The easiest win

Easiest Win. DDN article on tobacco harm reduction for homeless people. Image of a man smoking with a dog on the street‘There’s so much to be gained by getting tobacco harm reduction to the highest-risk groups,’ says David MacKintosh, director at Knowledge Action Change (KAC). And one of the highest-risk groups of all is the rough sleeping population. KAC runs the Global State of Tobacco Harm Reduction (GSTHR) project, which is funded by a grant from the Foundation for a Smoke-Free World.

Director of Foundation for a Smoke Free World (FSFW) programmes, David MacKintosh
David MacKintosh, director at Knowledge Action Change, which runs the Global State of Tobacco Harm Reduction project

While smoking rates in the UK have been falling for decades now, it’s estimated that up to 85 per cent of homeless people still smoke – more than six times the rate in the general population. Not just that, but they’re smoking in riskier ways. 

A study by homelessness charity Groundswell found that not only were most smoking the equivalent of more than 20 cigarettes (including rolled tobacco) per day, they were also smoking ‘dogends’ and sharing cigarettes – increasing their exposure to infectious diseases – with two thirds regularly making roll-ups from discarded cigarettes. 

Poor lung health is a serious – and inevitable – problem for homeless populations, with chest infections, pneumonia and unmanaged COPD often requiring hospital admissions. Smoking sits alongside constant exposure to vehicle emissions as ‘one part of that horrible tapestry that leads to absolutely appalling respiratory health in this population – the cold, damp, poor diet,’ says MacKintosh. ‘And to this appalling life expectancy statistic’ – currently 44 for men, and 42 for women. 

But while a far higher pro­por­tion of people experiencing home­lessness smoke than the general population, the proportion who actively want to quit is around the same – 50 per cent, according to a health audit by Homeless Link. The stumbling block, however, is the lack of appropriate services. ‘Even during periods of more generous funding in the UK for smoking cessation services, few have specifically focussed on the needs of people who are rough sleeping,’ says a December 2023 briefing paper by the GSTHR.

Sub header image: Leave no smoker behindAn earlier report from the Society for the Study of Addiction, Leaving no smoker behind, found that at least two thirds of rough sleepers who smoked would be willing to try vaping devices if they were free, and would access smoking cessation support if their homelessness services provided it. But it was COVID-19 that proved overwhelmingly that the demand was there. 

The GSTHR document points out that while there had been small-scale, local initiatives to help rough sleepers quit, it was the pandemic that provided the stimulus for large-scale action. The ‘Everyone In’ strategy, which required local councils to move everyone sleeping rough into temporary accommodation, was also an ideal opportunity to deliver tobacco harm reduction interventions – mainly through the provision of free vaping devices. ‘Whether the result of formal commissioning or more informal support’, the briefing states, it demonstrated the ‘potential of tobacco harm reduction for an extremely vulnerable client group’.

sub header image: harm reduction‘It’s a shame that it took a global pandemic to make people think about harm reduction, but it did,’ says MacKintosh. ‘You’ve got thousands of people you need to get into accommodation fast, many of whom have drug and alcohol issues, and more than three quarters of them smoke – what are you going to do?’ The answer was a ‘whole range of pragmatic interventions’, he says. ‘People from homelessness services were very aware that often a big problem keeping people indoors was that they light up a fag. Whether they’re in a hostel or they’ve been put in the Travelodge it causes trouble, so in a very pragmatic way it was a case of, “Why don’t we try some of these new-fangled vape things?”’

The Pan-London Homeless Hotel Drug and Alcohol Service (HDAS) recognised the importance of harm reduction to address the risks associated with sharing cigarettes during the pandemic – as well as minimising fire risks and reducing the likelihood of evictions – and supplied more than 3,000 vape starter kits, 20,000 refill pods and nicotine replacement products like gum or oral spray. It then produced leaflets signposting people to smoking cessation support and provided education and training for hotel and healthcare staff, and soon found that hotels were regularly requesting further tobacco harm reduction supplies. 

‘If you wanted proof of concept at scale, that was it,’ says MacKintosh. ‘Very quickly you could see people at frontline level accepting that this seems to work. There were all sorts of things going on around it – incentivisation, the engagement stuff – but it happened really quickly, and until very recently there was no system of guidance to support a lot of this work, and real issues about who was funding it and where you sourced the kit from.’ 

Models over the pandemic period ranged from ‘begging and borrowing from people who ran vape stores through to some areas where the director of public health said, “Here’s the money, go out and do it”,’ he says. Although the impetus was largely lost afterwards, it did offer commissioners and service providers ‘valuable real-life examples of what could be achieved for this population over the longer term,’ says the GSTHR paper. The National Institute for Health and Care Research is now funding work with London Southbank University, UCL and homelessness services that will trial the provision of vape starter kits and provide direct comparisons with smoking cessation care pathways. 

sub header image: Elephant in the roomSmoking, however, remains something of an elephant in the room for drug and alcohol services as well. According to the latest OHID figures, around half of people in treatment are smokers, but less than 5 per cent have even been offered a smoking cessation referral ( 

‘There is a massive mismatch,’ says MacKintosh. ‘Think about dual diagnosis. We’ve been banging on about this for a quarter of a century, but often it’s still, “Sorry, you need to go up the road for that”. We like dealing with one problem at a time, although that isn’t how they tend to manifest in individuals. Helping people around their smoking is actually quite simple, but how many services even know where their local smoking cessation services are?’

One issue is that many service staff are still smokers themselves. ‘At one time smoking was a bit of an engagement tool, and that wasn’t unique to drug services,’ he says. ‘Probation workers, mental health workers, these are jobs where you still see higher than average-population smoking rates. If you’re trying to engage with a guy on a cardboard box in a shop doorway then a cigarette isn’t a bad way of doing it.’ 

Sub header image; Funding challengeAn obvious challenge is that drug services are inevitably focused on their core business, he says. ‘I think it’s improving, but until relatively recently the idea of smoking hadn’t crept into the consciousness much. And who was going to fund it? It’s not coming out of your pot of money for drug and alcohol work. 

‘We’re hopefully in a position now where that could change quite rapidly. We know that drug services are an important step in keeping people alive – there’s that big protective factor just by someone being engaged – but the reality for most people is the drug that’s likely to kill them probably isn’t heroin or crack cocaine. Fifty per cent of our heroin users will not die from heroin, but 50 per cent of smokers will die because they smoke. So whether it’s smoking cessation or helping people find an alternative, there’s a huge potential win there for the individuals and services.’ 

It’s also something that can be done relatively cheaply with a significant impact, he points out. ‘So I hope we’re moving towards a situation where people are thinking more about it. There’s going to be central guidance from OHID about how areas can commission and buy the stuff, which is going to be helpful, and the money is being put money out there. So I’m hopeful we’ll see this going from projects dealing with dozens or hundreds of people to thousands. In a couple of years we could have evidence at scale, which could fundamentally change the argument.’ One scheme in Yorkshire includes external monitoring of people’s health from the outset, and ‘we know that some of the improvements in people’s lungs are really, really quick’, he states. ‘I think it will be a very powerful argument for why people should be doing this.’

A key aspect of harm reduction has always been how pragmatic it is, he says. ‘It’s often a lot cheaper than any other intervention, and you can do it at scale – the moving people on comes later. This really is something services should be looking at in terms of long-term benefits to their clients, and potentially their staff.  It’s an easy win, and it really shouldn’t be controversial. You’re helping adults move from something that 50 per cent of them will die from. You put in all this investment to save people from the wicked world of drugs, so why let cigarettes carry them off?’  DDN

Link to briefing on tobacco harm reduction for homeless people

We value your input. Please leave a comment, you do not need an account to do this but comments will be moderated before they are displayed...