While I was volunteering at an Irish homelessness service called Dublin Simon Community a couple of years ago, I helped work on their harm reduction policy. One day, a staff member said: “What about tobacco smoking?”
This led me down a rabbit hole which changed the way I thought about this issue. I eventually applied for a tobacco harm reduction grant and conducted a small study—looking at the challenges, opportunities and efficacy of tobacco harm reduction in the very supported temporary accommodation (STA) service in inner-city Dublin where the staff member had asked the question. The study, which was run by Waterford Institute of Technology’s School of Health Sciences, was recently published in Harm Reduction Journal.
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.
Tobacco smoking is widely overlooked when we consider substance-use supports for people experiencing homelessness. Firstly, as with alcohol, people often don’t consider tobacco a drug, or smoking it a form of drug use. Secondly, unlike in mainstream society, tobacco smoking is normalized in many contexts around homelessness; a majority of unhoused people smoke. Thirdly, there exists a nihilistic belief that helping a homeless person with their smoking is either a losing battle, or one that would increase stress and impede their other efforts—such as reducing or abstaining from other substance use.
That last notion has been disproved in a range of studies (see, for example, this review of tobacco-related interventions in substance use treatment). Smoking-related interventions can work in tandem with, and complement, those for other drugs.
Unfortunately, people experiencing homelessness are disproportionately affected by tobacco-related harms like COPD, asthma and lung cancer. Indeed, several of the participants of my study were affected by these diseases.
The thinking for our study was simple. We would give people experiencing homelessness who wished to quit or reduce their smoking a safer form of nicotine—in the form of a vape and a supply of e-liquid. We would then meet them regularly over a three-month period to see how it worked for them.
“No faff, easy to switch coils and easy to refill.”
First we needed to choose which vaping device to offer participants. So Andy Morrison—a Scottish tobacco harm reduction advocate and vaper, who was one of my mentors for the project—and I met up with Tom Russell, who runs a UK vape retailer called Refill Station.
As someone who generally specializes in helping smokers to switch and stay off cigarettes (as opposed to supplying established vapers), Russell was incredibly helpful. After some discussion he suggested a device called the Endura T22e, which has a relatively long battery life and is low-maintenance. As Andy Morrison described it, “The devices and tanks were selected because of their durability and easy of use—no faff, easy to switch coils and easy to refill.”
It’s also a “mouth to lung” device, which feels more like a cigarette than “direct to lung” alternatives. Tom Russell provided us with all the kits at cost price, and on a use-or-return basis.
Once we had our vaping products, it was time to offer them to smokers at the STA in Dublin, where residents are typically offered a room for a six-month period. A majority of the nine participants who completed the study (seven) identified as men, with two identifying as women. On average, participants were in their 40s, first experienced homelessness at over 35 years of age, and had experienced homelessness for over seven years. On average, they started smoking at 13, smoked for over 30 years and smoked over 25 cigarettes a day.
“When I got the chance of getting a vape, I jumped at it.”
As one participant said of their willingness to participate: “I must have spent a fortune on cigarettes. When I got the chance of getting a vape, I jumped at it.”
Every week during the study period between March and June 2019, I would arrive at the STA with a bag of e-liquids, parts and devices, ready to meet anyone who wanted to meet. I distributed new bottles of e-liquid, replaced parts and discussed life and smoking. Of the different flavors we made available, most participants preferred fruit or tobacco flavor, with menthol less popular.
One person said he did not think the tobacco flavor “hit the g-spot at the back of the throat.” We tried a range of strengths and various different tobacco flavors, but with no luck. This suggests that further work needs to be done for people who are actively looking for the sensation and taste of smoking tobacco.
However, although he was not using the device, we still met for regular conversations. Conversations and support can be extremely valuable in these contexts—something that has been found by Professor Kevin McGirr of University of California, San Francisco, another of my mentors for this study, who is conducting a tobacco harm reduction study in California.
“Individuals in vulnerable communities like those with substance use or mental health challenges often need extended and intensive support in making any behavioural change,” McGirr said. “Participants in our San Francisco study report that the six-month support and motivational boosts provided by their counsellor was the primary facilitator in achieving their goal.”
“The reported number of cigarettes participants smoked reduced significantly, from an average of 26.7 to nine per day.”
Participants in Dublin would sometimes bring in broken devices, which were generally easily fixed by drying out parts or by unscrewing the tank from the battery. They also blew into a carbon monoxide monitor—which is similar to an alcohol breathalyzer, and essentially checks for smoke exposure as a measure of the amount people are smoking.
Overall, the reported number of cigarettes participants smoked reduced significantly, from an average of 26.7 to nine per day. A general decrease in carbon monoxide measured was also observed, with carbon monoxide measurements decreasing by 35 percent on average.
Participants themselves reported significant benefits—including financial savings, physical feelings (for example, “more energy”) and mental health improvements (including increased concentration).
In one case, a participant also reported that her relationship with her son had improved significantly as a result of addressing her smoking. Altogether, it became clear that supporting people who access homelessness services with tobacco harm reduction is not only possible, but can lead to a wider-than-expected range of benefits!
Some minor side effects of the switch from smoking to vaping (for example cracked lip, bloody nose, coughing) were reported. One person in particular with COPD had significant coughing when first using the device. However, he reported that his health improved after switching to vaping during the study period. Similar findings were reported in a recent study that showed long-term health benefits for smokers with COPD who switch to vaping.
“When you have to get up to get out to vape, you usually end up having to smoke.”
There were, however, a number of more serious challenges for participants who wanted to give up smoking, and these related principally to their experiences of homelessness. Peer norms related to smoking were one significant barrier. Institutional rules were another.
One participant essentially stopped smoking during the study period. He reported that his health was improving and that he was saving significant money. However, he moved to a new residential facility with a vaping ban in private rooms, which meant that he needed to go outside to vape.
“When you have to get up to get out to vape, you usually end up having to smoke,” he said. “People end up getting you to smoke. I don’t know if it’s their guilty conscience or I look sad. It’s like being forced to go to the pub. I could drink two-to-three orange juices but I’m not likely to.”
It became abundantly clear during the study that participants were heavily affected by stress, and that this stress negatively affected their smoking habits. Participants anecdotally reported smoking more when they were worried about paying rent, about being homeless, or about a distressing event (for example, hearing of the suicide of a peer).
Unfortunately, a number of participants experienced extreme stress events in the three-month period—including one person’s mother dying, and family members and partners being hospitalized. During all of those experiences, impacted participants’ smoking increased dramatically. This highlights the need for stress-management, coping-techniques and bereavement supports—both in general, and during interventions of this kind.
Despite such challenges, the project at a minimum facilitated important discussion and awareness around tobacco harm reduction for the participants.
“It allowed us to open up a conversation about tobacco-related harms and harm reduction with our clients, which in the current context of COVID-19 is more important than ever,” said Michelle Connolly, Research and Advocacy officer with Dublin Simon Community, looking back on the project. “It was very encouraging to see 23 of the 30 people in the service sign up to take part in the initiative. It showed a willingness and motivation to engage in a harm reduction intervention, even where a person’s personal circumstances are incredibly challenging.”
“If I was in a house on my own, I would be off the cigarettes altogether.”
For some, positive changes around smoking seemed to have been linked to positive changes in life circumstances. Two study participants reported stopping smoking completely: One of them had found permanent housing and the other had recently started a part-time job.
Although this is a small sample and doesn’t demonstrate causation, these outcomes reemphasize the point that helping people experiencing homelessness to gain housing and other forms of “social capital” should always be considered in the context of any engagement with this population. And those times when housing, employment or education are secured might also be opportune moments to engage people around tobacco harm reduction.
As one participant noted about the project: “…if I was in a house on my own, I would be off the cigarettes altogether.”
Photo by TBEC Review via Wikimedia Commons/Creative Commons 2.0
This article is based on the author’s study—“An exploratory non-randomized study of a 3-month electronic nicotine delivery system (ENDS) intervention with people accessing a homeless supported temporary accommodation service (STA) in Ireland”—published in Harm Reduction Journal in October 2020. Harm Reduction Journal is an open-access, peer-reviewed publisher of research into drugs and many intersecting areas. Filter is proud to partner with Harm Reduction Journal to help bridge the gap between research and public understanding.
The author’s study was funded by a scholarship from Knowledge-Action-Change (KAC). The Influence Foundation, which operates Filter, has also received scholarships from KAC. One of Professor McGirr’s research projects has been supported by a grant from the Foundation for a Smoke-Free World. The Influence Foundation has also received grants from the Foundation for a Smoke-Free World. Filter’s Editorial Independence Policy applies.