Should Homeless People Smoke?

I pondered that question at about 11:30 p.m. on a Friday night in June, while attempting to fall asleep on my cot in the basement of a church I had never set foot in previously, where I served as an overnight volunteer for Project Home.

Project Home provides emergency shelter for children and their families in Ramsey County, by arranging sleeping accommodations and breakfasts in the basements of churches and synagogues. The overnight chaperone socializes with the families before bedtime, tries to get a little sleep overnight, and awakens early to offer the parents and children food before a bus arrives early to take them to a day program.

While chatting on the church steps until the mandatory 10:00 p.m. bedtime, several of the parents smoked, and the secondhand smoke caused me to cough a few times – yes, even in the fresh air. Later on, pondering the effects of the smoke on the kids kept me awake.

An article in the July 18 issue of The New England Journal of Medicine notes that, “Although the prevalence of smoking in the United States has declined, vulnerable and marginalized groups continue to use tobacco at high rates.” The article points out that smoking-related deaths among homeless people occur at a rate twice as high as the rate among people in stable living situations.

Unique challenges do exist with respect to reducing smoking among homeless people – such as above average nicotine dependence, psychiatric conditions, and histories of abuse and trauma, in addition to lack of health insurance which limits access to smoking cessation services.

Yet, my experience that Friday night convinced me we must make reducing smoking among the homeless population a priority.

A 9-week-old baby staying at the shelter, who appeared healthy for the most part, had a raspy wheeze. And despite the fact he had seemingly very loving, caring parents, they were heavy smokers. His mother said that a nurse informed her that tobacco smoke could cause wheezing. I tried to remain supportive, nonjudgmental, so I mildly affirmed the nurse’s comment, even while I choked back my emotions.

A 30-something father talked with pride about his 12-year-old daughter, who accompanied him to the shelter. She had earned all A’s and B’s at school during the past year, despite the lack of housing stability and despite some stressful events involving racist taunting, which she had to endure. The girl demonstrated athletic ability out on the sidewalk. Her father, who smoked several cigarettes that evening, said that she wanted to play two different sports, but her asthma prevented her from engaging in prolonged and intense physical activity. Might the severity of her asthma have some connection to his smoking? I tried to understand why the girl’s father was unable to make the connection between his daughter’s asthma and the smoke he blew around her.

The children in these shelters are precious resources. We know that their environments – family and community – will significantly shape their health; environmental influences of many types will literally add/diminish years from their lives. (See, for example, our report on “the unequal distribution of health”.) So, at a minimum, we should perhaps seek to transform the adage that “your right to swing your fist ends where my nose begins” to “your right to blow smoke ends where a child begins to inhale.”

In 2004, Minnesota State Representative Marty Seifert proposed that welfare clients who smoke cigarettes should have a reduction in their benefits. As the StarTribune reported, his proposal “drew laughs and criticism from Teresa Nelson, legal counsel for the Minnesota Civil Liberties Union. ‘That's pretty wild,’ she said. ‘Certainly, giving up the right to put legal substances in your body should not be a condition of qualifying for government benefits.’”

Well, giving attorney Nelson the benefit of the doubt, I attempted, to no avail, to identify some justification for her assertion. Smoking typically appears as a condition affecting the cost of life insurance, for example. So, what socially responsible value or principle should inhibit  government from taking a life-saving approach for adults and their children, saying: “If you do not smoke, you will receive X amount of dollars, but if you do smoke, you will receive less”? That approach would put pressure on people to engage in behavior which protects their health and the health of others, and we could evaluate its effectiveness.

Financial rewards and penalties constitute just one approach. We probably need multiple approaches, given the complexity of the issue – addiction, psychiatric illnesses, etc. In the case of homeless shelter volunteers such as me, even some coaching about key messages, what to say when a shelter resident lights up a cigarette, might help. Perhaps you have thoughts to share?

In the final analysis, though, we must not deal with this problem by ignoring it. I concur with the authors of The New England Journal of Medicine article, who conclude strongly that we must “change the culture of complacency that has enabled our acceptance of smoking as an inextricable aspect of homelessness. Though the challenges of addressing tobacco use in this population are many, we believe that ignoring this issue is no longer justifiable — and that the conversation should shift away from the question of whether to address smoking among homeless people and toward the question of how.”