In this study a combination of MI+CBT + pharmacotherapy demonstrated promising effects for smoking cessation among a sheltered homeless population. Among the intervention group, CO-confirmed abstinence rates were 15.5% and 13.6% at 12 and 24-weeks, respectively. In contrast, none of the participants in the concurrent group were abstinent at 12-weeks.
Among the intervention group, the baseline average readiness score placed them in the contemplation stage, suggesting a rationale for beginning with a MI approach prior to CBT to enhance motivation and intention. Success of treatment depends on interest and readiness of smokers to change behavior, and there is evidence that treatment targeted at the current level of readiness may increase abstinence rates.22,35,36
Our findings warrant further study to understand more clearly how these psychological interventions work, taking into account the complex context of social environment and co-morbidities associated with homelessness.37
Differences between sheltered homeless smokers who chose to enroll in a treatment program and those who did not provided additional information regarding how we may improve enrollment rates. Not surprisingly, at baseline, smokers in the concurrent group were less ready to quit, less confident about quitting and less likely to endorse the negative health effects of tobacco use than the intervention group. These findings suggest a need to develop “pre treatment” interventions that address the skill, confidence, and knowledge gaps that may represent some of the barriers to committing to a course of smoking cessation treatment. Successful psychological interventions tailored to individual smoker’s readiness to quit have primarily been studied in the context of an abstinence-focused program. 22,36
Introducing behavioral approaches that “start where the client is” prior to enrollment in a smoking cessation program, may be particularly important in a population in which a large proportion of smokers are not ready to quit.
Our results also demonstrate the feasibility of enrolling and retaining homeless clients in an intensive smoking cessation protocol and obtaining follow-up assessments after treatment is completed. Over 70% of smokers completed both 12 and 24 week follow-up interviews. Further, participants in the intervention group who completed the program (i.e. completed the 12 week susrvey) attended an average of two-thirds of the 12 sessions.
Although attendance rates were encouraging, additional strategies may be needed to improve these rates, particularly if a non sheltered homeless population is to be included in subsequent studies. One approach used by Okuyemi and colleagues was to engage formerly or current homeless individuals as part of the research team who were responsible for participant contacts outside of the study. 16
Additionally, the length of the program may limit the potential for dissemination. Therefore, we need to continue to explore novel strategies for delivering care to this vulnerable population. Alternatives may include a stepped-care approach, routine integration of cessation services into other group treatment programs for homeless, interspersing the cessation intervention with other support group activities that clients find attractive, and allowing for rolling admissions in which clients can join at various points in the program and may reenroll. Several subjects who completed one 12-week program expressed a desire to reenroll in the intervention but were not allowed to because of restrictions associated with the study protocol.
Our approach of addressing tobacco use while clients were in treatment and sheltered, even transiently, took advantage of a window of opportunity to engage this hard-to-reach population. Providing care to homeless clients is complex, but previous studies support such an integrated approach, demonstrating that when comprehensive clinical and social services address the specific needs of the homeless and are located near or in shelters, utilization, compliance and follow-up to treatment are as high as for the domiciled poor.38
This study has several limitations. First, this was a non randomized study that lacked a comparison group. Based on service provision parameters established by the health care administrators at Project Renewal, our partnering organization, we were not able to randomize, blind or withhold intervention from clients. We were able to survey clients enrolled in parallel treatment groups at the study sites in order to track the natural history of cessation in a group that declined treatment, however these clients differed in key baseline indicators of cessation, including readiness and confidence to quit. Second, the small sample size and uniqueness of the Project Renewal population (gender, age, and racial ethnic composition) may limit generalizability to the broader sheltered homeless population. Finally, we found differences between dropouts and non-dropouts on certain smoking-related variables; however, we adopted the most conservative analysis for our intent-to-treat sample, assuming that all dropouts continued to smoke at the same levels and had no cessation activity. Despite these limitations, this pilot study provides initial data to inform the design and future study of smoking cessation programs in homeless populations.