Shelter proximity and affect among homeless smokers making a quit attempt

Between 2 and 3.5 million adults in the United States experience homelessness on an annual basis.1 Smoking prevalence among the homeless is high, with some estimates suggesting that as many as 4 out of every 5 homeless adults are current smokers.2–8 In fact, any history of homelessness independently doubles the odds of being a current smoker after accounting for sociodemographic and behavioral health confounders.9 Moreover, some research suggests that homeless smokers may smoke more cigarettes per day than the general population of smokers,10,11 and that the experience of homelessness itself might be the catalyst for increasing cigarette consumption.12 Consequently, smoking-related deaths are disproportionately high among the homeless.8 Therefore, smoking among the homeless represents a significant public health issue. Estimates suggest that approximately one third of homeless smokers are interested in quitting smoking6,10 and would like professional help to assist with cessation.10 A national study indicated that the currently homeless do not differ from the formerly homeless or the never homeless with regard to past-year desire to quit smoking.9 Unfortunately, lifetime quit rates among the homeless are low3 – significantly lower than quit rates among smokers who have never experienced homelessness.9 Not unexpectedly, homeless smokers encounter numerous barriers that interfere with the ability to quit smoking and remain abstinent, including the acceptability of smoking among peers, the pervasiveness of smoking around homeless shelters,12–14 high rates of co-morbid substance use and mental illness,14–16 unpredictable daily routines,12 and limited access to cessation services.12 Although a few studies have focused on how to address smoking among the homeless more effectively,6,12,17–23 abstinence rates in effectiveness/efficacy studies generally have been low (eg, 13%–17.4% at 8 weeks post-quit,20 15.5% at 12 weeks post-quit,19 5.6% –9.3% at 26 weeks post-quit21). Consequently, little is known about how best to intervene with homeless smokers to facilitate cessation, and more research is needed in this area. There has been interest in understanding more about where homeless persons spend time24 and travel25 inasmuch as this information can help to inform policy and interventions to address the myriad of health outcomes experienced by this group. However, to our knowledge, no previous studies have assessed homeless smokers’ daily travel to improve understanding of how it might be associated with experiences during a specific quit attempt. The smoker’s proximity to the shelter during the course of the quit attempt might be of particular interest, as the shelter represents a particularly significant place for homeless smokers. For example, the transitional shelter is not only “home,” but also the place where smoking cessation treatment services are commonly provided. Yet, the shelter also might represent the place where the risk of smoking relapse is highest given the prevalence of smoking on shelter grounds,14 the high availability of cigarettes from peers, and potential for increased social pressure to smoke in that setting.26 Anecdotal evidence suggests that smokers often congregate outside of the shelter to smoke. Laboratory-based research suggests that places previously associated with smoking behaviors may evoke stronger withdrawal symptoms among smokers attempting to quit,27,28 which might include a greater array of affective symptoms. Consequently, smokers’ proximity to a shelter during a quit attempt might be associated with a myriad of (potentially mixed) emotions, including negative affect, which is a robust predictor of smoking relapse.29,30 Understanding more about associations between homeless smokers’ daily travel relative to the shelter and their emotions may help to inform interventions to address smoking among this vulnerable and underserved population. Because affect is a state-dependent variable, known to fluctuate in-the-moment in response to environmental, social, and physiological events, it is difficult to capture accurately using questionnaire-based measures assessed at a later time point because of retrospective recall errors. Ecological Momentary Assessment (EMA) is an innovative method developed for real-time data collection that entails repeatedly administering assessments throughout the day at random or scheduled times, typically via a smartphone or other handheld device.31 EMA allows comparatively more ecologically valid data collection for time-varying constructs such as smokers’ affect during a quit attempt,31 and has improved the field’s understanding of smokers’ cognitions, emotions, and behaviors at the time of their occurrence in the natural environment.32 Although EMA has been applied to understand the role of affect better in the context of a smoking cessation quit attempt among diverse populations of smokers, it has not been used previously with homeless smokers, who are likely to face unique daily challenges that distinguish them from other groups of smokers attempting to quit. The purpose of this study was to explore how proximity to the shelter was associated with real-time affect as measured by EMA in the weeks immediately before and after an aided quit attempt among homeless smokers who resided there and received cessation intervention on-site, while controlling for demographics, objective indicators of socioeconomic status (eg, income, education), tobacco dependence, and daily smoking status. Although smoking was not allowed inside this shelter, it was permitted outside the building on the shelter campus without restriction.