Harm reduction treatment for smoking (HaRT-S): findings from a single-arm pilot study with smokers experiencing chronic homelessness

Abstract

Background: Smoking prevalence and mortality is 5 times higher for the chronically homeless versus general population. Unfortunately, traditional smoking cessation treatment does not optimally engage this population. In a preliminary study, smokers experiencing chronic homelessness suggested providers avoid giving advice to quit and instead use a more compassionate, nonjudgmental style to discuss a broader menu of patient-driven options, including safer nicotine use. Most had negative perceptions of smoking cessation medications; however, 76% expressed interest in a switchover to electronic nicotine delivery systems (ENDS). Methods: Using a community-based participatory research approach, we codeveloped harm-reduction treatment for smoking (HaRT-S) together with people with lived experience of chronic homelessness and smoking and a community-based agency that serves them. In HaRT-S, interventionists embody a compassionate, advocacy-oriented “heart-set” and deliver manualized components: a) participant-led tracking of smoking-related outcomes, b) elicitation of harm-reduction goals and progress made toward them, c) discussion of relative risks of nicotine delivery systems, and d) distribution and instructions on use of safer nicotine products. We then conducted a single-arm, 14-week pilot of HaRT-S (N = 44). Results: Participants rated procedures “totally acceptable/effective,” which was reflected in 26% overrecruitment within a 4-month period and 70% retention at the 14-week follow-up. For each week in the study, participants experienced an 18% increase in odds of reporting 7-day, biochemically verified, point-prevalence abstinence. All participants reporting abstinence used ENDS. Participants evinced reductions in cigarette dependence (−45%), frequency (-29%), and intensity (−78%; ps < .05). Participants who used ENDS experienced an additional 44% reduction in smoking intensity and a 1.2-point reduction in dependence compared to participants who did not. Conclusions: Harm-reduction counseling plus ENDS shows promise for smokers experiencing chronic homelessness. Randomized controlled trials are needed to establish the efficacy of this approach in decreasing smoking-related harm and improving health-related quality of life for this marginalized and disproportionately affected population.

Keywords:

• Smoking
• smoking treatment
• harm reduction
• homelessness
• community based participatory research
• smoking-related harm

Acknowledgments

We acknowledge our partners at the Downtown Emergency Service Center (DESC) who have supported this work, especially David Helde, Margaret King, Sam McKnight, Kataira Moreland, and Vanessa Ross. We thank research coordinators, Alyssa Hatsukami and Victor King, for conducting assessment interviews and data entry. We also thank student research assistants, including Sunny Chang, Alex Clark, Samantha Doerr, Joanne Gliane, Robby Hardy, Gary Lee, Victoria Orfaly, Clarissa Song, Bow Suprasert, Alex Vess, and Teresa Wu for their support on data entry, cleaning, and management. Most of all, we thank participants in this study for expending their time and energy to support this research, decrease their smoking-related harm, and improve future treatment options for their communities.

Disclosure statement

All other authors declare that they have no conflicts of interest pertaining to this manuscript.

Author contributions

Dr. Collins codeveloped the original study idea with Mr. Malone. She led the study design, implementation and evaluation efforts; conducted the primary statistical analyses; and serves as lead author. She has had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the analyses. Dr. Nelson contributed to study design, HaRT-S development, and study implementation. He codeveloped the training and then trained and supervised interventionists. Mr Stanton, Mr. Mayberry and Ms. Ubay contributed to the study design, HaRT-S development, implementation, and data interpretation. In addition, Ms. Ubay created tables for the current manuscript. Ms. Taylor, Hoffmann, and Goldstein contributed to data management and preliminary analyses for the manuscript. Mr. Malone codeveloped the original study idea and oversaw study implementation onsite at DESC. Dr. Clifasefi contributed to the original study conceptualization. Drs. Okuyemi and Saxon contributed to intervention design and made suggestions and edits for the paper. The HaRT-S Community Advisory Board members codeveloped the treatment, oversaw the implementation of the study, conducted analyses to support the study, interpreted study data, and contributed to and edited interim drafts. All authors critically reviewed, provided edits for and approved the final article. There is no one else who fulfills these criteria but has not been included as an author.

Note on Authorship

The HaRT-S Community Advisory Board members include (in alphabetical order): Andrew Coak, Susan E. Collins, Elizabeth Duffie, Maria Metzler, Joey Stanton, Tatiana Ubay, and Grover “Will” Williams. We also acknowledge the early contributions of an initiating member, Danielle Burt.

Notes

1 ENDS was deemed an appropriate pharmacological adjunct to harm-reduction counseling for a few important reasons. First, our preliminary study indicated it was perceived far more positively than NRT or other medications, and these findings were affirmed by community members on our CAB.¹⁷ Additionally, considering the relative safety of this approach was important. Fortunately, in their 2018 comprehensive, systematic review, the National Academies of Sciences, Engineering and Medicine concluded ENDS use is safer than smoking.⁶⁴ The level of tobacco-specific nitrosamines (TSNAs), the primary group of carcinogens endogenous to tobacco, is up to 380 times higher in cigarette smoke than in ENDS vapor,⁶⁵ and the concentration of urinary TSNAs is 97% lower in ENDS users than smokers.⁶⁶ A study of cigarette smokers who switched to ENDS for 2 weeks showed nicotine exposure was unchanged, while exposure to toxicants was substantially reduced.⁶⁷ The observed reductions in toxicants paired with the National Academies’⁶⁴ observation that a complete switchover from smoking to ENDS results in reduced short-term adverse health outcomes have bolstered the conclusion in a recent Nature Reviews: Cardiology article that “the adoption of ENDs rather than cigarette smoking might result in an overall benefit for public health.”⁶⁸ Unintended exposure for children was another important factor to consider; however, the proposed setting for this study serves only single adults, not children and family, and efforts were made to ensure packaging and flavorants were not appealing to children.

2 Regarding the onsite substance-use policy, the shelter does not allow smoking, alcohol or other drug use onsite. If a shelter stayer is found smoking or with alcohol or other drugs, they have the choice to give up the substances to staff and continue to receive services or to keep the substances and receive a day-long bar from shelter services. People who are visibly intoxicated may receive shelter services as long as the person is deemed by staff to be “safe and in behavioural control” (A. Coak, personal communication, August 3, 2018).