May 5, 2021
Efforts to prevent and reduce smoking among adolescents and young adults have neglected a particularly at-risk population: homeless youth. As many as 70 percent of unaccompanied homeless youth smoke cigarettes, a rate that is several times higher than the national average for adolescents and young adults. The well-established health risks posed by smoking may be heightened among homeless youth to the extent that their health is already compromised by harsh living environments, poor nutrition, substance abuse, and limited access to health care and prevention services. Yet almost no information is available on the smoking behaviors of those who smoke, whether they are currently receiving services for smoking cessation, and how to best help them quit. To address this knowledge gap, a RAND team examined smoking among homeless youth in Los Angeles County. The goal of this research was to develop feasible recommendations for service providers who want to implement smoking cessation programs for homeless youth.
The research team surveyed 292 homeless youth smokers between June and October 2013, randomly sampling youth from street sites in Hollywood and Venice Beach/Santa Monica.,  Youth were eligible for the survey if they were ages 13–25, had smoked in the past month, and had smoked at least 100 cigarettes in their lifetime. The survey indicated that in the past 30 days:
The survey also asked youth about their current interest in quitting smoking, whether they had tried to quit in the past, and what methods they had used to help them quit. Results indicated the following:
In September and October of 2012, the team conducted telephone interviews with service providers representing 23 shelters and drop-in centers for homeless youth in Los Angeles County. These interviews asked about smoking cessation programming currently offered, interest in providing smoking cessation services to clients, and barriers to providing services. Results were as follows:
To identify what kinds of smoking cessation programs would be most easily integrated and sustainable in existing service contexts, the team described four specific smoking cessation programs to service providers. The programs had different levels of intensity, as defined by the amount of training required to deliver the program, as well as the amount of time involved for the site and the youth participants (see table). All of the programs promote smoking cessation in adult smokers, although smoking cessation rates are higher for more intensive programs (e.g., more sessions and more time).
|Smokers' Helpline referral
|Routinely screen for smoking and hand smokers a card about the California Smokers' Helpline (a toll-free number that smokers can call to get various services to help them quit).
|Lowest: Takes 1 minute. Can be delivered by any staff person, with virtually no training.
|Brief cessation counseling
|Routinely screen for smoking and immediately offer smokers brief advice to quit, following a script that asks youth about prior quit attempts, asks youth whether they are willing to make a quit attempt now, and offers brief recommendations of strategies that can help them quit.
|Lower: Takes 3 minutes. Can be delivered by any staff person, with minimal training on script.
|Extended cessation counseling
|Routinely screen for smoking and refer smokers to an in-house cessation counselor. The counselor follows a script that asks youth about prior quit attempts and whether they are willing to make a quit attempt now, offers more detailed strategies that can help them quit, and focuses on boosting confidence to quit.
|Moderate: Takes 15–20 minutes. Requires half-day training in smoking cessation counseling. Youth access to program is dependent on when a counselor is available.
|Multisession group counseling
|Routinely screen for smoking and refer smokers to an in-house weekly smoking cessation program that is offered on a regular basis.
|Higher: Typically 4–7 sessions. Requires half-day training in smoking cessation counseling. Ideally, staff would have counseling background or experience facilitating groups. Youth access to program is dependent on when program is offered.
Results from this part of the interview on smoking program preferences suggested the following:
Use of Other Substances. Despite cigarette smoking being the leading cause of preventable disease and death in the United States, there is sometimes concern that quitting smoking will have unintended negative consequences for homeless youth, such as increasing their use of other substances. Research on homeless adults has found that this is not the case, use.[6–8]
Mental Health Problems. Smokers often report that they smoke to cope with negative affective states, raising the question of whether quitting smoking will exacerbate existing mental health problems among homeless youth. Again, existing research suggests that this is not the case. Although studies have not been conducted with homeless smokers specifically, a number of studies show that smoking cessation is actually associated with lower rates of mood/anxiety disorders and perceived stress, including among individuals with a history of mental disorders., , , 
Treatment Effectiveness. In general, "more is better" when it comes to smoking cessation treatment.11 Routinely screening for smoking and offering brief (three-minute) advice to quit may be a good option for agencies interested in offering a low-cost, evidence-based program. But the more intensive option of a 15-minute counseling session is likely to be even more effective, and a multisession program will be more effective than a single counseling session. Providing pharmacotherapy (e.g., nicotine patch) in combination with any type of cessation counseling will increase the likelihood of quitting even more. Ultimately, a program that incorporates multiple components will be the most beneficial.
Implementing Smoking Cessation Programs in Service Settings. Homeless youth are embedded in a culture of smoking, sometimes even in the settings where they seek services. In addition to offering smoking cessation counseling to homeless youth who smoke, it is important to create an environment within these settings that is supportive of quitting. Routinely screening youth for smoking during intake, providing ongoing education on smoking cessation to staff, having reading materials on quitting smoking available in waiting rooms, and establishing a smoke-free outdoor area are relatively small changes that can have a potentially big impact on preventing and reducing tobacco use among homeless youth.