J Community Health DOI 10.1007/s10900-015-0040-2
ORIGINAL PAPER
Attitudes Toward Smoking Cessation Among Sheltered Homeless Parents Holly C. Stewart1 • Terrell N. Stevenson1 • Janine S. Bruce1 • Brian Greenberg1 Lisa J. Chamberlain1
•
Springer Science+Business Media New York 2015
Abstract The prevalence of smoking among homeless adults is approximately 70 %. Cessation programs designed for family shelters should be a high priority given the dangers cigarette smoke poses to children. However, the unique nature of smoking in the family shelter setting remains unstudied. We aimed to assess attitudes toward smoking cessation, and unique barriers and motivators among homeless parents living in family shelters in Northern California. Six focus groups and one interview were conducted (N = 33, ages 23–54). The focus groups and interviews were audiorecorded, transcribed verbatim, and a representative team performed qualitative theme analysis. Eight males and 25 females participated. The following major themes emerged: (1) Most participants intended to quit eventually, citing concern for their children as their primary motivation. (2) Significant barriers to quitting included the ubiquity of cigarette smoking, its central role in social interactions in the family shelter setting, and its importance as a coping mechanism. (3) Participants expressed interest in quitting ‘‘cold turkey’’ and in e-cigarettes, but were skeptical of the patch and pharmacotherapy. (4) Feelings were mixed regarding whether individual, group or family counseling would be most effective. Homeless parents may be uniquely motivated to quit because of their children, but still face significant shelter-based social and environmental barriers to quitting. Successful cessation
& Holly C. Stewart [email protected] 1
Stanford Medical School, 291 Campus Drive, Stanford, CA 94305, USA
programs in family shelters must be designed with the unique motivations and barriers of this population in mind. Keywords Cigarettes Smoking cessation Homelessness Family homelessness Shelter environment
Introduction The prevalence of smoking among homeless adults in the United States an estimated 70–80 % [2, 40] as compared to 18.1 % in the general population [1]. Homeless smokers smoke more cigarettes per day, initiate smoking at a younger age [8], and homelessness appears to be associated with present smoking independent of individual demographics, socioeconomic status, and health behavior [3]. The negative health effects of tobacco among the homeless may be exacerbated by poor diet, substance abuse, mental illness, communicable and chronic disease, and limited healthcare access [13]. Despite substantial barriers to smoking cessation, homeless smokers appear to be motivated to quit. They report a similar number of quit attempts as compared to non-homeless smokers, understand the dangers of tobacco use, recognize that homelessness and tobacco use are financially incompatible, and many plan to quit in the immediate future [32]. Preliminary research suggests interventions, including small financial incentives [7], smoke-free shelter policies [44], and telephone-delivered cessation programs [6] may achieve higher smoking cessation rates among homeless smokers. The nature of smoking in the family shelter remains relatively unstudied, despite increases in family homelessness across the United States [41] secondary to poor economic conditions and insufficient social welfare [22].
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Smoking poses considerable risk to the health of family shelter residents. Unlike homeless single adults, who are found on the streets as well as in the shelter, homeless families are predominantly shelter-based [31] with people in families comprising nearly 50 % of the total sheltered homeless population in January of 2013 [43]. Comparisons of homeless sheltered and low-income non-homeless women demonstrate asthma rates to be more than four times higher in the homeless cohort [46]. Children living in homeless facilities where smoking is prevalent are more likely to experience environmental tobacco exposure, which increases the risk of lower respiratory illness, middle ear effusion, asthma, and sudden infant death syndrome [15]. Additionally, children of current and former smokers are more likely to become smokers [45] and parental smoking cessation may help lower risk for adolescent smoking [11]. Previous research finds meaningful differences between homeless adults living with children and single homeless adults [47] that warrant special consideration. We call specifically for a better understanding of the unique smoking practices and attitudes toward cessation in the family shelter setting, which is essential for development of cessation programs appropriate for environments where children are present. Therefore, the aim of this study was to conduct multiple focus groups with homeless parents living in family shelters in Northern California to characterize participants’ readiness to quit and desired cessation methods, and to identify shelterspecific barriers to quitting.
Methods Recruitment We aimed to include participants that would express ‘‘typical’’ or ‘‘average’’ perspectives on smoking, and therefore recruited participants using typical case sampling [14, 28, 33]. In each of the participating shelters, focus groups were advertised at the weekly shelter-wide meeting by the program director. Shelter residents who met our study criteria were able to sign up at weekly, all-shelter meetings or one-on-one through their case managers. Focus group dates were decided upon by the program director at each shelter, and were offered in both the evenings and mid-day to accommodate different schedules of shelter residents. Within the focus group literature, recommendations regarding the ideal number of participants are variable, ranging from 4 to 12 [18, 23, 26, 27, 37–39]. Our aim was to recruit between six and eight participants for each focus group but over-recruited by approximately 25 % to allow for the possibility that participants who signed up would not attend the groups.
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Inclusion and Exclusion Criteria Inclusion criteria included residing in an InnVision Shelter Network family shelter in San Mateo County, being 18 years of age or older, being a current smoker. In our study, shelter residents were considered ‘‘current smokers’’ if they reported smoking five or more cigarettes per day or quitting within the past six months. Shelter residents who reported living with a primary relative who was a smoker were also included in our study. Light food and refreshments were provided at each focus group. Participants were compensated with a $15 gift card to a large local grocery store. Data Collection Six focus groups and one interview were conducted across four family shelters in San Mateo County, California between June and August of 2013. All four of these shelters were designated transitional facilities where shelter residents actively work towards obtaining employment and long-term housing; one of the four sites additionally provided emergency housing for families. Focus groups and interviews lasted approximately 45 min. All focus groups and the interview were conducted by the primary investigator (HS), who prior to this project received training in qualitative methods through graduatelevel coursework and a community health research program at Stanford University. With the exception of one shelter, shelter staff members were not present for the focus groups. Prior to the focus group, each participant was asked to complete a brief survey on demographic information and smoking-related data. The moderator’s guide was adapted from questions used by Okuyemi et al. [32], and asked participants to discuss their attitudes toward smoking, their attitudes toward smoking cessation, and any motivating factors or barriers to smoking cessation that they encounter in their day-to-day life. Focus group participants were asked to voluntarily introduce themselves at the beginning of each session, providing only their first name or a pseudonym for the purpose of confidentiality. All focus groups were audio-recorded with participants’ consent. The focus group recordings were subsequently transcribed verbatim by the primary investigator (HS) and proofread for accuracy. Any identifying information was removed from the transcripts prior to analysis. This study was approved by the Institutional Review Board at Stanford University. Data Analysis Ryan and Bernard propose four key steps in qualitative analysis: (1) discovering themes and subthemes; (2)
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winnowing themes to a manageable few; (3) building hierarchies; and (4) linking themes into theoretical models. In our analysis, a team-based approach was implemented for discovery of themes and subthemes [35]. Team-based analysis is a recognized approach for generating preliminary codes in qualitative research [4, 24], and multiple coders are thought to provide an important mechanism for assessing reliability and validity of the codes [24]. The team that identified preliminary themes and subthemes for the present study had no prior knowledge of the study protocol or specific aims, but all team members had professional expertise relevant to our research question. The team included a second-year pediatric resident and a second-year medical student who recognize the health risks posed by smoke exposure; a shelter staff member with intimate knowledge of operations at the family shelters included in our study; and a post-baccalaureate fellow with academic training in anthropology and qualitative research. The analysis team was provided with detailed instructions regarding reading of the transcripts and independent margin coding. A subsequent group discussion of margin codes was facilitated by the primary investigator (HS) in which team members presented their margin codes for each domain in the moderator’s guide. Codes reported by more than half of the team members were included in the preliminary codebook [21, 36]. Consistent with Ryan and Bernard’s framework, the preliminary codes generated by the team-based analysis was subsequently refined and built into a hierarchy of domains, themes, and subthemes by the principal investigator (HS). These domains differed from those included in the moderator’s guide. An iterative coding process was then used to apply codes to the data: the principal investigator (HS) and an additional team member applied codes to a portion of the complete transcript, reconciled inconsistencies in application of codes, and subsequently revised and redefined codes as necessary. This process was repeated a total of four times, and yielded a finalized codebook that was applied to the data [24, 36]. Cohen’s j was calculated using DedooseTM Online Software v 5.1.26 to assess interrater reliability between the principal investigator and the team member. A pooled j = 0.80 was achieved during the final coding process [10]. On completion of the codebook, combinations of primary and secondary codes were used to examine the coded data to identify significant patterns and preliminary themes. Generated themes were iteratively revised, and thematic statements were developed with careful attention paid to recurrent concepts, and whether or not the concept characterized the unified experience of all participants [29, 35]. Throughout the theme analysis process the principal investigator (HS) elicited feedback from shelter staff, coinvestigators, and medical professionals specializing in
substance use. We elicited feedback from professionals with content expertise to increase the credibility of our findings and to account for any potential research biases or preconceptions that may have influenced the analysis [28]. Elicited feedback also helped shape a meaningful theoretical model to which themes could be linked [35]. For analysis of the survey data, Stata v. 13.0 (StataCorp LP, College Station, TX) was used to calculate descriptive statistics for gender, race and ethnicity, plans to quit in the next six months, plans to quit within the next thirty days, and past use of nicotine replacement products. Means and standard deviations were calculated for age, cigarettes smoked per day, duration of smoking (in years), and quit attempts in the past year (Table 1).
Results Demographic characteristics and data on smoking behaviors were collected for 96.9 % of study participants (Table 2). The majority of this sample of sheltered, homeless parents were Caucasian females. The mean age was 32.7 years. Most had taken college-level courses or earned a higher degree. The majority of smokers reported smoking every day out of the last thirty days (48.3 %), and 29 % smoked two to five cigarettes per day. A substantial number of participants (22.5 %) were never-smokers, but were included because one of their primary relatives was a smoker. Four major themes emerged in focus group discussions: (1) the central role cigarette smoking plays in the family shelter environment; (2) children as a motivator for quitting; (3) the role of will power in cessation; (4) and mixed feelings regarding counseling options. Smoking and Its Central Role in the Family Shelter Environment All four shelters included in this study prohibit indoor smoking, but allow smoking in a designated outdoor area at the shelter’s front entrance. Study participants reported that cigarettes were ubiquitous in the shelters included in our study. Smoking was described as an activity that helped shelter residents to both cope with daily stressors and build friendships with fellow smokers. When asked to describe the reasons they enjoyed smoking, participants explained that cigarettes could effectively alleviate feelings of anger, boredom, and stress. Smoking was described as a means of managing both dayto-day stressors like ‘‘having your phone get cut off’’ or ‘‘having someone flake on you’’ as well as the more constant stressors associated with homelessness and the precariousness of shelter life:
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J Community Health Table 1 Moderator’s guide Smoking practices and readiness to quit What led you to start smoking? What do you enjoy about smoking? What are some of the negative things about smoking? How does being a parent influence the way you think about smoking? Attitudes towards cessation For those of you who are thinking about quitting, what are some reasons you would like to quit smoking? For those of you who are not thinking about quitting, what would make you want to quit? How might quitting be different for people who are parents? Barriers to cessation Overall, what are some of the things that would make quitting hard for you? What are some of the things in your day-to-day life that would make quitting hard for you? Preferred cessation methods What methods have you tried to help you quit smoking in the past? How did it go? What methods would you be interested in using to try and quit smoking? What would you think about having a counselor to help you quit smoking? What would you think about going to group meetings to help you quit smoking? Which would you prefer: individual, group, or family counseling and why?
…it’s my only way of releasing stress. I can’t yell, I can’t hit, I can’t walk away, I can’t just say goodbye, I don’t have anybody to take one, so it’s…kind of obvious. Smoke. Despite their negative feelings about smoking, participants describe using cigarettes as a coping mechanism: Me personally I don’t like nothing about smoking. I just do it…a lot of times I do it because I have nothing to do or if I’ve been stressed out or just like a comfort zone. For some, cigarettes were used to manage stress and anxiety in lieu of other drugs or alcohol: I think for me personally while I’m in this situation there’s no reason for me to quit anything. You know I just quit drugs and alcohol two and a half years ago– that was hard enough and I’m still stressin’ on that…I wish that I never would’ve smoked but unfortunately that’s not how my situation is …there’s really nothin’ I can do about it. Beyond its role as a coping mechanism, smoking appears to provide an opportunity for adults to socialize in these shelters. Even those who self-identified as nonsmokers acknowledged the designated smoking areas as a spaces where adults could mingle with one another. And a few times we would go out there, it was a nice evening and we’d go out there just to talk, you know, and uh we weren’t smoking but just, they were out there and we were talking and stuff like that.
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Smoking is described as one of the only activities that provided adults to interact with each other in the absence of their children, and consequently appears to be one of the primary mechanisms by which shelter residents were able to form friendships and built social capitol: …I think that people that smoke here—that [smoking] kind of helps them. I mean me, from the outside, I feel like the people that do smoke…make a support group for each other so they get to know each other. They talk to each other, they get to know each other [better] than the people that are not smoking so I feel like I…don’t know the people here. Both smokers and non-smokers reported personal experience or recounted instances of shelter residents who picked up smoking after arriving at the shelter due to its ubiquity and its key role in socialization among adults. Motivating Factors for Smoking Cessation Among the most commonly cited reasons to quit smoking were personal appearance—including the smell of cigarettes and nicotine staining of nails or teeth—and personal health. Participants also described feeling ashamed of being identified as a smoker: I care about what other people think and so…it bothers me…when I’m with my mother…and she lights up and [the smoke] goes behind her and people are like, [coughing]. That bothers me. It’s embarrassing. So I don’t do stuff like that.
J Community Health Table 2 Focus group participants’ demographics and smoking behaviors (n = 31) Percentage Sex (female)
74.2
Ethnicity (Hispanic/Latino)
29.0
Mean (SD)
Race Caucasian
45.1
African American
12.9
Asian
6.5
Pacific Islander/Hawaiian American Indian/Alaskan Native
3.2 6.5
Mixed races Other
6.5 32.72 (5.75)
Educational level Did not finish high school
16.1
Completed high school or GED
38.7
College or other higher degree
45.1
Days smoked out of last 30 0 days
25.8
1–2 days
6.5
3–5 days
0
6–9 days
6.5
10–19 days
3.2
20–29 days All 30 days
9.7 48.3
Cigarettes smoked per day None \1
25.8 0
1 per day
12.9
2–5 per day
38.7
6–10 per day
9.7
11–20 per day
9.7
More than 20 per day
3.2
Number of prior quit attempts I have never smoked
22.5
None
12.9
1 time
9.7
2 times
29.0
3–5 times 6–9 times 10 or more times
You know, I’ve done the whole thing like four or five times about ‘‘if you spend this much and this much in a year’’ and it comes out to a lot. I’m just like, I’m in a frickin’ shelter. I spend that much money on cigarettes and I’m freaking here? It’s like, nuts Children were discussed as a motivator for quitting in all seven focus groups:
12.9
Age
frequently expressing their understanding that smoking and homelessness are financially incompatible:
9.7 12.9 3.2
If I wasn’t a parent I would not be thinking about it. As sad as that is to say for my own health and the commercials you see and the advertisements, I would probably continue smoking and would smoke way more than I do now. Participants described feelings of anxiety regarding the risk smoking poses to their children’s health, and expressed feelings of guilt for exposing their children to cigarette smoke: When you’re not a parent it’s basically you, you hurting only yourself. And when you are a parent, it’s not only you…your child is innocent they didn’t ask to be there. They didn’t ask to be held in the smoke. So I don’t think it’s fair for the child. Participants also expressed concern that by smoking they were setting a bad example for their children: He’ll see a cigarette and he’ll [say] ‘‘Here, Mommy!’’ You know, before he used to take them and break them…I don’t want to set a bad example. It’s a bad example so that’s another reason why I want to quit. Both smokers and non-smokers were frustrated by shelter rules that specify that children must accompany parents who wish to go outside to smoke. Participants explained that this rule sends confusing messages to children, and also makes them vulnerable to second-hand smoke exposure: Before he didn’t always see me smoking. I would hide… but now I gotta drag him with me I gotta go smoke, gotta go smoke you know and he is getting that idea in his head that it’s okay. The Role of Will Power in Smoking Cessation
Participants also expressed feelings of shame with respect to specific smoking-related behaviors: I have a lot of pride and I will go pick up butts, okay? Like…I could never feel lower in the world.
When participants were queried about the specific tools they would like to use to quit smoking, many expressed interest in the patch. However, there was also widespread concern regarding side-effect associated with the patch:
The high cost of cigarettes was cited across focus groups as a major motivating factor for quitting, with participants
I know from using the patches…they give you really bad nightmares, they burn your skin, they make you
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sick…but you still have that habit. You know what I mean? Participants were equally concerned about the side effects associated with medications that are commonly used for smoking cessation. One participant described her experience with Chantix [Varenicline, a prescription used to treat nicotine addiction]: The only thing that worked for me was Chantix. But I almost robbed a bank. I wanted to rob a bank. I’m serious…it was horrible. Of the cessation tools discussed, participants were much more interested in e-cigarettes or replacing smoking with an alternative habit than they were in using either patches or medication. Across all seven sites, participants appeared most interested in quitting without use of cessation aids. When asked what cessation method they would prefer to use to quit smoking, multiple participants across all shelter sites simply responded by saying ‘‘cold turkey.’’ I don’t think I’m addicted to it like that much where I need a substitute…cold turkey would be best. Out of these discussions emerged the idea that addiction to tobacco products is a matter of will. Participants talked about ability to quit coming from with a person, and explained that they did not believe classes or cessation aids were necessary tools for quitting smoking: I mean, it doesn’t take to go to a class to stop. You know what I mean? You can stop yourself inside. I mean, you might, you know, there might be triggers to what makes us, you know, smoke? But all in all, a lot of people make excuses to why they need to do this class or do this to stop when it’s really in here. It’s all inside, you know? If you want to stop, you stop. From in here. Participants also expressed their belief that addiction was sustained by the act of smoking, not nicotine: Just, being in this situation and dealing with all of this is what you know, gets me or at least gives me the urge to want to smoke. So. For me it’s not necessarily the chemical it’s just the smoking itself. Mixed Feelings Regarding Counseling Options Participants were asked to share their thoughts on three counseling options: individual, group and family counseling. Participants identified benefits and drawbacks to all three counseling types, and ultimately feelings were mixed regarding which type of counseling would be best.
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Participants identified privacy and one-on-one attention as clear benefits of individual therapy, as well as the opportunity to explore the emotions associated with smoking. However, many participants felt that weekly, one-on-one counseling would not provide them with enough support for smoking cessation. Additionally, several participants felt that smoking would take a backseat to other issues in individual therapy sessions. In discussing the group counseling option, participants suggested that accountability to fellow group members and the opportunity to derive inspiration from other group members’ stories were clear benefits. Drawbacks to group counseling included a lack of privacy, and some participants felt that they would not be motivated by strangers’ stories. The last therapy option, family counseling, was proposed by a participant in the first focus group, who expressed an interest in involving her children in the cessation process. When participants in subsequent focus groups were asked to share their opinions on family counseling, many saw possible benefits, including having a safe space to explain smoking to their children. Some participants suggested that family counseling might help prevent their children from becoming smokers themselves: The first cigarette I had is when I was ten. And if my parents would have talked to me or my grandparents would have talked to me I don’t think I would be smoking today. However, some participants expressed serious concern over family counseling. Some worried that family counseling would send the message that it is okay to start smoking because it is possible to quit later. Some participants felt that smoking was an adult issue and that children should not be involved in discussions about smoking.
Discussion Our findings suggest that changing the shelter environment may be key in encouraging shelter residents to consider smoking cessation. Participants reported the prevalence of cigarette smoking and its central role in socialization as major barriers to smoking cessation, which reinforces previous research highlighting the importance of the social context of smoking practices [3]. Descriptions of the ubiquity of cigarette smoking in the shelter setting are consistent with the convention of allowing cigarette smoking in homeless shelters while prohibiting use of alcohol and illicit substances [40]. Descriptions of cigarette smoking as a powerful tool for socializing and building social capital are consistent with the notion that smoking is
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a ‘‘network phenomenon’’ [12]. Participants also cited stress relief, a common self-perceived motivation for smoking [19], as a major barrier to smoking cessation. Despite barriers to successful smoking cessation, many participants reported their intentions or desire to quit. Participants mentioned many of the same motivating factors reported by single homeless adults in previous research—including the high cost of smoking, personal health and personal appearance [32]—but children were the most commonly cited motivator for smoking cessation in this group of homeless parents. This finding, though not surprising, is a meaningful one: homeless parents and homeless single adults face similar barriers to cessation, but homeless parents report a powerful additional motivator. They may therefore be more receptive to shelter-based cessation programs. Innovative programming to support tobacco cessation in this unique population is therefore warranted [9]. There appeared to be a knowledge gap regarding the biological basis of nicotine addiction in this highly educated group of homeless parents. Participants reported their desire to quit ‘‘cold turkey,’’ and their belief that smoking addiction is emotional or psychological in origin. Quitting was largely considered to be matter of will power by participants. These beliefs are inconsistent with the literature, which indicates that nicotine maintains tobacco addiction [42] and that nicotine replacement therapy such as the nicotine patch is effective for smoking cessation [5, 20]. However, most participants expressed skepticism regarding nicotine replacement therapy and pharmacotherapy and fear of associated side effects. Consistent with prior findings that flexible services for smoking cessation are valuable, and that programs tailored to individual context, culture, and personal life situation are most acceptable, feelings among participants were mixed regarding what form of counseling would be most effective [34]. Our findings suggest future directions for both future interventions and further research. In line with social-ecological principles, these interventions should consider not only unique motivating factors, but also environmental interventions that aim to mitigate shelter-specific barriers to cessation [30]. Possible pilot environmental interventions may include protected time for adults to socialize over non-smoking activities, encouragement of smoking cessation by shelter staff, increased regulations regarding where and when individuals are allowed to smoke, and an overall emphasis on a culture of non-smoking. Recent research also suggests that smoke-free policies in homeless shelters lead to reduced consumption of cigarettes and increased quit attempts [44], and consideration of such policies for the shelters we included in our study may be advisable given the influence of the shelter environment on smoking behaviors. Beyond environmental interventions,
educational sessions about the physiology of nicotine addiction may help shelter residents devise more realistic plans for smoking cessation. Lastly, results from these focus groups suggest that offering multiple modalities of behavioral therapy (individual, family, and group counseling) as part of a cessation program may help shelter residents find a quit strategy that is consistent with their desires and priorities. Further research is needed to characterize the nature of smoking and attitudes toward smoking cessation in the family shelter setting. Future potential directions for research in this area include quantifying the degree of nicotine dependence among family shelter residents using tools such as the Fagerstrom Tolerance Questionnaire [16, 17, 25]; comparison studies across family shelters and shelters for single adults; and evaluation of any resultant pilot cessation programs. Strengths and Limitations Limitations of this study include our small sample size and the composition of our study sample. We utilized typical case sampling in order to recruit a study population representative of sheltered homeless parents living in San Mateo County, but group demographics and size varied considerably among groups. High levels of educational attainment, low reported number of cigarettes smoked per day, and a predominance of Caucasian females will hinder the generalizability of these findings beyond the study population. Our focus groups included a mixture of smokers and non-smokers who had lived with a primary relative who smoked. It is possible that this heterogeneity lead to mixed and confounded focus group results, however it has been argued in the focus group literature that it can be advantageous to bring together a diverse group to maximize exploration of different perspectives within a group setting (22). Our decision to include smokers and nonsmokers simultaneously was driven our aim of eliciting a broad range of opinions on smoking in shelters, and also by logistic challenges inherent in scheduling focus groups with shelter residents who are actively transitioning out of homelessness. There are also two potential sources of bias that must be recognized: first, it is possible that among current smokers living in the shelters included in our study, only those amenable to the idea of quitting chose to participate in the present study. This selection bias would result in a misrepresentation of the general attitude toward smoking cessation among shelter residents, and would lead the investigators to overestimate the extent of interest in smoking cessation among shelter residents. Second, while the moderator remained consistent across all seven focus groups, the ethnicity and social position of the moderator
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may have influenced the attitudes shared in this study: study participants may have (either consciously or subconsciously) responded in a manner they thought would be acceptable to a Caucasian medical student. Finally, to make research with this historically hard-toreach, vulnerable population technically feasible, and in light of high turnover at the shelters included in our study, certain adjustments were made to our methodology. First, our original aim was to conduct a series of focus groups in San Mateo County family shelters. For one of the seven scheduled focus groups, only one shelter resident was present. Because participants were provided with an incentive for participation and because of our commitment to providing shelter residents with an opportunity to share their experiences, we felt that it was more appropriate to conduct a one-on-one interview with this participant using the focus group moderator’s guide than exclude them from the study. This interview was analyzed concurrently with the focus group transcripts because the same questions were asked. Second, at only one of the four shelter sites a staff member was present for the focus groups. This staff member attended focus groups because in all previous collaborations between the research team and this shelter (which included an educational series on childhood asthma and cigarette smoking) a staff member was present. We felt that it was better to maintain this status quo and allow the staff member to attend the focus groups than risk jeopardizing the healthy relationship we maintained with the individual shelter sites and our community partner throughout the present study. We recognize that the presence of a staff member may have biased responses—for example with participants being less willing to share anecdotes related to substance use or breaking shelter rules—however the nature of the responses from the focus groups conducted at this shelter were consistent with those conducted at the other sites where no staff person attended. Despite these limitations, we believe that the main strength of the present study is that it provides preliminary insights into the nature of smoking in family homeless shelters that are otherwise not represented in current literature. While we encountered many technical challenges in carrying out this research, we aimed throughout the present study to maintain methodological rigor while honoring our community partner and creating an opportunity for as many shelter residents to share their perspective as possible.
Conclusion This study represents an attempt to begin characterizing the smoking practices, shelter-specific barriers to cessation, and desired smoking cessation methods among sheltered
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homeless parents. Our preliminary findings from a series of focus groups in Northern California suggest that children serve as a profound motivator for smoking cessation, but that the central role of smoking in the shelter environment poses a major obstacle for sheltered homeless parents who may be ready to quit. As smoking in the family shelter setting poses a risk not only to the smokers themselves but also to children living in these environments, future efforts must be aimed not only at further characterizing the role of smoking in the family shelter setting, but also at providing desired resources to shelter residents who demonstrate an interest in quitting. Acknowledgments This work was supported by a CATCH Grant issued by the American Academy of Pediatrics (Grant 2123) and by the Medical Scholars Research Program at Stanford Medical School. Conflict of interest
The authors have no competing interests.
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28. Malterud, K. (2001). Qualitative research: Standards, challenges, and guidelines. The Lancet, 358(9280), 483–488. doi:10.1016/ S0140-6736(01)05627-6. 29. Maxwell, J. A. (2012). Qualitative research design: An interactive approach (applied social research methods). Thousand Oaks, CA: Sage. 30. Minkler, M. (1999). Personal responsibility and health? A review of the arguments and the evidence at century’s end. Health Education and Behavior, 26(1), 121–140. doi:10.1177/109019819902600110. 31. O’Flaherty, B. (1996). Making room: The economics of homelessness. Cambridge, MA: Harvard University Press. 32. Okuyemi, K. S., Caldwell, A. R., Thomas, J. L., Born, W., Richtter, K. P., Nollen, N., et al. (2006). Homelessness and smoking cessation: insights from focus groups. Nicotine & Tobacco Research, 8(2), 287–296. doi:10.1080/14622200500494971. 33. Patton, M. Q. (1990). Qualitative evaluation and research methods (2nd ed.). Newbury Park, CA: Sage. 34. Ritchie, D., Schulz, S., & Bryce, A. (2007). One size fits all? A process evaluation—The turn of the ‘story’ in smoking cessation. Public Health, 121(5), 341–348. doi:10.1016/j.puhe.2006.12.001. 35. Ryan, G. W., & Bernard, H. R. (2003). Techniques to identify themes. Field Methods, 15(1), 85–109. doi:10.1177/ 1525822X02239569. 36. Saldan˜a, J. (2009). The coding manual for qualitative researchers. Thousand Oaks, CA: Sage. 37. Sampson, P. (1986). Qualitative research and motivation research (3rd ed). In R. Worcester & J. Downham (Eds.), Consumer market research handbook. Amsterdam: Elsevier. 38. Slater, P. E. (1958). Contrasting correlates of group size. Sociometry, 21(2), 129–139. doi:10.2307/2785897. 39. Tang, K. C., & Davis, A. (1995). Critical factors in the determination of focus group size. Family Practice, 12(4), 474–475. doi:10.1093/fampra/12.4.474. 40. Tsai, J., & Rosenheck, R. (2012). Smoking among chronically homeless adults: Prevalence and correlates. Psychiatric Services, 63(6), 569–576. doi:10.1176/appi.ps.201100398. 41. US Conference of Mayors. (2013). A status report on hunger and homelessness in America’s Cities: 2013. Washington, DC: US Conference of Mayors. http://www.usmayors.org/pressreleases/ uploads/2013/1210-report-HH.pdf. Accessed January 14, 2015. 42. US Department of Health and Human Services. (2014). The health consequences of smoking—50 years of progress: A report of the Surgeon General. Atlanta, GA: Public Health Service, Centers for Disease Control and Prevention, Office of Smoking and Health. http://www.surgeongeneral.gov/library/reports/50years-of-progress/full-report.pdf. Accessed January 14, 2015. 43. US Department of Housing and Urban Development, Office of Community Planning. (2013). The 2013 Annual Homeless Assessment Report (AHAR) to Congress. Washington, DC: US Department of Housing and Urban Development. https://www. hudexchange.info/resources/documents/ahar-2013-part1.pdf. Accessed January 14, 2015. 44. Vijayaraghavan, M., & Pierce, J. P. (2015). Interest in smoking cessation related to a smoke-free policy among homeless adults. Journal of Community Health. (online publication). doi:10.1007/ s10900-014-9985-9. 45. Vuolo, M., & Staff, J. (2013). Parent and child cigarette use: A longitudinal, multigenerational study. Pediatrics, 132(2), 1–10. doi:10.1542/peds.2013-0067. 46. Weinreb, L., Goldberg, R., & Perloff, J. (1998). Health characteristics and medical service use patterns of sheltered homeless and low-income housed mothers. Journal of General Internal Medicine, 13(6), 389–397. doi:10.1046/j.1525-1497.1998.00119.x. 47. Winkleby, M. A., & Boyce, T. (1994). Health-related risk factors of homeless families and single adults. Journal of Community Health, 19(1), 7–23. doi:10.1007/BF02260518.
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ORIGINAL PAPER
Attitudes Toward Smoking Cessation Among Sheltered Homeless Parents Holly C. Stewart1 • Terrell N. Stevenson1 • Janine S. Bruce1 • Brian Greenberg1 Lisa J. Chamberlain1
•
Springer Science+Business Media New York 2015
Abstract The prevalence of smoking among homeless adults is approximately 70 %. Cessation programs designed for family shelters should be a high priority given the dangers cigarette smoke poses to children. However, the unique nature of smoking in the family shelter setting remains unstudied. We aimed to assess attitudes toward smoking cessation, and unique barriers and motivators among homeless parents living in family shelters in Northern California. Six focus groups and one interview were conducted (N = 33, ages 23–54). The focus groups and interviews were audiorecorded, transcribed verbatim, and a representative team performed qualitative theme analysis. Eight males and 25 females participated. The following major themes emerged: (1) Most participants intended to quit eventually, citing concern for their children as their primary motivation. (2) Significant barriers to quitting included the ubiquity of cigarette smoking, its central role in social interactions in the family shelter setting, and its importance as a coping mechanism. (3) Participants expressed interest in quitting ‘‘cold turkey’’ and in e-cigarettes, but were skeptical of the patch and pharmacotherapy. (4) Feelings were mixed regarding whether individual, group or family counseling would be most effective. Homeless parents may be uniquely motivated to quit because of their children, but still face significant shelter-based social and environmental barriers to quitting. Successful cessation
& Holly C. Stewart [email protected] 1
Stanford Medical School, 291 Campus Drive, Stanford, CA 94305, USA
programs in family shelters must be designed with the unique motivations and barriers of this population in mind. Keywords Cigarettes Smoking cessation Homelessness Family homelessness Shelter environment
Introduction The prevalence of smoking among homeless adults in the United States an estimated 70–80 % [2, 40] as compared to 18.1 % in the general population [1]. Homeless smokers smoke more cigarettes per day, initiate smoking at a younger age [8], and homelessness appears to be associated with present smoking independent of individual demographics, socioeconomic status, and health behavior [3]. The negative health effects of tobacco among the homeless may be exacerbated by poor diet, substance abuse, mental illness, communicable and chronic disease, and limited healthcare access [13]. Despite substantial barriers to smoking cessation, homeless smokers appear to be motivated to quit. They report a similar number of quit attempts as compared to non-homeless smokers, understand the dangers of tobacco use, recognize that homelessness and tobacco use are financially incompatible, and many plan to quit in the immediate future [32]. Preliminary research suggests interventions, including small financial incentives [7], smoke-free shelter policies [44], and telephone-delivered cessation programs [6] may achieve higher smoking cessation rates among homeless smokers. The nature of smoking in the family shelter remains relatively unstudied, despite increases in family homelessness across the United States [41] secondary to poor economic conditions and insufficient social welfare [22].
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Smoking poses considerable risk to the health of family shelter residents. Unlike homeless single adults, who are found on the streets as well as in the shelter, homeless families are predominantly shelter-based [31] with people in families comprising nearly 50 % of the total sheltered homeless population in January of 2013 [43]. Comparisons of homeless sheltered and low-income non-homeless women demonstrate asthma rates to be more than four times higher in the homeless cohort [46]. Children living in homeless facilities where smoking is prevalent are more likely to experience environmental tobacco exposure, which increases the risk of lower respiratory illness, middle ear effusion, asthma, and sudden infant death syndrome [15]. Additionally, children of current and former smokers are more likely to become smokers [45] and parental smoking cessation may help lower risk for adolescent smoking [11]. Previous research finds meaningful differences between homeless adults living with children and single homeless adults [47] that warrant special consideration. We call specifically for a better understanding of the unique smoking practices and attitudes toward cessation in the family shelter setting, which is essential for development of cessation programs appropriate for environments where children are present. Therefore, the aim of this study was to conduct multiple focus groups with homeless parents living in family shelters in Northern California to characterize participants’ readiness to quit and desired cessation methods, and to identify shelterspecific barriers to quitting.
Methods Recruitment We aimed to include participants that would express ‘‘typical’’ or ‘‘average’’ perspectives on smoking, and therefore recruited participants using typical case sampling [14, 28, 33]. In each of the participating shelters, focus groups were advertised at the weekly shelter-wide meeting by the program director. Shelter residents who met our study criteria were able to sign up at weekly, all-shelter meetings or one-on-one through their case managers. Focus group dates were decided upon by the program director at each shelter, and were offered in both the evenings and mid-day to accommodate different schedules of shelter residents. Within the focus group literature, recommendations regarding the ideal number of participants are variable, ranging from 4 to 12 [18, 23, 26, 27, 37–39]. Our aim was to recruit between six and eight participants for each focus group but over-recruited by approximately 25 % to allow for the possibility that participants who signed up would not attend the groups.
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Inclusion and Exclusion Criteria Inclusion criteria included residing in an InnVision Shelter Network family shelter in San Mateo County, being 18 years of age or older, being a current smoker. In our study, shelter residents were considered ‘‘current smokers’’ if they reported smoking five or more cigarettes per day or quitting within the past six months. Shelter residents who reported living with a primary relative who was a smoker were also included in our study. Light food and refreshments were provided at each focus group. Participants were compensated with a $15 gift card to a large local grocery store. Data Collection Six focus groups and one interview were conducted across four family shelters in San Mateo County, California between June and August of 2013. All four of these shelters were designated transitional facilities where shelter residents actively work towards obtaining employment and long-term housing; one of the four sites additionally provided emergency housing for families. Focus groups and interviews lasted approximately 45 min. All focus groups and the interview were conducted by the primary investigator (HS), who prior to this project received training in qualitative methods through graduatelevel coursework and a community health research program at Stanford University. With the exception of one shelter, shelter staff members were not present for the focus groups. Prior to the focus group, each participant was asked to complete a brief survey on demographic information and smoking-related data. The moderator’s guide was adapted from questions used by Okuyemi et al. [32], and asked participants to discuss their attitudes toward smoking, their attitudes toward smoking cessation, and any motivating factors or barriers to smoking cessation that they encounter in their day-to-day life. Focus group participants were asked to voluntarily introduce themselves at the beginning of each session, providing only their first name or a pseudonym for the purpose of confidentiality. All focus groups were audio-recorded with participants’ consent. The focus group recordings were subsequently transcribed verbatim by the primary investigator (HS) and proofread for accuracy. Any identifying information was removed from the transcripts prior to analysis. This study was approved by the Institutional Review Board at Stanford University. Data Analysis Ryan and Bernard propose four key steps in qualitative analysis: (1) discovering themes and subthemes; (2)
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winnowing themes to a manageable few; (3) building hierarchies; and (4) linking themes into theoretical models. In our analysis, a team-based approach was implemented for discovery of themes and subthemes [35]. Team-based analysis is a recognized approach for generating preliminary codes in qualitative research [4, 24], and multiple coders are thought to provide an important mechanism for assessing reliability and validity of the codes [24]. The team that identified preliminary themes and subthemes for the present study had no prior knowledge of the study protocol or specific aims, but all team members had professional expertise relevant to our research question. The team included a second-year pediatric resident and a second-year medical student who recognize the health risks posed by smoke exposure; a shelter staff member with intimate knowledge of operations at the family shelters included in our study; and a post-baccalaureate fellow with academic training in anthropology and qualitative research. The analysis team was provided with detailed instructions regarding reading of the transcripts and independent margin coding. A subsequent group discussion of margin codes was facilitated by the primary investigator (HS) in which team members presented their margin codes for each domain in the moderator’s guide. Codes reported by more than half of the team members were included in the preliminary codebook [21, 36]. Consistent with Ryan and Bernard’s framework, the preliminary codes generated by the team-based analysis was subsequently refined and built into a hierarchy of domains, themes, and subthemes by the principal investigator (HS). These domains differed from those included in the moderator’s guide. An iterative coding process was then used to apply codes to the data: the principal investigator (HS) and an additional team member applied codes to a portion of the complete transcript, reconciled inconsistencies in application of codes, and subsequently revised and redefined codes as necessary. This process was repeated a total of four times, and yielded a finalized codebook that was applied to the data [24, 36]. Cohen’s j was calculated using DedooseTM Online Software v 5.1.26 to assess interrater reliability between the principal investigator and the team member. A pooled j = 0.80 was achieved during the final coding process [10]. On completion of the codebook, combinations of primary and secondary codes were used to examine the coded data to identify significant patterns and preliminary themes. Generated themes were iteratively revised, and thematic statements were developed with careful attention paid to recurrent concepts, and whether or not the concept characterized the unified experience of all participants [29, 35]. Throughout the theme analysis process the principal investigator (HS) elicited feedback from shelter staff, coinvestigators, and medical professionals specializing in
substance use. We elicited feedback from professionals with content expertise to increase the credibility of our findings and to account for any potential research biases or preconceptions that may have influenced the analysis [28]. Elicited feedback also helped shape a meaningful theoretical model to which themes could be linked [35]. For analysis of the survey data, Stata v. 13.0 (StataCorp LP, College Station, TX) was used to calculate descriptive statistics for gender, race and ethnicity, plans to quit in the next six months, plans to quit within the next thirty days, and past use of nicotine replacement products. Means and standard deviations were calculated for age, cigarettes smoked per day, duration of smoking (in years), and quit attempts in the past year (Table 1).
Results Demographic characteristics and data on smoking behaviors were collected for 96.9 % of study participants (Table 2). The majority of this sample of sheltered, homeless parents were Caucasian females. The mean age was 32.7 years. Most had taken college-level courses or earned a higher degree. The majority of smokers reported smoking every day out of the last thirty days (48.3 %), and 29 % smoked two to five cigarettes per day. A substantial number of participants (22.5 %) were never-smokers, but were included because one of their primary relatives was a smoker. Four major themes emerged in focus group discussions: (1) the central role cigarette smoking plays in the family shelter environment; (2) children as a motivator for quitting; (3) the role of will power in cessation; (4) and mixed feelings regarding counseling options. Smoking and Its Central Role in the Family Shelter Environment All four shelters included in this study prohibit indoor smoking, but allow smoking in a designated outdoor area at the shelter’s front entrance. Study participants reported that cigarettes were ubiquitous in the shelters included in our study. Smoking was described as an activity that helped shelter residents to both cope with daily stressors and build friendships with fellow smokers. When asked to describe the reasons they enjoyed smoking, participants explained that cigarettes could effectively alleviate feelings of anger, boredom, and stress. Smoking was described as a means of managing both dayto-day stressors like ‘‘having your phone get cut off’’ or ‘‘having someone flake on you’’ as well as the more constant stressors associated with homelessness and the precariousness of shelter life:
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J Community Health Table 1 Moderator’s guide Smoking practices and readiness to quit What led you to start smoking? What do you enjoy about smoking? What are some of the negative things about smoking? How does being a parent influence the way you think about smoking? Attitudes towards cessation For those of you who are thinking about quitting, what are some reasons you would like to quit smoking? For those of you who are not thinking about quitting, what would make you want to quit? How might quitting be different for people who are parents? Barriers to cessation Overall, what are some of the things that would make quitting hard for you? What are some of the things in your day-to-day life that would make quitting hard for you? Preferred cessation methods What methods have you tried to help you quit smoking in the past? How did it go? What methods would you be interested in using to try and quit smoking? What would you think about having a counselor to help you quit smoking? What would you think about going to group meetings to help you quit smoking? Which would you prefer: individual, group, or family counseling and why?
…it’s my only way of releasing stress. I can’t yell, I can’t hit, I can’t walk away, I can’t just say goodbye, I don’t have anybody to take one, so it’s…kind of obvious. Smoke. Despite their negative feelings about smoking, participants describe using cigarettes as a coping mechanism: Me personally I don’t like nothing about smoking. I just do it…a lot of times I do it because I have nothing to do or if I’ve been stressed out or just like a comfort zone. For some, cigarettes were used to manage stress and anxiety in lieu of other drugs or alcohol: I think for me personally while I’m in this situation there’s no reason for me to quit anything. You know I just quit drugs and alcohol two and a half years ago– that was hard enough and I’m still stressin’ on that…I wish that I never would’ve smoked but unfortunately that’s not how my situation is …there’s really nothin’ I can do about it. Beyond its role as a coping mechanism, smoking appears to provide an opportunity for adults to socialize in these shelters. Even those who self-identified as nonsmokers acknowledged the designated smoking areas as a spaces where adults could mingle with one another. And a few times we would go out there, it was a nice evening and we’d go out there just to talk, you know, and uh we weren’t smoking but just, they were out there and we were talking and stuff like that.
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Smoking is described as one of the only activities that provided adults to interact with each other in the absence of their children, and consequently appears to be one of the primary mechanisms by which shelter residents were able to form friendships and built social capitol: …I think that people that smoke here—that [smoking] kind of helps them. I mean me, from the outside, I feel like the people that do smoke…make a support group for each other so they get to know each other. They talk to each other, they get to know each other [better] than the people that are not smoking so I feel like I…don’t know the people here. Both smokers and non-smokers reported personal experience or recounted instances of shelter residents who picked up smoking after arriving at the shelter due to its ubiquity and its key role in socialization among adults. Motivating Factors for Smoking Cessation Among the most commonly cited reasons to quit smoking were personal appearance—including the smell of cigarettes and nicotine staining of nails or teeth—and personal health. Participants also described feeling ashamed of being identified as a smoker: I care about what other people think and so…it bothers me…when I’m with my mother…and she lights up and [the smoke] goes behind her and people are like, [coughing]. That bothers me. It’s embarrassing. So I don’t do stuff like that.
J Community Health Table 2 Focus group participants’ demographics and smoking behaviors (n = 31) Percentage Sex (female)
74.2
Ethnicity (Hispanic/Latino)
29.0
Mean (SD)
Race Caucasian
45.1
African American
12.9
Asian
6.5
Pacific Islander/Hawaiian American Indian/Alaskan Native
3.2 6.5
Mixed races Other
6.5 32.72 (5.75)
Educational level Did not finish high school
16.1
Completed high school or GED
38.7
College or other higher degree
45.1
Days smoked out of last 30 0 days
25.8
1–2 days
6.5
3–5 days
0
6–9 days
6.5
10–19 days
3.2
20–29 days All 30 days
9.7 48.3
Cigarettes smoked per day None \1
25.8 0
1 per day
12.9
2–5 per day
38.7
6–10 per day
9.7
11–20 per day
9.7
More than 20 per day
3.2
Number of prior quit attempts I have never smoked
22.5
None
12.9
1 time
9.7
2 times
29.0
3–5 times 6–9 times 10 or more times
You know, I’ve done the whole thing like four or five times about ‘‘if you spend this much and this much in a year’’ and it comes out to a lot. I’m just like, I’m in a frickin’ shelter. I spend that much money on cigarettes and I’m freaking here? It’s like, nuts Children were discussed as a motivator for quitting in all seven focus groups:
12.9
Age
frequently expressing their understanding that smoking and homelessness are financially incompatible:
9.7 12.9 3.2
If I wasn’t a parent I would not be thinking about it. As sad as that is to say for my own health and the commercials you see and the advertisements, I would probably continue smoking and would smoke way more than I do now. Participants described feelings of anxiety regarding the risk smoking poses to their children’s health, and expressed feelings of guilt for exposing their children to cigarette smoke: When you’re not a parent it’s basically you, you hurting only yourself. And when you are a parent, it’s not only you…your child is innocent they didn’t ask to be there. They didn’t ask to be held in the smoke. So I don’t think it’s fair for the child. Participants also expressed concern that by smoking they were setting a bad example for their children: He’ll see a cigarette and he’ll [say] ‘‘Here, Mommy!’’ You know, before he used to take them and break them…I don’t want to set a bad example. It’s a bad example so that’s another reason why I want to quit. Both smokers and non-smokers were frustrated by shelter rules that specify that children must accompany parents who wish to go outside to smoke. Participants explained that this rule sends confusing messages to children, and also makes them vulnerable to second-hand smoke exposure: Before he didn’t always see me smoking. I would hide… but now I gotta drag him with me I gotta go smoke, gotta go smoke you know and he is getting that idea in his head that it’s okay. The Role of Will Power in Smoking Cessation
Participants also expressed feelings of shame with respect to specific smoking-related behaviors: I have a lot of pride and I will go pick up butts, okay? Like…I could never feel lower in the world.
When participants were queried about the specific tools they would like to use to quit smoking, many expressed interest in the patch. However, there was also widespread concern regarding side-effect associated with the patch:
The high cost of cigarettes was cited across focus groups as a major motivating factor for quitting, with participants
I know from using the patches…they give you really bad nightmares, they burn your skin, they make you
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sick…but you still have that habit. You know what I mean? Participants were equally concerned about the side effects associated with medications that are commonly used for smoking cessation. One participant described her experience with Chantix [Varenicline, a prescription used to treat nicotine addiction]: The only thing that worked for me was Chantix. But I almost robbed a bank. I wanted to rob a bank. I’m serious…it was horrible. Of the cessation tools discussed, participants were much more interested in e-cigarettes or replacing smoking with an alternative habit than they were in using either patches or medication. Across all seven sites, participants appeared most interested in quitting without use of cessation aids. When asked what cessation method they would prefer to use to quit smoking, multiple participants across all shelter sites simply responded by saying ‘‘cold turkey.’’ I don’t think I’m addicted to it like that much where I need a substitute…cold turkey would be best. Out of these discussions emerged the idea that addiction to tobacco products is a matter of will. Participants talked about ability to quit coming from with a person, and explained that they did not believe classes or cessation aids were necessary tools for quitting smoking: I mean, it doesn’t take to go to a class to stop. You know what I mean? You can stop yourself inside. I mean, you might, you know, there might be triggers to what makes us, you know, smoke? But all in all, a lot of people make excuses to why they need to do this class or do this to stop when it’s really in here. It’s all inside, you know? If you want to stop, you stop. From in here. Participants also expressed their belief that addiction was sustained by the act of smoking, not nicotine: Just, being in this situation and dealing with all of this is what you know, gets me or at least gives me the urge to want to smoke. So. For me it’s not necessarily the chemical it’s just the smoking itself. Mixed Feelings Regarding Counseling Options Participants were asked to share their thoughts on three counseling options: individual, group and family counseling. Participants identified benefits and drawbacks to all three counseling types, and ultimately feelings were mixed regarding which type of counseling would be best.
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Participants identified privacy and one-on-one attention as clear benefits of individual therapy, as well as the opportunity to explore the emotions associated with smoking. However, many participants felt that weekly, one-on-one counseling would not provide them with enough support for smoking cessation. Additionally, several participants felt that smoking would take a backseat to other issues in individual therapy sessions. In discussing the group counseling option, participants suggested that accountability to fellow group members and the opportunity to derive inspiration from other group members’ stories were clear benefits. Drawbacks to group counseling included a lack of privacy, and some participants felt that they would not be motivated by strangers’ stories. The last therapy option, family counseling, was proposed by a participant in the first focus group, who expressed an interest in involving her children in the cessation process. When participants in subsequent focus groups were asked to share their opinions on family counseling, many saw possible benefits, including having a safe space to explain smoking to their children. Some participants suggested that family counseling might help prevent their children from becoming smokers themselves: The first cigarette I had is when I was ten. And if my parents would have talked to me or my grandparents would have talked to me I don’t think I would be smoking today. However, some participants expressed serious concern over family counseling. Some worried that family counseling would send the message that it is okay to start smoking because it is possible to quit later. Some participants felt that smoking was an adult issue and that children should not be involved in discussions about smoking.
Discussion Our findings suggest that changing the shelter environment may be key in encouraging shelter residents to consider smoking cessation. Participants reported the prevalence of cigarette smoking and its central role in socialization as major barriers to smoking cessation, which reinforces previous research highlighting the importance of the social context of smoking practices [3]. Descriptions of the ubiquity of cigarette smoking in the shelter setting are consistent with the convention of allowing cigarette smoking in homeless shelters while prohibiting use of alcohol and illicit substances [40]. Descriptions of cigarette smoking as a powerful tool for socializing and building social capital are consistent with the notion that smoking is
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a ‘‘network phenomenon’’ [12]. Participants also cited stress relief, a common self-perceived motivation for smoking [19], as a major barrier to smoking cessation. Despite barriers to successful smoking cessation, many participants reported their intentions or desire to quit. Participants mentioned many of the same motivating factors reported by single homeless adults in previous research—including the high cost of smoking, personal health and personal appearance [32]—but children were the most commonly cited motivator for smoking cessation in this group of homeless parents. This finding, though not surprising, is a meaningful one: homeless parents and homeless single adults face similar barriers to cessation, but homeless parents report a powerful additional motivator. They may therefore be more receptive to shelter-based cessation programs. Innovative programming to support tobacco cessation in this unique population is therefore warranted [9]. There appeared to be a knowledge gap regarding the biological basis of nicotine addiction in this highly educated group of homeless parents. Participants reported their desire to quit ‘‘cold turkey,’’ and their belief that smoking addiction is emotional or psychological in origin. Quitting was largely considered to be matter of will power by participants. These beliefs are inconsistent with the literature, which indicates that nicotine maintains tobacco addiction [42] and that nicotine replacement therapy such as the nicotine patch is effective for smoking cessation [5, 20]. However, most participants expressed skepticism regarding nicotine replacement therapy and pharmacotherapy and fear of associated side effects. Consistent with prior findings that flexible services for smoking cessation are valuable, and that programs tailored to individual context, culture, and personal life situation are most acceptable, feelings among participants were mixed regarding what form of counseling would be most effective [34]. Our findings suggest future directions for both future interventions and further research. In line with social-ecological principles, these interventions should consider not only unique motivating factors, but also environmental interventions that aim to mitigate shelter-specific barriers to cessation [30]. Possible pilot environmental interventions may include protected time for adults to socialize over non-smoking activities, encouragement of smoking cessation by shelter staff, increased regulations regarding where and when individuals are allowed to smoke, and an overall emphasis on a culture of non-smoking. Recent research also suggests that smoke-free policies in homeless shelters lead to reduced consumption of cigarettes and increased quit attempts [44], and consideration of such policies for the shelters we included in our study may be advisable given the influence of the shelter environment on smoking behaviors. Beyond environmental interventions,
educational sessions about the physiology of nicotine addiction may help shelter residents devise more realistic plans for smoking cessation. Lastly, results from these focus groups suggest that offering multiple modalities of behavioral therapy (individual, family, and group counseling) as part of a cessation program may help shelter residents find a quit strategy that is consistent with their desires and priorities. Further research is needed to characterize the nature of smoking and attitudes toward smoking cessation in the family shelter setting. Future potential directions for research in this area include quantifying the degree of nicotine dependence among family shelter residents using tools such as the Fagerstrom Tolerance Questionnaire [16, 17, 25]; comparison studies across family shelters and shelters for single adults; and evaluation of any resultant pilot cessation programs. Strengths and Limitations Limitations of this study include our small sample size and the composition of our study sample. We utilized typical case sampling in order to recruit a study population representative of sheltered homeless parents living in San Mateo County, but group demographics and size varied considerably among groups. High levels of educational attainment, low reported number of cigarettes smoked per day, and a predominance of Caucasian females will hinder the generalizability of these findings beyond the study population. Our focus groups included a mixture of smokers and non-smokers who had lived with a primary relative who smoked. It is possible that this heterogeneity lead to mixed and confounded focus group results, however it has been argued in the focus group literature that it can be advantageous to bring together a diverse group to maximize exploration of different perspectives within a group setting (22). Our decision to include smokers and nonsmokers simultaneously was driven our aim of eliciting a broad range of opinions on smoking in shelters, and also by logistic challenges inherent in scheduling focus groups with shelter residents who are actively transitioning out of homelessness. There are also two potential sources of bias that must be recognized: first, it is possible that among current smokers living in the shelters included in our study, only those amenable to the idea of quitting chose to participate in the present study. This selection bias would result in a misrepresentation of the general attitude toward smoking cessation among shelter residents, and would lead the investigators to overestimate the extent of interest in smoking cessation among shelter residents. Second, while the moderator remained consistent across all seven focus groups, the ethnicity and social position of the moderator
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may have influenced the attitudes shared in this study: study participants may have (either consciously or subconsciously) responded in a manner they thought would be acceptable to a Caucasian medical student. Finally, to make research with this historically hard-toreach, vulnerable population technically feasible, and in light of high turnover at the shelters included in our study, certain adjustments were made to our methodology. First, our original aim was to conduct a series of focus groups in San Mateo County family shelters. For one of the seven scheduled focus groups, only one shelter resident was present. Because participants were provided with an incentive for participation and because of our commitment to providing shelter residents with an opportunity to share their experiences, we felt that it was more appropriate to conduct a one-on-one interview with this participant using the focus group moderator’s guide than exclude them from the study. This interview was analyzed concurrently with the focus group transcripts because the same questions were asked. Second, at only one of the four shelter sites a staff member was present for the focus groups. This staff member attended focus groups because in all previous collaborations between the research team and this shelter (which included an educational series on childhood asthma and cigarette smoking) a staff member was present. We felt that it was better to maintain this status quo and allow the staff member to attend the focus groups than risk jeopardizing the healthy relationship we maintained with the individual shelter sites and our community partner throughout the present study. We recognize that the presence of a staff member may have biased responses—for example with participants being less willing to share anecdotes related to substance use or breaking shelter rules—however the nature of the responses from the focus groups conducted at this shelter were consistent with those conducted at the other sites where no staff person attended. Despite these limitations, we believe that the main strength of the present study is that it provides preliminary insights into the nature of smoking in family homeless shelters that are otherwise not represented in current literature. While we encountered many technical challenges in carrying out this research, we aimed throughout the present study to maintain methodological rigor while honoring our community partner and creating an opportunity for as many shelter residents to share their perspective as possible.
Conclusion This study represents an attempt to begin characterizing the smoking practices, shelter-specific barriers to cessation, and desired smoking cessation methods among sheltered
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homeless parents. Our preliminary findings from a series of focus groups in Northern California suggest that children serve as a profound motivator for smoking cessation, but that the central role of smoking in the shelter environment poses a major obstacle for sheltered homeless parents who may be ready to quit. As smoking in the family shelter setting poses a risk not only to the smokers themselves but also to children living in these environments, future efforts must be aimed not only at further characterizing the role of smoking in the family shelter setting, but also at providing desired resources to shelter residents who demonstrate an interest in quitting. Acknowledgments This work was supported by a CATCH Grant issued by the American Academy of Pediatrics (Grant 2123) and by the Medical Scholars Research Program at Stanford Medical School. Conflict of interest
The authors have no competing interests.
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