The implementation of a smoking cessation and alcohol abstinence intervention for people experiencing homelessness | BMC Public Health

We present participant demographics, followed by key findings from the interviews in relation to overarching CFIR domains (Intervention Characteristics, Outer Setting, Inner Setting, Characteristics of Individuals, Implementation Process).


A subset of participants were recruited from the main study population of 432. Baseline demographic characteristics of the subset of participants from the RCT who participated in the interviews are shown in Table 1, [11] and were broadly reflective of the main study demographics. Thirty-two participants identified as African American/Black, six as White, one as Native American/Alaska Native, and one as more than one race. Eleven participants were female, and 29 were male. Housing stability was assessed by self-report on a scale of 0 (not at all stable) to 10 (extremely stable) and the mean (± SD) response was 3.53 ± 3.48 (range, 0 to 10). Most participants identified themselves as unemployed. Participants smoked on average 14.6 ± 8.3 (range 2.5 to 40) cigarettes per day at their eligibility screening and just over half had their first cigarette of the day within 30 min of waking. Participant AUDIT scores averaged 14.9 ± 4.87 (range 7 to 24) which corresponds to risky/hazardous or high-risk/harmful alcohol use risk levels.

Table 1 Participant baseline demographics and characteristics

Intervention characteristics

The intervention included a combination of counseling and nicotine replacement therapy (NRT patch plus gum or lozenge) to help manage nicotine withdrawal. Overall the smoking and alcohol treatment intervention was perceived as acceptable by participants. Some participants described appreciating the opportunity to discuss their health, as much of the resource services offered by the shelter focused on addressing their homelessness. Participants who were randomized to the smoking and alcohol counseling arm (vs health education) mentioned the importance of their counselors’ kind demeanor. Having a warm, friendly, and approachable attitude was key to participants’ overall experience in the study.

“Yeah, as far as staff, I never felt like I was less than them just because of being in here at (the shelter). They always made me feel welcome. (Intervention group participant).

Counseling sessions, which became a part of participants’ routine, were described as contributing to an increased sense of purpose. However, while most of the participants saw the benefits of the counseling sessions, some participants were resentful of having to participate in counseling sessions, and felt their counselor was nosy and intrusive. Some participants receiving the one time health education counseling session group believed they would have benefitted from going to the ongoing counseling sessions while others were relieved not to have to attend them. While a few participants believed they would have benefitted from more frequent sessions, for the most part participants were content with the amount of counseling sessions received.

“I liked it the whole session. I didn’t just want the patches, to come and go. I needed the counseling, too” (Intervention group participant).

Overall, participants described that staff provided a comfortable and respectful environment, with the counseling providing a space for focus, reflection, motivation, and skill-building. Occupying one’s time with other, non-smoking activities was a key strategy participants used when they had the urge to smoke or drink. Across the board, participants were educated about the consequences of smoking or drinking on the body and were able to reflect on the ways in which those behaviors were detrimental to their own health. The health consequences of tobacco or alcohol use strongly resonated with participants and the impact of this was present throughout participant responses.

In addition to counseling, participants were also offered Nicotine Replacement Therapy (NRT). NRT for the most part, was described as helping participants manage their cravings. NRT gum and lozenges were reported as being moderately successful in managing craving, with participants being most enthusiastic about having an option for using gum. Most participants shared positive experiences of NRT patches helping to reduce cravings, feeling they had been very helpful. However, some participants reported that the patch did not reduce the urge to smoke.. Some people reported difficulties in keeping the patch adhered to their skin. Physiological cravings were reported to increased appetite and overeating, which led to weight gain and a fear of putting on weight.

Outer setting

Participants described a range of external factors to the intervention or intervention setting, such as the broader physical environment, or their own motivation, that impacted their experience of the study. A significant challenge related to the shelter environment was the perception of the ubiquitous use of cigarette smoking and alcohol abuse. In fact, some participants reported having started smoking for the first time since their stay at the shelter. Participants described experiencing frequent temptation and peer pressure to drink and smoke from other shelter residents in areas immediately around the shelter. Smoking and drinking were both described as very important in the social life for shelter residents.

“It’s kind of hard, you’re walking down the street and all of a sudden you’re in a puff of smoke, you’re like wait, I could use one of those” (Intervention group participant).

Getting to counseling sessions was convenient for participants who lived in the shelter; However, for participants who had moved to more stable housing during the study duration, returning to the shelter for appointments was a challenge. Additionally participants described challenges getting to appointments because of adverse weather, conflicts with work, and conflicts with doctor appointments.

The need to find housing, while having very limited financial resources, was another challenge for participants. Cutting back on cigarettes and problem drinking was reported as helping some participants alleviate the financial burden of smoking and/or drinking, cultivating feelings of accomplishment and pride in cutting back their consumption behaviors, and feeling better physically and emotionally.

Many participants described feeling that their personal strength and ability to focus on their goals was what led them to be a part of the study. Participants faced common challenges to smoking cessation, such as with cravings and dealing to smoke. Study participants were asked to set a goal of quitting smoking and drinking, however participants frequently identified that they often had their own goal of lessening smoking or drinking, rather than quitting. For many, smoking and drinking were described as habitually intertwined. Engagement in either habit was seen as a trigger spurring engagement in the other. Likewise, reduction or quitting of one, was also associated with the reduction or quitting of the other. Participants reported reductions in smoking or drinking as personal successes.

“I was doing like a couple packs a day, so for me to go from that to six cigarettes a day, that’s like a miracle to me!” (Intervention group participant).

Many participants described forming a bond with the PTQ2 staff and reliance on them for emotional support and encouragement. Many were also glad to have the opportunity to branch out and interact with different people.

Inner setting

The shelter setting offered convenience for participants, however it also presented some challenges as it did not always feel very quiet or confidential to some. Additionally, while the shelters themselves were smoke-free and alcohol-free environments, the social pressure, direct or indirect, from fellow shelter residents was challenging. Despite this, participants described a range of motivators and expectations. Many were motivated to enroll for health reasons, including fear of future diagnoses such as cancer. Participants also described the belief that personal willpower was needed before being ready to engage with help and attempt to quit.

“First of all, change has to come from within; If you’re not ready to change, you’re not going to change. I got irons in every fire I can. My motto is ‘I need all the help I can get!’” (Intervention group participant).

Implementation process

Participants were mostly positive about their study participation, and many reported feeling motivated to address their smoking. Participation was described as helping foster sober social time, positive feelings about contributing to the community, and a focused attitude to improve their situation.

“I think it’s good. It made me feel like I had something to do or like I had a purpose. You know what I mean, not a purpose but it wasn’t like the homeless” (Intervention group participant).

Participants were able to participate in the intervention activities successfully and for some, the contact with study staff was appreciated. Some reported that they wished there were more cessation counseling sessions available, particularly if they enjoyed the supportive encounters with the study staff. Some became champions of the intervention participants, encouraging other shelter residents to consider enrolling in the study. For some, the study was a welcome activity that focused on their wellness and helped beat experiences of boredom.

Across conditions, participants completed regular study outcomes surveys at multiple time points throughout the trial. While a few participants viewed the survey with no particular value, the majority, including control arm participants, viewed this component of the study as meaningful, and helpful in monitoring and reducing smoking behaviors. This suggests that self-monitoring may play an important role in cessation, even if not an intended consequence of the frequent surveys. Notably, nearly all participants were grateful and enthused by the financial incentives.

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