The Biden administration is considering a policy to eliminate menthol-flavored tobacco and invest $240 million in cancer prevention, including tobacco prevention and cessation, through the White House Cancer Moonshot initiative. These landmark efforts that align tobacco policy with tobacco treatment are likely to help thousands of people quit smoking, including people experiencing homelessness, who have the highest rates of tobacco use in the U.S.
About 70% of people experiencing homelessness report current tobacco use. Some of the earliest studies — dating back to the 1980s — that characterize the health of people experiencing homelessness in the U.S. report a similar percentage of tobacco use. Few statistics have remained the same in 50 years. In contrast, cigarette smoking in the general U.S. population has declined from 50%-60% in the 1950s-1960s to around 11% today.
Deaths among people experiencing homelessness have increased in recent years, in part due to drug overdose and violence. But tobacco-related cardiovascular disease and cancer are also leading causes of preventable death, yet they are often neglected despite being long-term silent killers among people experiencing homelessness.
In my primary care practice at the San Francisco General Hospital, my patients who experience homelessness and who smoke generally present with heart or lung disease 10 to 20 years earlier than those who are housed. They also present with a more severe form of tobacco-related chronic disease, needing acute emergency care or a hospitalization.
In the general population, declines in tobacco use are due to tobacco control policies and programs like clean air policies and cigarette taxes, mass media campaigns, comprehensive state-funded tobacco control programs, and access to tobacco treatment. But not all populations have experienced these declines equally.
At the outset, this might look like an issue of “haves” versus “have nots”; progress has reached our affluent societies more so than our unhoused communities. Mental health and substance use disorders are also linked with tobacco use; at least a third of the people who experience homelessness and who smoke report a mental health and/or substance use disorder. While these characterizations are accurate, they neglect the complexity behind the staggering rates of tobacco use among people experiencing homelessness.
Tobacco use among people experiencing homelessness is a structural issue. Tobacco has long been used as a coping mechanism for the structural injustices linked with homelessness. Decades of structural racism — including redlining and housing discrimination, lack of social and economic opportunities, and deep-rooted experiences of multi-generational trauma — are some of the reasons. There are strong links between smoking and acute experiences of discrimination and racism.
Among Black Americans experiencing homelessness, the structural issues underpinning tobacco use are particularly salient. In our studies focused on tobacco treatment, Black Americans experiencing homelessness comprise 30% to 40% of our study populations, despite comprising 5% of the population in San Francisco.
Menthol tobacco is common among Black Americans in the general population and among those experiencing homelessness. Black participants in our studies have spoken about smoking Kools or Newports, and associating with Black celebrities smoking those same products. Menthol has been heavily marketed in urban inner cities where low-income Black Americans are disproportionately impacted, solidifying menthol’s presence in those communities for decades.
These issues highlight a need for widespread access to tobacco treatment among people experiencing homelessness. There are well-established, guideline-recommended tobacco treatments that include behavioral counseling and pharmacotherapy, but they are not readily accessible in homeless services settings.
We, in the homelessness advocacy and provider community, are complicit in the normalization of tobacco use among people experiencing homelessness.
In the homelessness provider and advocacy community, tobacco has long been considered a lesser evil and historically used to bridge therapeutic alliance between providers and people experiencing homelessness. Furthermore, competing priorities of helping people access shelter or housing or avert crisis situations push tobacco down lower on the list of priorities. For these reasons, we don’t ask about tobacco, nor do we treat tobacco use.
The reality is that people experiencing homelessness attempt to quit at the same rate as the general population. Access to treatment does increase quitting. Providing support to quit through behavioral counseling and pharmacotherapy and incentivizing tobacco cessation through financial and/or other incentives could substantially increase quitting long-term while increasing financial stability. For the community using menthol tobacco, policies that eliminate menthol and flavored tobacco will substantially increase quitting, particularly if they are accompanied with access to tobacco treatment.
I believe these treatments should be offered to every individual experiencing homelessness who smokes, and any encounter in clinical and/or homeless services settings could be an opportunity to provide treatment.
In our work, we have increased awareness and trained staff in shelters and permanent supportive housing on how to provide tobacco treatment using culturally relevant training with accessible materials, and case-based role modeling. Providing treatment will not only increase quitting among those who smoke, but also reduce exposure to secondhand smoke for people living and working in homeless services settings. These best practices are translatable to other sites regionally and nationally.
Providing tobacco treatment will substantially reduce harm, save lives, and improve financial stability by supporting quitting. Most importantly, providing tobacco treatment and eliminating menthol-flavored tobacco will reverse the many years of structural injustices that have led to high rates of tobacco use among people experiencing homelessness.
Maya Vijayaraghavan, MD, MAS, is associate professor of medicine and director of the Smoking Cessation Leadership Center at the University of California, San Francisco. She is a public voices fellow on homelessness with the OpEd Project in partnership with the UCSF Benioff Homelessness and Housing Initiative.
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