On July 18, 2013, the New England Journal of Medicine published “Tobacco Use among Homeless People—Addressing the Neglected Addiction,” an article by Health Care for the Homeless Clinicians’ Network member Travis Baggett and his colleagues, Matthew Tobey and Nancy Rigotti. The authors provide information on the health burden of smoking in patients who are homeless, including increased rates of mortality, respiratory illnesses, throat and lung cancers, and cardiovascular issues.
The authors note that smoking is not necessarily seen as a priority issue for health care providers or patients to address, considering the severity of other health conditions and challenges among people experiencing homelessness. The authors also highlight findings from a study of HCH Clinicians’ Network members, in which 15% of respondents reported they had given tobacco to patients to foster relationships or improve treatment compliance; 30% of the respondents knew other providers who had done the same.
The National Health Care for the Homeless Council recognizes the central importance of building trust and maintaining relationships with patients to keep them in care, and the difficulties entailed in that effort. We understand that providers may feel the need to engage patients by any means necessary, including the occasional provision of tobacco as an incentive for engagement. Recognizing the dire health consequences of tobacco use and the disproportionate burden on people experiencing homelessness, however, we recommend that other less harmful techniques and incentives be employed. The National HCH Council offers technical assistance and training on many topics regarding the intersection of homelessness and health, including outreach and engagement.
The authors also recommend that more research be conducted to identify effective interventions for tobacco cessation within the homeless population. This year, the National HCH Council will conduct a feasibility study of Nicotine Anonymous tobacco cessation support groups at three HCH sites recruited from our Practice-Based Research Network. If we find that such support groups can be organized and sustained within HCH settings, we will then seek funding to test the approach’s effectiveness on tobacco cessation with patients experiencing homelessness.
Addictions treatment, including assistance with tobacco cessation, will become available to most people experiencing homelessness who enroll in Medicaid under the Affordable Care Act. The National HCH Council recommends that all states expand their Medicaid programs to people below 138% of the Federal Poverty Level, and that health care providers and advocates work vigorously to assure that people experiencing homelessness become enrolled in available health insurance.