Adding Substance to Homeless Lives by Subtracting Tobacco

"Tobacco affects you head to toe, every single organ in your body."
"If you can quite tobacco, you can quit crack, heroin, whatever it happens to be."
Dr. Smita Pakhale, respirologist, clinical researcher, The Ottawa Hospital

"It goes hand in hand, [smoking and drug use] it's very much like milk and cookies. If you can reduce or quit smoking, you can quit anything."
"I wondered how relevant it would be in the beginning, like how hand-in-hand these things are, but [smoking] kinda opens the door to the other issues [mental health and addiction]."
Kelly Florence, peer researcher

"I've had a lot of people who made other changes once they started seeing progress with the reducing of cigarettes."
"I've got a lot out of it [the study]. I've learned a lot of new skills. I feel comfortable with myself."
"I got my confidence and self-esteem back."
Tiffany Rose, peer researcher

Dr. Smita Pakhalé, a staff respirologist at The Ottawa Hospital and clinical researcher, led research designed to reduce smoking in a drug-using population. She stands outside a clinic on Murray Street with two of her peer researchers, Kelly Florence, left, and Tiffany Rose. Julie Oliver / Ottawa Citizen

Among those in the science-health community involved in researching the trials and tribulations of people living on the street, a new consensus has arisen, that smoking-related diseases are on the rise, striking street-livers in huge numbers. An Ottawa conference was addressed by a physician out of Boston in the fall that his multi-year study of 287,000 homeless patients indicated that tobacco and alcohol remained the leading killers, not the abuse of hard drugs.

Now, a study of 858 HIV-positive drug users that began in Ottawa in 2013 has revealed the unexpected statistic that 86 percent were smokers. Which brought Dr. Smita Pakhale, a "lung doctor" into the picture. As a health professional on the front lines she had become frustrated with "band-aids" at the clinical level, deciding to puzzle out the source. Which is to say the results of heavy smoking.

Her interest focused on the vulnerable population of street people, suffering pulmonary disease, strokes, cancers of every conceivable kind, rotten teeth, and additional sicknesses. Her small team has completed a study. For convenience purposes that study took place next to the Shepherds of Good Hope shelter, well used for the non-judgemental assistance it offers to the city's street population.

Traditionally, medical professions regarded smoking in the homeless population as incidental to the greater problems afflicting the unhoused, people who often had a history of mental illness and substance abuse. Smoking was considered to be relatively benign, a source of creature comfort, not the scourge that it is held to be in the general population. Dr. Pakhale thought otherwise.

The PROMPT (Participatory Research in Ottawa: Management and Point-of-care of Tobacco) research resulted in unexpected discoveries, that drug users who reduced or abandoned their smoking habit cut back or quit their abuse of other substances at the same time, thus improving their overall physical well-being. Mr. Florence who was himself a homeless person with addictions spoke of four  young drug users and smokers who all entered treatment once they quit smoking.

 The 44-year-old Kelly Florence and 33-year-old Tiffany Rose, signed on to the social work aspect of agreeing to help Dr. Pakhale through roles assigned them as a peer research team, monitoring the participants of the study. The study guidelines took shape over a period of a year, and in 2015 it began to seriously track participants' progress. The participants were 80 smokers who also abused drugs.

Initially a survey was completed then a nicotine-replacement program was instituted, and participants checked in to the team at least once monthly A nurse with expertise in smoking cessation was present twice weekly while the peer researchers themselves were approachable on a constant basis. This, along with life-skill workshops were held in a multi-pronged approach to helping the homeless help themselves.

The study participants were given nicotine substitutes; a patch, gum, lozenge or inhaler. They had their lungs tested. They were motivated by being paid $25 for attending monthly check-ins. By the time six months had elapsed 53 percent remained in the study. Of that number, nine percent had stopped smoking while 80 percent reduced tobacco use, and 70 percent reported reducing or stopping other substance abuse.

Dr. Pakhale recently presented her study results at an American medical conference. She envisages the program established on a more permanent basis, and transplanted other cities. She emphasizes that peer engagement along with a suitable, off-hospital location are key to the success of such a program.