Eva Scott started smoking by the time she was 11 and calls smoking her drug of "last resort" to ease the trauma of years of alcoholism and homelessness.

Scott stopped drinking 10 years ago, but says the addiction to cigarettes is much harder to break. "It would be awesome," she said, to be part of a research project coming to Toronto, modelled on a project in Ottawa, in which 80 people were given nicotine patches and nicotine gum to help them stop smoking.

Smokers were supported throughout by four peer counselors — insecurely housed, homeless, or multi-drug users themselves — who also helped to design the study.

Respirologist Dr. Smita Pakhalé led a research project in Ottawa that helped street-involved people cut back on smoking. Like most other smokers, said Pakhale, 'the majority of them want to quit, have tried quitting and have failed quitting.'

Dr. Smita Pakhalé, a hospital respirologist and lead author of the study at The Bridge, a community research and drop-in program in Ottawa, says that "community-building approach" is key to the project's dramatic results.

Over a period of six months, people living in poverty or homelessness, many of whom struggled with mental illness, cut back their smoking from an average of 20 cigarettes a day to nine, and also reported their use of opioids and other illicit drugs dropped by almost 19 per cent.

The study was published in BMJ_Open, an online publication of the British Medical Journal.



The shifting burden of tobacco

"Tobacco doesn't happen in isolation. Opioids don't happen in isolation," said Pakhalé. She says both are intricately connected to the so-called social determinants of health — poverty, isolation, racialized minority, inter-generational trauma.

"And in that population, all these addictions are more common than the general population," she told CBC Toronto.

Research from Toronto's Centre for Addiction and Mental Health (CAMH) shows that while tobacco use has dropped to about 14 or 15 per cent in the general population in Ontario, tobacco use is much higher — as high as 60 to 90 per cent — amongst the province's most vulnerable populations.

Victor Willis, head of PARC, says Dr. Pakhale's smoking reduction program was a 'natural fit' with PARC's tradition of peer-support counsellors. (Mary Wiens/CBC)

"It's hard to quit smoking for anybody," said Victor Willis, head of the Parkdale Activity-Recreation Centre (PARC), an agency that supports street-involved people in Toronto. "The fact that this program was able to do this with people living in poverty or with mental illness or homelessness was even more astounding in my mind. Wow, what an amazing program! How do we bring it to Toronto?"

Willis is collaborating with Pakhalé and Dr. Peter Selby at CAMH, in the hopes of producing even stronger results with the people who come to PARC. The Toronto version will start by this summer, and run for three years. Participants will be followed for a year.

Connection and relationships

Willis says what he finds most profound about the project is its use of peer counsellors. "It's all about connection and relationships", said Willis, and tying those relationships to healthcare goals along with the use of tools like nicotine patches, gum, and electronic cigarettes.

Selby, head of the Addictions Program at CAMH, researches how people stop smoking through the ongoing STOP Study, which has treated over 130,000 people in Ontario.

Dr. Peter Selby says Ontario's most vulnerable bear the burden of smoking today. CAMH research shows high smoking rates among people who are mentally ill, impoverished or homeless. (CAMH)

Selby says that as smoking rates have gone down in the general population, the burden of smoking has shifted to people struggling with poverty, mental illness and addiction. He says researchers are still learning how to apply the skills to stop smoking to a population dealing with severe economic and social issues.

"We are shifting our understanding," said Selby of people who are marginalized. In the past, agencies were reluctant to suggest they stop smoking. "The idea is that we can't take their 'last pleasure' from them."

But the reality, says Selby, is that when people are smoking, their psychiatric medication doesn't work as well and that people with severe mental illness die 25 years earlier than average, because of the combined impact of tobacco and poverty.

Mixing alcohol and tobacco is also toxic, doubling the risk of cancer. "Within a week of access to care, we've seen them reduce their smoking," Selby said. He calls that a "transformation," in which peer counselors are key.

"As researchers, it keeps us humble," said Selby, "when people with lived experience give us reality checks on our studies to tell us what works. This is very important to the future of research."

As a peer counsellor, Eva Scott supports other women with addictions at Sistering, an agency at Parkdale's Masaryk-Cowan Centre. But after years of homelessness, Scott says it's hard for her to give up smoking

Eva Scott still smokes up to half a pack of cigarettes a day, but even though she hasn't given up nicotine, she's a peer counsellor helping women stop drinking, through Sistering, an agency for at-risk women, just up the street from PARC.

"I don't even know how it feels to stop the nicotine part," she admits.

But she knows that someone with experience can go a long way to help.

"When people come to talk to me about their addictions, I listen to them and I give them hope by sharing my own experience," said Scott.

"And hopefully, this nicotine project will do the same thing."