NicA's r - nhchc.org - National Health Care for the Homeless Council

website. Literature not created by Nicotine Anonymous World Services can be ..... and educational opportunities, and continued hosting the meetings until approximately 16 .... NicA may fit best into a smoking cessation program that also offers ...
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Tobacco use is the single most preventable cause of morbidity and mortality in the United States (U.S. Department of Health and Human Services, 2014). Studies have consistently demonstrated that people who are homeless have high rates of tobacco use and high-risk smoking practices, including the misuse of tobacco products (Baggett & Rigotti, 2010; Torchalla, Strehlau, Okoli, Li, Schuetz, & Krausz, 2011). Smoking, in particular, is more prevalent in the homeless population (69-80%) than in the general U.S. adult population (17%) (Baggett & Rigotti, 2010; Centers for Disease Control & Prevention, 2015; Connor 2002, Tsai & Rosenheck, 2012). Out of the 890,283 patients served by the U.S. Health Care for the Homeless (HCH) health center program in 2015, 12% had a primary diagnosis of tobacco use disorder and 59% received smoking and tobacco use cessation counseling at their health center compared to 5% and 72% respectively in the general community health center population (Uniform Data System, 2015). Individuals who are homeless and smoke have the desire to quit, preferring nicotine replacement therapy like patches and lozenges to other smoking cessation tools, and are interested in the prospect of utilizing e-cigarettes as well (Baggett, 2010; Connor, 2002; Okuyemi, 2006; Okuyemi, 2013). Individuals without homes also make efforts to quit at rates similar to their housed counterparts, though their success rates are lower (Baggett, LebrunHarris, & Rigotti, 2012; Businelle, 2014; Butler, 2002). Their barriers to quitting include high levels of nicotine dependence, depressed mood, stress, restlessness, and lack of readiness to quit on the stages of change (Businelle, 2014; Shelley, 2010; Torchalla, Strehlau, Okoli, Li, Schuetz, & Krausz, 2011). Peer-supported smoking cessation programs may be useful interventions. The literature suggests that former smokers want to help others quit and smokers are more ready to quit if they have support. Additionally, cessation is more likely if the person attempting cessation knows other quitters (Connor, 2002; Goldade, 2012; Goldade, 2013). Motivational interviewing is a useful tool to help providers identify their client stage of readiness to quit smoking (Shelley, 2010). Motivational interviewing has a positive impact on smoking cessation and is a delivery approach used in many homeless health care settings for a variety of medical and behavioral health issues (Okuyemi, 2006). Screening for tobacco use and offering treatment to quit are essential primary care services but can prove challenging when patients have more immediate health concerns or social service needs. Many homeless health care clinics screen for tobacco use at primary care visits and providers are encouraged to give smoking cessation advice. About half of patients seen in federally-funded Health Care for the Homeless clinics reported receiving advice to quit and a large majority of providers in these same clinics reported screening for tobacco use (Baggett, 2010; Baggett, 2013). These federally-qualified health centers are required each year to report on rates of adult patients who have been screened for tobacco use and, if screened positive, rates of adults provided with cessation counseling or pharmacotherapy (Bureau, 2015). However, smoking programs that may involve group counseling and support are not consistently available. Providers may also focus on other health issues that seem like a higher priority than

smoking cessation, such as addressing alcohol and drug use, mental health issues, and acute medical conditions. Individuals who are homeless may also be difficult to engage in care and some clinic staff report offering tobacco to potential patients to help build rapport and trust. A trustworthy relationship proves foundational when trying to engage individuals in care and bring them into the clinic setting (Baggett, 2013). Although smoking policies vary widely among emergency homeless shelters, residents of shelters with “no smoking” policies perceive smoking more negatively and may be more likely to a