8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26886544

23. Businelle MS, Cuate EL, Kesh A, Poonawalla IB, and Kendzor DE. Comparing homeless smokers to economically disadvantaged domiciled smokers. American Journal of Public Health, 2013; 103 Suppl 2:S218-20. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24148069

24. Pratt R, Pernat C, Kerandi L, Kmiecik A, Strobel-Ayres C, et al. "It's a hard thing to manage when you're homeless": the impact of the social environment on smoking cessation for smokers experiencing homelessness. BMC Public Health, 2019; 19(1):635. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31126265

25. Patterson JG, Glasser AM, Macisco JM, Hinton A, Wermert A, et al. "I Smoked That Cigarette, and It Calmed Me Down": A Qualitative Analysis of Intrapersonal, Social, and Environmental Factors Influencing Decisions to Smoke Among Youth Experiencing Homelessness. Nicotine & Tobacco Research, 2022; 24(2):250-6. Available from: https://www.ncbi.nlm.nih.gov/pubmed/34605550

26. Baggett TP, Campbell EG, Chang Y, Magid LM, and Rigotti NA. Posttraumatic Stress Symptoms and Their Association With Smoking Outcome Expectancies Among Homeless Smokers in Boston. Nicotine & Tobacco Research, 2016; 18(6):1526-32. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26508393

27. Durazo A, Hartman-Filson M, Perez K, Alizaga NM, Petersen AB, et al. Smoke-Free Home Intervention in Permanent Supportive Housing: A Multifaceted Intervention Pilot. Nicotine & Tobacco Research, 2021; 23(1):63-70. Available from: https://www.ncbi.nlm.nih.gov/pubmed/32123908

28. Tucker JS, Linnemayr S, Pedersen ER, Shadel WG, Zutshi R, et al. Pilot Randomized Clinical Trial of a Text Messaging-Based Intervention for Smoking Cessation Among Young People Experiencing Homelessness. Nicotine & Tobacco Research, 2021; 23(10):1691-8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/33852730

29. Hartman-Filson M, Chen J, Lee P, Phan M, Apollonio DE, et al. A community-based tobacco cessation program for individuals experiencing homelessness. Addictive Behaviors, 2022; 129:107282. Available from: https://www.ncbi.nlm.nih.gov/pubmed/35184003

30. Pedersen ER, Linnemayr S, Shadel WG, Zutshi R, DeYoreo M, et al. Substance Use and Mental Health Outcomes from a Text Messaging-Based Intervention for Smoking Cessation Among Young People Experiencing Homelessness. Nicotine & Tobacco Research, 2022; 24(1):130-4. Available from: https://www.ncbi.nlm.nih.gov/pubmed/34375409

31. Skelton E, Lum A, Cooper LE, Barnett E, Smith J, et al. Addressing smoking in sheltered homelessness with intensive smoking treatment (ASSIST project): A pilot feasibility study of varenicline, combination nicotine replacement therapy and motivational interviewing. Addictive Behaviors, 2022; 124:107074. Available from: https://www.ncbi.nlm.nih.gov/pubmed/34509787

32. De Los Reyes G, Ng A, Valencia Chavez J, Apollonio DE, Kroon L, et al. Evaluation of a Pharmacist-Linked Smoking Cessation Intervention for Adults Experiencing Homelessness. Substance Use and Misuse, 2023:1-9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/37401115

33. Wilson SM, Blalock DV, Young JR, Griffin SC, Hertzberg JS, et al. Mobile health contingency management for smoking cessation among veterans experiencing homelessness: A comparative effectiveness trial. Preventive Medicine Reports, 2023; 35:102311. Available from: https://www.ncbi.nlm.nih.gov/pubmed/37455761

34. Segan CJ, Maddox S, and Borland R. Homeless Clients Benefit From Smoking Cessation Treatment Delivered by a Homeless Persons' Program. Nicotine and Tobacco Research, 2015; 17(8):996–1001. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26180225

35. Power J, Mallat C, Bonevski B, and Nielssen O. An audit of assessment and outcome of intervention at a quit smoking clinic in a homeless hostel. Australasian Psychiatry, 2015. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26139703

36. Ramclam A, Taing M, Kyburz B, Williams T, Casey K, et al. An epidemic and a pandemic collide: Assessing the feasibility of tobacco treatment among vulnerable groups at COVID-19 protective lodging. Fam Syst Health, 2022; 40(1):120-5. Available from: https://www.ncbi.nlm.nih.gov/pubmed/34914487