Tobacco use among homeless people--addressing the neglected addiction.

n engl j med 369;3 nejm.org july 18, 2013 201 wide who are homeless in any given year. Approximately three quarters of homeless adults are cigarette smokers1 — a prevalence 4 times that in the U.S. adult population and 2.5 times that among impoverished Americans in general. The coexisting psychiatric and addictive conditions and life circumstances of homeless smokers have long fueled a fatalistic attitude among health care professionals toward addressing tobacco use in this population. We believe that this approach should change. Smoking-related deaths among homeless and marginally housed people occur at double the rate seen among more stably housed people and account for a considerable fraction of the absolute mortality disparities between these groups.2 In our study of more than 28,000 adults seen at the Boston Health Care for the Homeless Program in 2003 through 2008, cancer was the secondleading cause of death overall and the leading killer among adults 45 years of age or older. Malignant neoplasms of the trachea, bronchus, and lung caused more than one third of these deaths, a finding that underscores the excess burden of lung-cancer mortality in this population that has been documented elsewhere.2 Studies have also shown higher rates of death due to circulatory and respiratory diseases among homeless people than among people with homes. A number of factors create challenges for reducing tobacco use and its consequences in this population. Homeless smokers have a high burden of nicotine dependence, psychiatric symptoms, and coexisting substanceuse disorders.3 They are more likely than homeless nonsmokers to have experienced physical or sexual trauma.1 Many homeless people lack health insurance and a usual source of care, which limits their access to smokingcessation therapies. The circumstances of homelessness add to these barriers. Whereas most homeless shelters no longer permit smoking indoors, smoking around shelters is comTobacco Use among Homeless People — Addressing the Neglected Addiction