A community-based trial of a voluntary smoke-free home intervention in permanent supportive housing for formerly homeless adults

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PROJECT SUMMARY The focus of this proposal is on expanding access to voluntary smoke-free homes to formerly homeless residents residing in permanent supportive housing, and examining the impact of this intervention on reducing tobacco-caused disparities. Permanent supportive housing is subsidized housing with closely linked or on-site medical and/or social services for individuals with a history of chronic homelessness, and who are living with disabilities, mental health and/or substance use disorders. Permanent supportive housing uses a harm reduction framework, prioritizing housing stability over any pre-conditions of abstinence. In 2017, over 370,000 formerly homeless individuals lived in permanent supportive housing in the US. Tobacco use is highest among many of the same populations that live in permanent supportive housing, including people living with disabilities, mental health and substance use disorders, and who live below the federal poverty line. Approximately 50% of people living in permanent supportive housing report current smoking, yet there are no mandated smoke-free policies in permanent supportive housing. One of the concerns is that such policies may contradict permanent supportive housing’s harm reduction framework if it had the unintended consequence of increasing evictions related to policy violations. One strategy that we developed and tested in a pilot study is an intervention to increase voluntary adoption of smoke-free homes. The multi-faceted intervention, delivered by study staff includes: 1) one-on-one counseling to permanent supportive housing residents who are smokers on how to adopt a smoke-free home, and 2) training for permanent supportive housing staff on how to provide referrals to cessation services. In this study, we will conduct a multi-site, community-based cluster-randomized wait-list controlled trial of our multi-faceted smoke-free home intervention among 400 permanent supportive housing residents residing in 20 permanent supportive housing sites across the San Francisco Bay Area with the goal of increasing voluntary adoption of smoke-free homes. Our specific aims are: Aim 1: Conduct a cluster randomized trial to estimate the effect of our smoke-free home intervention on residents' voluntary adoption of smoke-free homes. Aim 2: Evaluate the cost-effectiveness of the smoke-free home intervention. Aim 3: Determine characteristics of high and low adopters at the individual level, and social and environmental barriers and enablers of adoption, scalability and sustainability of the intervention. The long-term goal is to develop evidence-based strategies that can be brought to scale in permanent supportive housing in order to reduce tobacco-caused cancer disparities among vulnerable populations disproportionately impacted by tobacco use.