Why Isn’t Tobacco Harm Reduction Prioritized for Unhoused People?

    People experiencing homelessness are among a number of marginalized groups who remain acutely vulnerable to smoking-related harms, even as global smoking prevalence has declined.

    In the United Kingdom, for example, where the smoking rate has fallen significantly, 14.5 percent of the adult population smokes. Yet evidence suggests that among unhoused people, the rate is a staggering 76-85 percent.

    This is mirrored in the United States, where 80 percent of the unhoused population is estimated to smoke cigarettes.

    It’s a situation that compounds the inherent injustice of homelessness with a devastating health disparity.

    Many unhoused people say they smoke in order to relieve stress or boredom. But prevalence rates aren’t the whole story, noted a recent briefing paper on the issue from Global State of Tobacco Harm Reduction (GSTHR). It cited evidence that unhoused people are disproportionately likely to smoke heavily, to share cigarettes and to smoke discarded cigarettes.

    Already, “We’re looking at a group of people who smoke at six or seven times the rate of the general population,” David Mackintosh, a director of Knowledge-Action-Change, which publishes GSTHR, told Filter. But these added factors further “increase the health risks.”

    “Every person experiencing homelessness that I talked to was eager to try and address their tobacco use when presented with the chance.”

    Homelessness is a grave health risk in itself. The GSTHR briefing noted that average ages of death for men and women in the UK are 76 and 81, respectively; for unhoused men and women, those ages are 44 and 42.

    “Smoking does, obviously, affect health, and those experiencing homelessness often have exacerbated health conditions if they spend any time sleeping rough,” Emma Johnson, general manager at UnityMK, a British charity offering support to unhoused people, told Filter.

    Exposure to pollution and cold weather add to smoking-related harms. Groundswell, another UK homelessness charity, found that 64 percent of people who had slept outdoors reported chest infections.

    In this context, the need for tobacco harm reduction, with both access and accurate information, couldn’t be clearer. It gives people the chance to cut down or stop smoking in a more manageable way,” MacKintosh said. “Helping people switch away from smoking will save lives.”

    Evidence suggests there’s no lack of appetite for tobacco harm reduction among unhoused people. Florian Scheibein, a research assistant and PhD student at South East Technological University’s School of Health Sciences, conducted a small study in Dublin, Ireland, providing vapes to unhoused people in supported temporary accommodation.

    “Every person experiencing homelessness that I talked to was eager to try and address their tobacco use when presented with the chance to do so,” he told Filter.

    “Unfortunately, people experiencing homelessness are often faced with significant daily adversity, such as precarious housing, poverty, trauma and stress, which can make addressing tobacco use difficult,” Scheibein continued. His participants’ reasons for wishing to do so were both health-related and financial. 

    “There’s no doubt smoking has often been ignored by service providers.”

    The GSTHR briefing also described some notable outreach efforts in the UK. The PanLondon Homeless Hotel Drug and Alcohol Service, for instance, has supplied over 3,000 vape starter kits, with supporting information for residents and staff.

    Yet overall, “There’s no doubt smoking has often been ignored by service providers,” MacKintosh said.

    Why is this?

    “Ultimately, smoking cessation is far down the priority list,” Peter Kryant, campaigns lead at Cranstoun, told Filter. The charity works to empower and reduce harms for people impacted by substance use, criminal-legal involvement, housing difficulties and other issues.

    A more urgent need is “helping [people] avoid taking a fatal overdose,” Kryant explained.

    As MacKintosh acknowledged, it’s “no wonder” that service providers with “extremely limited resources” set their priorities accordingly. Death from smoking, after all, is not instant. But there has to be a way to make room, he contended: “Cigarettes will kill half of those who smoke them. We can’t continue to ignore that fact.”

    Kryant, who supports tobacco harm reduction and previously experienced homelessness himself, emphasized the importance of unhoused people being permitted to vape in temporary accommodation. Regardless of the temporary nature of the accommodation, it should be considered a person’s “home,” he said, adding that this “is something that is recognized within the [UK] prison system.”

    In Scheibein’s study, one person who had switched to vaping moved to accommodation with a vaping ban. This forced him to go outside to vape, and he ultimately resumed smoking.

    One US study looked at smoking abstinence among 40 participants in two urban housing shelters. Its authors wrote that “participants valued the opportunity to obtain both counseling and nicotine-replacement therapy products.” However, “the culture of alcohol use and cigarette smoking around the shelter environment presented a serious challenge. The study setting and the multiple competing needs of participants were reported as the most challenging barriers to implementation.”

    “There exists a nihilistic belief that helping a homeless person with their smoking is either a losing battle, or one that would impede their other efforts.”

    The “multiple competing needs” problem arises in many settings. In the UK, GPs are often the first point of contact for people who wish to quit cigarettes. “We would support clients wishing to stop smoking by referring them to the [National Health Service] for help and to talk to their GP,” said Johnson of UnityMK. The NHS recognizes the tobacco harm reduction efficacy of vapes.

    Yet according to Groundswell, only 50 percent of unhoused people are advised by their GPs to stop smoking. Again, this may be because other issues feel more pressing. As the GSTHR briefing noted, an estimated 78 percent of unhoused people in the UK suffer from a physical health condition and 45 percent have a mental health diagnosis; a majority have more than one condition.

    Different countries’ anti-vape policies also disproportionately impact unhoused people. The UK government’s plan to ban disposable vapes, for example, will make it harder for this population to switch, when disposables, as low-barrier, low-initial-cost options, are favored by disadvantaged groups.

    In Australia, the country’s prescription-only vapes policy also makes access much tougher for unhoused people. Paul Blamire is a tobacco harm reduction advocate there who is currently experiencing homelessness. He smoked for 30 years until he discovered vaping. “Vaping [is] the only thing that really helps,” he told Filter, “but I’ve been dual-using again [both vaping and smoking] because of the situation that I’m in.”

    “There exists a nihilistic belief that helping a homeless person with their smoking is either a losing battle, or one that would impede their other efforts,” Scheibein concluded. All people experiencing homelessness should be supported to address their smoking with services that are cognizant of the significant adversity faced by them.”  



    Photograph via Pickpik

    The Influence Foundation, which operates Filter, has received restricted grants and donations from Knowledge-Action-Change. Filter‘s Editorial Independence Policy applies.


    • Kiran is a tobacco harm reduction fellow for Filter. She is a writer and journalist who has written for publications including the Guardian, the Telegraph, I Paper and the Times, among many others. Her book, I Can Hear the Cuckoo, was published by Gaia in 2023. She lives in Wales.

      Kiran’s fellowship is supported by an independently administered tobacco harm reduction scholarship from Knowledge-Action-Change—an organization that has separately provided restricted grants and donations to Filter.

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