here ’ s so much to be gained by getting tobacco harm reduction to the highestrisk 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 .

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 propor tion of people experiencing home lessness 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 , how ever , 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 Global State of Tobacco Harm Reduction ( GSTHR ).

LEAVE NO SMOKER BEHIND An 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 ’.

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

Ian Walker / Alamy