LETTERS SMOKING CESSATION AND SOCIAL JUSTICE We were very pleased that Borrelli, Busch, and Dunsiger1 directed our attention to the needs of the mobility impaired community as one of the underserved populations with high rates of smoking and little targeting of culturally appropriate smoking cessation interventions. As an anthropologist and sociologist who have long been researching and advocating on behalf of the homeless population, we have searched in vain for smoking cessation services for homeless individuals. The rate of smoking among homeless populations is estimated to be 73%2 and smoking greatly impacts their mortality and morbidity.3 When we recently asked a group of formerly homeless adults what they would do if they needed help in quitting smoking, their response was that they would “look on the bus for an advertisement for a study and join the study.” Joining a study is not the same as having access to a standard and effective smoking cessation program. This response highlights the dearth of accessible smoking cessation programs for homeless individuals. Further, when we inquired through the Health Department of Rhode Island for accessible smoking cessation programs, we

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discovered that there is only one smoking cessation professional who is funded to offer a free smoking cessation program to the uninsured and underinsured residents of Rhode Island. In an excellent previous article regarding smoking cessation, Borrelli4 advocates for integrating smoking cessation services into the infrastructure of existing agencies. Having such programs within homeless service agencies would greatly increase access and would also have the advantage of making the interventions more culturally appropriate. However, smoking cessation programs are not available in the homeless service agencies with whom we work. Their ability to provide such programs would require outside assistance as the staff of these agencies are too stressed and focused on providing basic needs to homeless individuals to allow for the internal development of smoking cessation services. We agree that researching culturally appropriate interventions is an excellent use of research funds. However, we recommend that the public health community also confront the reality of poor access to smoking cessation programs among underserved populations. This is a matter of social justice. j Irene Glasser, PhD Eric Hirsch, PhD

About the Authors Irene Glasser is with the Department of Anthropology and the Center for Alcohol and Addiction Studies at Brown University, Providence, RI. Eric Hirsch is with the Department of Sociology at Providence College and the Rhode Island Coalition for the Homeless, Providence, RI. Correspondence should be sent to Irene Glasser, Department of Anthropology, Box 1921, Brown University, Providence, RI 02912, USA (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This letter was accepted November 7, 2014. doi:10.2105/AJPH.2014.302461

Contributors Both authors contributed equally to this letter.

References 1. Borrelli B, Busch A, Dunsiger, S. Cigarette Smoking Among Adults With Mobility Impairments: A US

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Population-Based Survey. Am J Public Health. 2014;104 (10):1943---1949. 2. Baggett TP, Rigotti NA. Cigarette smoking and advice to quit in a national sample of homeless adults. Am J Prev Med. 2010;39(2):164---172. 3. Baggett TP, Hwang SW, O’Connell JJ, et al. Mortality Among Homeless Adults in Boston: Shifts in Causes of Death Over a 15-Year Period. JAMA Intern Med. 2013;173(3):189---195. 4. Borrelli, B. Smoking Cessation: Next Steps for Special Populations Research and Innovation Treatments. J Consult Clin Psychol. 2010;78(1):1---12.

BORRELLI RESPONDS Previously, I proffered a definition of “underserved smoker” and presented data to support the hypothesis that smokers with mobility impairments are an underserved group.1,2 In their commentary, Glasser and Hirsch call our attention to the high smoking rates among homeless people. Indeed, people with mobility impairments1,2 and homeless people3 are more likely to smoke and are less likely to successfully quit than are smokers in the general population, despite comparable numbers of attempts and desire to quit. High smoking prevalence, in the context of high motivation to quit, suggests that these groups face systemic barriers to smoking cessation at multiple levels. On an individual level, it is equivocal whether existing Evidenced Based Treatments (EBTs) can reach, motivate, and be of sufficient intensity to help underserved smokers quit. For example, one study randomized homeless smokers to EBTs versus standard care and did not find significant differences in smoking cessation.4 Criteria have been established to determine whether there is a reasonable threat of failure of EBTs to warrant cultural adaption of an EBT with the goal of improving cessation rates among underserved smokers.1 Smokers with mobility impairments, for example, need treatments that eliminate architectural access issues but also take into account their unique constellation of risk factors for continued smoking (e.g., depression, activity restriction, medical comorbidities).5

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