Addressing Tobacco Use in a Homeless Population

描述(由申请人提供)：据估计，在给定的一年里，有230万至350万美国人无家可归。与美国普通人群相比，吸烟在无家可归者中的普遍程度要高出三倍多，这导致了过度的发病率和死亡率。尽管存在这种差异，但关于无家可归吸烟者的烟草使用特征和戒烟意愿预测因素的研究相对较少。很少有研究在这一人群中严格测试戒烟干预措施，到目前为止进行的那些研究表明，总体上效果不大。要解决这一弱势群体的烟草使用问题，就需要更好地了解这一问题，并采取新的治疗方法。为了解决这些证据上的差距，首席调查员(PI)提出了一个职业发展计划，将哈佛大学教师严格的方法论培训与创新的研究议程结合起来，建立在马萨诸塞州综合医院(MGH)和波士顿无家可归者医疗保健计划(BHCHP)之间独特的学术-社区合作伙伴关系之上。这一职业发展计划有三个科学目标：1)估计无家可归成年人队列中因吸烟而导致的死亡率、发病率和医疗保健利用情况；2)描述无家可归吸烟者的烟草使用特征，并评估影响吸烟决策平衡、吸烟回报价值和戒烟准备的因素；3)进行试点随机对照试验，以评估对无家可归吸烟者实施基于现金的应急管理(CM)戒烟干预的可行性和有效性。CM战略利用财政奖励来加强减少吸烟和戒烟；这种方法在促进其他弱势群体戒烟方面取得了令人振奋的结果，但从未在无家可归的吸烟者中进行过测试。这项拟议的研究项目是对国家药物滥用研究所(NIDA)战略重点的补充，该战略重点是开发新的行为治疗方法，并减少特殊人群中药物成瘾的差异。此外，该项目还涉及NIDA感兴趣的其他几个领域，包括流行病学、卫生服务和医疗后果。为了补充他在无家可归者医疗保健方面的内容专长，PI概述了一项计划，通过正规的研究生课程以及由非常合格的资深科学家组成的团队的指导，获得戒烟研究、行为科学、干预设计和无家可归人口研究方面的专业知识，这些资深科学家是与当前提案直接相关的研究领域的国际公认的领导者。这一职业发展计划的成功完成将使私人投资成为无家可归者中烟草使用方面的专家，并加强他作为独立调查者进行以病人为导向的研究的能力，重点是无家可归者的这一行为和其他高危健康行为。 与公共健康相关：据估计，每年有230万至350万美国人无家可归，其中四分之三的人吸烟。与美国普通人群相比，无家可归者的发病率和过早死亡率要高得多，但很少有研究将烟草使用作为造成这些差异的原因。为了推进减少无家可归人口中可预防的死亡和疾病的公共卫生目标，拟议的研究计划将列举无家可归成年人吸烟的医疗后果，描述无家可归吸烟者的烟草使用特征，并测试一种新的干预措施，利用经济激励促进这一人群减少吸烟和戒烟。

DESCRIPTION (provided by applicant): An estimated 2.3-3.5 million Americans are homeless during a given year. Cigarette smoking is over three times more common among homeless individuals in comparison to the US general population, contributing to excess morbidity and mortality. Despite this disparity, there is relatively little research on the tobacco use characteristics and predictors of readiness to quit in homeless smokers. Few studies have rigorously tested smoking cessation interventions in this population, and those conducted to date have demonstrated generally modest results. Addressing tobacco use in this vulnerable population will require a better understanding of the problem and a novel approach to its treatment. To address these gaps in evidence, the principal investigator (PI) proposes a career development program that blends rigorous methodologic training by Harvard faculty with an innovative research agenda that builds upon a unique academic-community partnership between Massachusetts General Hospital (MGH) and Boston Health Care for the Homeless Program (BHCHP). This career development plan has three scientific objectives: 1) To estimate smoking-attributable mortality, morbidity, and health care utilization in a cohort of homeless adults, 2) To describe the tobacco use characteristics of homeless smokers and assess the factors influencing decisional balance for smoking, reward value of smoking, and readiness to quit, and 3) To conduct a pilot randomized controlled trial to assess the feasibility and efficacy f a cash-based contingency management (CM) tobacco cessation intervention for homeless smokers. CM strategies utilize financial incentives to reinforce smoking reduction and cessation; such methods have shown promising results in promoting smoking cessation in other vulnerable populations but have never been tested in homeless smokers. The proposed research project complements the National Institute on Drug Abuse (NIDA) strategic focus on developing novel behavioral treatments and reducing disparities in drug addiction in special populations. Additionally, this project taps into several other areas of interest at NIDA, including epidemiology, health services, and medical consequences. To complement his content expertise in homeless health care, the PI has outlined a plan for acquiring expertise in tobacco cessation research, behavioral science, intervention design, and research in homeless populations through formal graduate-level coursework as well as mentorship by an exceptionally-qualified team of accomplished senior scientists who are internationally-recognized leaders in areas of research directly relevant to the current proposal. The successful completion of this career development plan will establish the PI as an expert in tobacco use among homeless individuals and enhance his ability to conduct patient-oriented research as an independent investigator focusing on this and other high-risk health behaviors in homeless persons. PUBLIC HEALTH RELEVANCE: An estimated 2.3-3.5 million Americans experience homelessness annually, and three-quarters of these individuals smoke cigarettes. Homeless persons experience considerably higher rates of illness and premature mortality than those in the US general population, but very few studies have focused on addressing tobacco use as a contributor to these disparities. To advance the public health objective of reducing preventable deaths and diseases in homeless populations, the proposed research plan will enumerate the medical consequences of smoking in homeless adults, describe the tobacco use characteristics of homeless smokers, and test a novel intervention that uses financial incentives to promote smoking reduction and cessation in this population.