What is being done to help homeless people beat smoking?
Not enough, says Katie Weiss, a-23-year-old freelance writer studying Postgraduate Journalism at Monash University in Melbourne.
Weiss says that initially, she wanted to explore how homeless smokers were feeling the pinch after tobacco prices soared under the Rudd Government earlier this year. However, in researching the story, she discovered few options are available to tackle this addiction among the destitute.
Meanwhile, Croakey has a query for readers: given that homeless people are likely to miss out on a range of public health initiatives, does anyone know of successful public health interventions for this group, whether in Australia or elsewhere? Please let us know, if so.
Katie Weiss writes:
Quit Victoria admits it has neglected homeless people – who have among the highest rates of smoking in the state – from its anti-tobacco campaigns.
Quit Victoria Manager Ian Ferretter said that Quit Victoria struggled to end tobacco abuse in the homeless community as it lacked awareness of the complexities of a homeless person’s agenda.
“I’m not sure what a homeless person’s agenda looks like,” Mr Ferretter said.
A Cancer Council Victoria report showed 77 per cent of homeless people in Australia smoked cigarettes.
The report, known as Tobacco in Australia, also revealed that 93 per cent of homeless people who lived on the street were smokers.
Mr Ferretter said that competing stresses in a person’s life were the main obstacles that prevented a person from quitting.
He said that smokers needed to place the decision to quit smoking at the top of their day to day lists in order to succeed.
“It might be about finding somewhere to stay rather than trying to quit smoking, he said of homeless people.
“Quitting smoking is competing with a range of priorities among homeless people. I think that getting on to that agenda is a difficult task.”
But Victorian Department of Health spokesman Bram Alexander believed that Quit Victoria was effectively addressing the issue of smoking among socio-economically disadvantaged groups.
When asked how the government was addressing tobacco addiction among the homeless, Mr Alexander said:
“Quit are at the forefront of social marketing and smoking cessation programs. As well as the free telephone advice line, Quit has specific programs to target socially and economically disadvantaged groups in the community.”
Yet, contrary to Mr Alexander’s suggestion, Mr Ferretter said that smoking cessation among Victoria’s homeless “hasn’t been a huge focus of our work.”
Quit Victoria lacked any ‘special programs’ addressing the specific needs of homeless people.
Quit Victoria said that, although a high proportion of homeless people smoked, this group was too small a minority in Australia to be considered as a “special target” for such programs.
According to Melbourne General Practice Network’s (MGPN) statistics, the mortality rate of homeless people was up to four times higher than that of the general population.
Because the homeless were commonly affected by mental disorders and physical ailments such as malnutrition, blood borne infections, heart and lung disorders and asthma, smoking was considered to be exceptionally dangerous.
“Many of us working in the health industry are well aware of the complex physical and mental health needs of those experiencing homelessness,” said MGPN Clinical Services Manager Julie Borninkhof.
The Victorian Department of Health gave $8.5 million to Quit Victoria’s anti-smoking advertisements as part of its 2008 Victoria Tobacco Control Strategy.
However, MGPN stressed that Quit Victoria’s anti-smoking advertisements and call services failed to reach people who were unable to access televisions or telephones.
According to Ms Borninkhof, many people living on the streets missed out on important lessons about the dangers of smoking and how to quit because public health promotions – along with social marketing – were unavailable to them.
“The homeless community especially pose significant challenges when we consider the current mechanisms used to raise awareness of the risks of smoking, such as TV and web based awareness campaigns,” Ms Borninkhof said.
Because homeless people were left out of these facilities, Ms Borninkhof believed that street dwellers were in “greater risk” of picking up tobacco smoking habits than the general public.
MGPN believed that anti-smoking campaigns could only be successful through research about health among homeless people.
The network, whose membership stretches to 500 members in Melbourne, received a research grant from the Federal Government in November last year to explore the health issues surrounding homeless people.
MGPN said it would use the money provided by Department of Families, Housing, Community Services and Indigenous Affairs to analyse the dynamics between homeless people and existing health facilities.
Such research would contribute to a greater understanding on how GPs and clinics should facilitate homeless people.
“As with any community we need to look at creative and sustainable ways of delivering key health messages,” Ms Borninkhof said.
“Whilst there are a number of programs and supports in place to assist this community, it is hoped that we can do more to better support all of the health needs of those experiencing homelessness in the future.”
Katie – this article on how the tobacco industry actually targeted homeless people will be of interest to you…tobacco industry support of charitable organisations that work with the homeless helps explain why some of these institutions may have been reluctant to institute tobacco control policies and programmes.
Marketing to the marginalised: tobacco industry targeting of the homeless and mentally ill
D E Apollonio,
R E Malone
Tob Control 2005;14:409-415
Results: The tobacco industry has marketed cigarettes to the homeless and seriously mentally ill, part of its “downscale” market, and has developed relationships with homeless shelters and advocacy groups, gaining positive media coverage and political support.
Discussion: Tobacco control advocates and public health organisations should consider how to target programmes to homeless and seriously mentally ill individuals. Education of service providers about tobacco industry efforts to cultivate this market may help in reducing smoking in these populations.
Becky
School of Public Health | Sydney Medical School
THE UNIVERSITY OF SYDNEY
The tobacco industry is a pussy cat compared with the tobacco control industry. At least there is an element of volition when we decide to use a product that is claimed to be harmful to health, tobacco control simply turns us all into abused property.
In North America elderly people who smoke are now being made homeless. This apparently is “the next front in the battle against Big Tobacco”
http://www.hsph.harvard.edu/news/hphr/fall-2010/smoking-public-housing.html
The ‘battle against big tobacco’ targets the most vulnerable members of society for denormalisation, stigma, unemployment, removal of health care, homelessness and exile from social venues.
I have paranoid schizophrenia and have no access to healthcare because if I get locked up for treatment I won’t get it, I’ll get forced withdrawal and substitutes that are proven ineffective (but profitable for the control industry sponsors – big pharm).
Some things are worse than death, being ‘helped’ by tobacco control is one.
Katie raises a very important issue in reducing smoking – social equity. Highly vulnerable groups such as homeless people and people with mental illness have been hit twice and hit hard by tobacco. First, by being targeted by the industry. Then, by not receiving the same level of assistance to quit as the rest of the population. These people suffer a huge burden related to tobacco and have been neglected too long.
Although smoking in the general population is now below 20% it is still much higher among disadvantaged groups. There is a clear social gradient in smoking status in Australia. Smoking is both an effect of, and a contributor to, social disadvantage.
But, there is some action in this area. Cancer Council NSW has been running a five-year program Tackling Tobacco, Action on Smoking and Disadvantage which addresses tobacco as an issue of social justice. As they point out disadvantaged groups have higher rates of smoking, carry an enormous health and financial burden and face more barriers to quitting. To date Cancer Council NSW have funded projects in the NGO/community sector and the health sector targeting disadvantaged groups including Aboriginal and Torres Strait Islander people, homeless people and people with mental illness.
People with mental illness want to quit at about the same rate as the rest of the population. They state the same reasons for quitting as other smokers, their physical health and the financial cost. Sadly, they are often discouraged by the system itself and the staff who care for them. Despite our awareness of the deadly nature of smoking concerns around the impact of quitting on symptoms and lack of guidance around supporting someone with mental illness to quit has led to inaction.
Research shows that people with mental illness can quit safely. They just need the support to do so. Providing leadership by introducing smoke-free facilities and accommodation is one step. But most of all, those who care for homeless people and for people with mental illness need the knowledge and skills to actively help them quit and to stay smoke free. Nicotine dependence needs to be treated as other dependencies and managed properly not put to the side as too difficult.
The Australian government has committed to a social inclusion agenda. We know the relationship between social determinants and health. Reducing smoking among disadvantaged populations will improve their health, benefit them financially and contribute to reducing social disadvantage.
Reaching these populations is very difficult. Much work is done by an underfunded community sector. Homeless people and those with mental illness often move in and out of care creating challenges for continuing care.
What do Croakey readers suggest can be done to effectively reach these groups?
Are there other specific programs aiming to reduce smoking among homeless people?
What are the barriers to continuing care as people move from care to community?
Surely there are bigger fish to fry in the area of public health than worrying about the smoking habits of the homeless.
Isn’t the number one cause of homelessness poor mental health? Are cigarettes causing mental health issues? I would say not as much as other factors. Better to worry about alcohol abuse/illicit drug use amongst the homeless (or in the wider community). Cigarettes would be a fair way down the list.
@ Scott.
Smoking actually contributes to homelessness. If you’re spending $20-$30 a day on smokes you don’t have a lot left for a decent place to live.
If you are admitted to a mental health facility co-existing drug and alcohol problems are addressed. You’re not always treated for nicotine addiction. It’s a pity to get off drugs but then die from smoking-related illness. Why not treat both?
Dear Katie – you may be interested to note that Cancer Council NSW has developed and implemented a strategy to reduce smoking related harm among the most disadvantaged groups in NSW. The “Tackling Tobacco Program” addresses tobacco as a social justice issue and works in partnership with community service organisations to reduce the prevalence of smoking and uptake of smoking amongst disadvantaged groups; assist disadvantaged smokers to quit; and address environmental and social factors that contribute to higher tobacco use and lower quit rates among the socially disadvantaged.
Our main target groups are: the homeless; vulnerable young people; people with a mental illness; Aboriginal and Torres Strait Islanders; disadvantaged single parents; people using drug and alcohol services; people in prison.
Over the last four years “Tackling Tobacco” has conducted twenty community based smoking cessation projects. Several of these were with organisations who work with homeless people e.g. The Wayside Chapel in Sydney. Seven of the twenty projects focussed on people with severe mental illness – a group among whom periods of homelessness are all too common.
These projects demonstrated that:
**Community service organisations that work with the very disadvantaged (such as homeless people) can provide effective smoking cessation to their clients. “Tackling Tobacco” has now trained over 700 community sector workers to address tobacco and provide smoking care. We have trained around 25 staff of Mission Australia services to homeless people in NSW as part of their Michael project – an initiative to provide comprehensive services to break the cycle of homelessness.
** Very disadvantaged people, including the homeless, are as interested in quitting smoking as others but are seldom asked. Access to affordable nicotine replacement therapy is an important issue for these groups – often as an incentive to make a quit attempt. Our projects found, sometimes to the surprise of workers, that clients were interested in quitting and some were able to do so or substantially reduce their smoking.
** Quitting and cutting down brings real improvements in quality of life for the most disadvantaged. Some of the main benefits are financial which can make an enormous difference to people on very low incomes that spend a high proportion of income on tobacco.
The tobacco control and public health fraternities need to see community service organisations as potential allies in the fight to reduce smoking related harm.
More information about the “Tackling Tobacco Program” is available at: http://www.cancercouncil.com.au/editorial.asp?pageid=2210
You may also be interested in the Cancer Council NSW report “Lifting the Burden: Tobacco Control and Social Equity Strategy (July 2006 to June 2011)”
Also, this recent article may be of interest. “Delivering smoking cessation support to disadvantaged groups: a qualitative study of the potential of community welfare organizations” Jamie Bryant; Billie Bonevski; Christine Paul; Jon O’Brien; Wendy Oakes -Health Education Research 2010
Regards,
Dr Allison Salmon
Manager, Tobacco Control Unit
Cancer Council NSW
think everyone is missing the point. although I am not an expert on mental health of the homeless, I believe that a significant portion of them are schizophrenic. There are many studies on the ‘venn diagram overlap’ of schizophrenics and smoking (often, heavy users). They do so to self-medicate-stimulating the actetylcholine systems in the brain to improve deficits in attention, cognition and screening out noise, etc. So, sure its a lousy habit and atrocious for long term health. But if the preceding is true, what is the benefit for denying it to them, particularly if it worsens their symptoms? Google for more information; start with this: http://brainblogger.com/2009/07/03/why-do-schizophrenics-smoke-cigarettes/
Several Divisions of General Practice do outreach work with people who are homeless, the Street Doctor mobile GP program run by the Perth Primary Care Network is an excellent example. They provide services such as vaccination, harm minimisation interventions and health promotion. I’m not sure whether or not any of these programs have specifically focussed on smoking but they certainly would have a good knowledge of the health care needs of homeless and marginalised people in their areas.
One thing that should be done is to find out from the Homeless themselves what their health priorities are and then devise some solutions. They might differ from the traditional priorities that seem to worry public health care professionals (like smoking). For example, one study that interviewed homeless older men sleeping on the streets, found that they were more concerned with their foot care (proper shoes/podiatry) than anything else as these homeless valued their mobility as a source of safety (and fitness). But these needs might differ from other homeless people who rely friends and family to provide shelter. Get a dialogue going with both groups and then see what the health needs of these communities are. Only then, can public health professionals accurately target the health of these individuals.
There’s a lot of mythology about smoking that is passed endlessly around about disadvantaged groups. Two assumptions are that (1) because disadvantaged groups smoke more, they somehow need extra help to quit (2) that people need help to quit. With (1) it is absolutely true that disadvantaged groups have higher smoking prevalence that more affluent groups. But this is because they have much lower “never smoked” proportions, not because their ex-smoker proportions are lower, reflecting some harder problem with quitting. In other words, if you look at ex-smokers by SES, you find fairly similar proportions of ex-smokers, regardless of SES. But you find BIG differences in the “never smoked” and “currently smoke” proportions.
So the idea that disadvantaged people cannot quit as well as wealthier people doesn’t stack up: it’s just that far more of them start and continue smoking. To me this means that inequity reducing strategies need to concentrate on reducing uptake in low SES groups, rather than erroneously arguing that disadvantaged people have big trouble quitting.
Second, between 2/3 and 3/4 of ex-smokers quit unassisted (see http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1000216) I know of no evidence that suggests that this proportion is lower for disadvantaged groups. So talk of services, subsidies etc is all about the tail of cessation, not the dog.
This is serious, right? This is actual research, and Quit are actually trying to get homeless people to quit? This is like telling the abused child he needs to get out and get some exercise!
These people are homeless. Most of them are mentally ill. But it’s important to raise Quitting Smoking in their Heirarchy Of Needs????
Maybe, get them some help with their mental illness and their other, more serious substance abuse problems? Maybe get them somewhere to live?
Honestly, this is a piss-take, right? I’ve just been zinged, yeah?
As some other commentators have pointed out, if you’re homeless you’re likely to have far greater problems, like mental health issues, or as ‘Scott’ pointed out, very very basic concerns like foot health. And those kinds of problems have no up side at all, whereas smoking is at least partly pleasurable for some people, and might sometimes help them get through their day.
The article even mentions that some of these people suffer ‘malnutrition’, and then says that because of this their smoking habit is even more dangerous – logically, isn’t the ‘malnutrition’ bit the bigger issue? Even if it doesn’t fit into the ‘Quit Lobby’s’ agenda? There’s a big risk in the priorities of health services coming ahead of the actual needs of homeless people themselves.
From the Quit Smoking lobby’s point of view, it might make sense to point some of their efforts towards the homeless (ie. why should all their hard work only go towards helping the better off?). But from the recipient homeless person’s viewpoint, it could be seen as kind of insulting to have someone trying to get you to kick the smokes (for your benefit? or theirs?) while ignoring the huge problems in your life that have led to you not having a bed to go to at night, leaving you open to getting murdered in your sleep on some park bench etc..
It makes sense to have free and easy-to-access help available for homeless folks who want to quit, when it’s that kind of help they’re seeking, but it would have to be done in context, and not pretending that they don’t have bigger needs and might in the meantime have a perfectly legitimate desire to maintain a little bad habit.
Thanks everyone for showing an interest in this little talked about issue!
It’s true that, with all the other immediate pressures homeless people experience (food, shelter, safety), kicking the habit might not be top on their priority list.
But, this doesn’t mean that smoking cessation programs should be reserved for those who have the luxury of not having to worry about primary needs like homeless people do.
I also think that ‘special treatment’ might be necessary for homeless people. This isn’t to say that homeless people are different from the rest of the population. I mean to stress that many people who are homeless lack the kind of exposure people like us who have computers (how you would read this blog!) or TVs to see ads against smoking.
That really is interesting (in a tragic way) Becky about tobacco industry targetting the poor. It’s ironic how much people who don’t have much money fork out most of their earnings on tobacco. It makes you wonder who exactly the government is profiting from as a result of these high taxes.
Actually, a homeless person I was interviewing thought it was unfair that politicians could fly to different countries and get their cigarette packs duty free.
Another important thing I discovered upon speaking to vendours from the Big Issue was that some people who are homeless don’t have a strong network of non-smokers to discourage them. If everyone’s doing it, it’s not that simple to quit.
Also, the shocking mortality rate of Australia’s homeless also places people who live in poor conditions at higher risk of becoming ill from cigarette side-effects.
-k
As [a mostly ex]-smoker, and someone who has battled mental illness for many years, I can tell you that most smokers prefer the psychological benefits of addiction to the physical health benefits of quitting. We will self medicate with whatever works and smoking was something that felt better than any prescribed drug I was ever given. Non-smokers and/or those whose mental health is reasonably OK rarely understand that stress and emotional pain which must be endured will seek ANY comfort. The psychological comfort of an addiction – no matter how illogical it looks to others – trumps the other issues and quitting is, as one comment above points out, low on an agenda full of other things to be dealt with. I have never been homeless (although I came close a few years ago) but I feel the stigma of mental illness and honestly, Quit campaigns have always made me feel even more laden with judgment and stigmatisation. As a result, the ads just make me want to reach for a cigarette straight away – even months after quitting! Also one thing that is also little understood is the rationalisation that people engage in when talking about something that they feel bad about. People who smoke may SAY that they would find it easier to give up if they had more information or support or were surrounded by fewer smokers but these things may instead be what we say to ourselves, and to others, when being met with what we perceive to be a negative judgment of our addiction – empathy and open mindedness aside, just being asked about smoking is enough for many people to have a perception that they are being judged. And despite the potential for low levels of awareness of the dangers of smoking in homeless communities, information about such dangers has been in schools and the general media for a good twenty years and most people will have come across that information at some point in that time – which is why many feel stigmatised about their smoking and why they would likely rationalise away their inability to quit in the first place!
Then there is the little acknowledged fact that the quitting of one addiction often leads to the uptake of another. My consumption of alcohol has increased since quitting earlier this year and during previous quit attempts, sugary, fatty food was my substitute. Also, there’s the other unacknowledged, untalked about issue for many with mental health problems – a lot of us want to die anyway. I gave up because I was getting emphysema, not dying (which I would have preferred), and was becoming more and more unable to look after my basic needs, even though I’ve not worked in any capacity for three years. However, without the improvement in my mental health, I’m not sure I could have done it and when my emotional state wavers, I still occasionally buy a pack.
I’m not saying no-one should quit if they are homeless or have mental health problems, just that other things need to be dealt with first and well-meaning assistance can create more pressure and make things worse. Worst of all, the government strategy of making smoking so expensive in order to dissuade people from smoking is hitting the poor and disadvantaged the most. I think our government needs to recognise that our nation can’t rid itself 100% of addictions like smoking (which like most addictions, are born from the desire to escape pain) and needs to stop making the poorest amongst us pay for such methods of campaigning.
I would like to see a campaign, instead, for the removal of the current restriction on psychiatric consultations of 52 psychiatrist visits per year (or 12 psychologist visits) and reset to pre-1996 levels so that people who need it have better access to mental health care. In addition I would like to see the removal of the cap on provider numbers, also set by the Howard govt in the late 1990s, so that there are more medical practitioners available to the population in general and to the mentally ill in particular. And of course more spending on public housing would be a big help, too. But of course, that is not popular with taxpayers who would rather that smokers be penalised for their addiction by paying higher taxes than for the well-off to pay higher taxes so as to close the gap between rich and poor, and to give assistance to the most needy of our society.