Background
Smoking is a leading cause of early death. Adults who are homeless are four times more likely to smoke than the UK average, but show the same interest in quitting. Things that help people to quit, like nicotine gum, patches, and support services are not highly regarded by many people experiencing homelessness.
Very little research has been done on what does help people stop smoking if they are homeless. Evidence shows e-cigarettes are now the most popular route to quitting in the UK, but start-up costs get in the way for people with less money.
Our aim was to learn if people accessing homeless centres would take part in a 6-month study to compare a free e-cigarette starter kit with the usual options, and how they would get on with one way of quitting compared to the other.
What we did
We invited people at 4 homeless services to take part in a private interview where they answered some questions about their circumstances, health and smoking habits. They also blew into a little machine which measured levels of carbon monoxide – a harmful chemical produced by smoking.
At the first meeting, we introduced them to a support worker who gave them either an e-cigarette starter kit with instructions and support to quit using the e-cigarette, or just instructions and support to quit with local Stop Smoking Services.
We worked with local support workers, providing staff training and on-going support. We learned from their experience and insights, too.
We invited people back to tell us how they were getting on after 4 weeks, then again at 12 weeks and 24 weeks. We also asked 12 participants and 12 support workers to tell us in more detail what they thought worked well and what could be improved.
We gave 48 people e-cigarettes and 32 people were offered usual care and everyone received a £15 shopping voucher at each visit.
How did people get on?
More than half of the people we asked agreed to take part (80/153). In some places, more people wanted to take part than we had spaces and in other places very few people took part. Day centres were better for recruitment than temporary accommodation, possibly because there were more people about and they were already out-and-about at the day centres.
At the 4-week follow ups, 60 of the 80 people came back. (That was 75% -- 3 out of 4!) At 12 weeks, almost two thirds of the 80 came back (63% or 50/80) and at 24 weeks, 47/80 people (59%) came back. More people were available in the e-cigarette group after 24 weeks, which was not just because of what group they were in but whether they were still able to attend their centre for any other reason.
At the 24-week follow-up, 27/48 people were still vaping, to replace – either completely or partly --their tobacco smoking. Twenty-two of those people still had the e-cigarette we had given them, and three of them blew breath tests that confirmed reduced amounts of carbon monoxide in their lungs from a sustained period of quitting. In the Usual Care group, 8/32 people (1/4) said they had been to the Stop Smoking Services but none had reduced levels of carbon monoxide.
We asked questions about how much people used health services like GP visits or trips to A&E. This was successful overall and provided useful information to help make sure people were not affected in a negative way and to help make cost comparisons. Most people were okay about sharing these answers, but some could not remember over a longer period of time and some told us the questions were repetitive, confusing, or none of our business.
What did the participants and support staff think about all this?
People agreed it was good to try something for free and good to be doing something to try to help people who are homeless. After taking part, most people thought the free e-cigarette kits were a good idea, and were surprised at how many people had been successful early on. They told us about things that made taking part better: the free e-cig (of course!), friendly and non-judgemental staff with time to listen, a lack of other options tailored for them, and their own desire to change. Some of the things they said got in the way were personal difficulties, problems with mental health, rolling cannabis with tobacco, and the assumptions some staff had made about smoking.
The staff at centres in both groups were well-equipped to support the study. At first, many were sceptical that smoking should really be a priority, but after learning that harm-reduction could be applied to smoking, they saw how it fit well with what they do in other areas. Staff are already always busy, so details like how to record any paperwork still needs extra thought, but their knowledge and relationships with the people they work with every day was an important part of being able to make introductions and get feedback.
What's next?
This was a fairly small study to see if the idea was a good one, whether we could collect information needed to explore cost-effectiveness, and to learn what kinds of things we would need to figure out to make a bigger study work even better. Our research team have been busy reporting what we found, recruiting extra partners, working out budgets, and shaping the ideas to run the study again across the whole of the UK.
Thank you!
Thanks to all the people who gave us their time and trust, who agreed to take part in this research and shared what things are really like for them. Thanks to the staff at the homeless centres who shared their expertise and time. Thanks to our public advisors, our steering committee, research partners, university staff colleagues, and our funders for making this research possible.
This study is funded by the National Institute for Health Research Public Health (project reference: 17/44/29). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.
For full details and published findings from the study, please go to https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0240968
Credits:
Created with images by Trostle - "cigarette cigarette butt butt" • Priscilla Du Preez - "untitled image"